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Otite FO, Morris N. Race, Ethnicity, and Gender Disparities in the Management and Outcomes of Critically Ill Adults with Acute Stroke. Crit Care Clin 2024; 40:709-740. [PMID: 39218482 DOI: 10.1016/j.ccc.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Racial, ethnicity and sex disparities are pervasive in the evaluation and acute care of ischemic stroke patients. Administration of intravenous thrombolysis and mechanical thrombectomy are the most critical steps in ischemic stroke treatment but compared to White patients, ischemic stroke patients from minority racial and ethnic groups are less likely to receive these potentially life-saving interventions. Sex and racial disparities in intracerebral hemorrhage or subarachnoid hemorrhage treatment have not been well studied.
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Affiliation(s)
- Fadar Oliver Otite
- Cerebrovascular Division, Upstate Neurological Institute, Syracuse, NY, USA.
| | - Nicholas Morris
- Neurocritical Care Division, Department of Neurology, University of Maryland, Baltimore, MD, USA
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2
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Li M, Dai S, Wang L, Di H. Perspectives of healthcare providers on withdrawal of life-sustaining treatment and advanced directives for unresponsive wakefulness syndrome in China. Front Neurol 2024; 15:1358747. [PMID: 39206297 PMCID: PMC11350639 DOI: 10.3389/fneur.2024.1358747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 06/28/2024] [Indexed: 09/04/2024] Open
Abstract
Objectives We performed the current research to describe healthcare providers' perspectives toward withdrawal of life-sustaining treatment (WLST) and advanced directive (AD) of patients with unresponsive wakefulness syndrome (UWS) and to identify influencing factors of their perspectives. Methods Healthcare providers were recruited during a professional conference on disorders of consciousness (DoC). Participants completed self-administered questionnaires which included demographics, personal perspectives regarding WLST and the perception of ADs. Results A total of 230 Chinese healthcare providers (female: 69.7%) were included. Only a small proportion reported positive attitudes toward withdrawing artificial nutrition and hydration (35.2%), antibiotics (30.9%), and do-not-resuscitation orders (23.5%) in UWS patients. As for predictors' identification, religion was significantly associated with the positive attitude toward DNR order (p = 0.004). Moreover, although 47.4% of the participants had never heard of ADs before of conference, almost all of them would consider ADs (95.7%) thereafter, especially for non-neurologists (p = 0.033). Conclusion The propensity to WLST for UWS in China is low and perspective on WLST is significantly associated with individual characteristics. The attitudes of healthcare providers toward integrating ADs in the decisional process are positive. Future research regarding ADs and their predictors should be carried out to improve the quality of end-of-life care of UWS in China.
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Affiliation(s)
- Meiqi Li
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
- Intensive Care Unite, Hangzhou First People’s Hospital, Hangzhou, China
| | - Siyu Dai
- School of Clinical Medicine, Hangzhou Normal University, Hangzhou, China
| | - Le Wang
- School of Clinical Medicine, Hangzhou Normal University, Hangzhou, China
| | - Haibo Di
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
- School of Basic Medicine, Hangzhou Normal University, Hangzhou, China
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3
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Huang AP, Holloway RG. Navigating Neurologic Illness: Skills in Neuropalliative Care for Persons Hospitalized with Neurologic Disease. Semin Neurol 2024. [PMID: 39053504 DOI: 10.1055/s-0044-1788723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Persons hospitalized for neurologic illness face multidimensional care needs. They can benefit from a palliative care approach that focuses on quality of life for persons with serious illness. We describe neurology provider "skills" to help meet these palliative needs: assessing the patient as a whole; facilitating conversations with patients to connect prognosis to care preferences; navigating neurologic illness to prepare patients and care partners for the future; providing high-quality end-of-life care to promote peace in death; and addressing disparities in care delivery.
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Affiliation(s)
- Andrew P Huang
- Department of Neurology, University of Rochester, Rochester, New York
| | - Robert G Holloway
- Department of Neurology, University of Rochester, Rochester, New York
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4
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Comer AR, Jawed A, Roeder H, Kramer N. The impact of sex and gender on advanced stroke interventions and end-of-life outcomes after stroke. J Stroke Cerebrovasc Dis 2024; 33:107820. [PMID: 38876458 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 06/07/2024] [Accepted: 06/11/2024] [Indexed: 06/16/2024] Open
Abstract
OBJECTIVES In this review, we examine the impact of sex and gender on advanced stroke interventions and end-of-life outcomes after stroke and discuss the current theories, available evidence, and gaps in the literature. METHODS A scoping review of the literature was conducted to determine gender differences on advanced stroke interventions and end-of-life outcomes after stroke. The study team utilized PubMed to conduct a review of the literature and included research studies related to sex, gender, advanced stroke interventions, and end-of-life outcomes after stroke. The PRISMA process for conducting a scoping review was followed. RESULTS This review found that although evidence regarding gender differences in advanced stroke interventions and end-of-life care after stroke is disparate, some gender differences do indeed exist. Women are less likely to receive thrombectomy or alteplase, women are more likely to receive palliative care intervention, hospice, and women experience stroke mortality at higher rates. CONCLUSIONS Gender differences in end-of-life care after stroke are apparent with women experiencing lower rates of life sustaining interventions, and higher rates of mortality, palliative and hospice care. More research is needed to identify variables associated with or responsible for gender differences during advance interventions and end-of-life care after stroke.
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Affiliation(s)
- Amber R Comer
- American Medical Association, Indiana University, United States.
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5
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Shlobin NA, Regenhardt RW, Young MJ. Ethical Considerations in Endovascular Thrombectomy for Stroke. World Neurosurg 2024; 185:126-134. [PMID: 38364896 DOI: 10.1016/j.wneu.2024.02.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 02/18/2024]
Abstract
INTRODUCTION Stroke is a leading cause of morbidity and mortality globally. Endovascular mechanical thrombectomy is considered for patients with large vessel occlusion stroke presenting up to 24 hours from onset and is being increasingly utilized across diverse clinical contexts. Proactive consideration of distinctive ethical dimensions of endovascular thrombectomy (EVT) can enable stroke care teams to deliver goal-concordant care to appropriately selected patients with stroke but have been underexplored. METHODS A narrative review with case examples was conducted. RESULTS We explain and critically evaluate the application of foundational bioethical principles and narrative ethics to the practice of EVT, highlight key ethical issues that may emerge in neuroendovascular practice and develop an ethical framework to aid in the responsible use of EVT for people with large-vessel occlusive ischemic stroke. CONCLUSIONS EVT for stroke introduces important ethical considerations. Salient challenges include decision-making capacity and informed consent, the telos of EVT, uncertainty, access to care, and resource allocation. An ethical framework focusing on combining patient values and preferences with the best available evidence in the context of a multidisciplinary care team is essential to ensure that the benefits of EVT are responsibly achieved and sustained.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Robert W Regenhardt
- Departments of Neurosurgery and Neurology, Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael J Young
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Zahuranec DB, Ortiz C, Lank RJ, Zhang G, Shi X, Case E, Morgenstern LB. Surrogate Decision-Making After Stroke in a Community Setting: The OASIS Project. Stroke 2024; 55:678-686. [PMID: 38214155 PMCID: PMC10922558 DOI: 10.1161/strokeaha.123.043947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 12/20/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Patients with severe stroke often rely on surrogate decision-makers for life-sustaining treatment decisions. We investigated ethnic differences between Mexican Americans (MAs) and non-Hispanic White (NHW) individuals in surrogate reports of physician quality of communication and shared decision-making from the OASIS study (Outcomes Among Surrogate Decision Makers in Stroke) project. METHODS Patients had ischemic stroke or intracerebral hemorrhage in Nueces County, TX. Surrogates self-identified as being involved in decisions about do-not-resuscitate orders, brain surgery, ventilator, feeding tube, or hospice/comfort care. Surrogate reports of physician quality of communication (scale score, range from 0 to 10) and shared decision-making (CollaboRATE scale score, binary score 1 versus 0) were compared by ethnicity with linear or logistic regression using generalized estimating equations, adjusted for prespecified demographics, clinical factors, and confounders. RESULTS Between April 2016 and September 2020, 320 surrogates for 257 patients with stroke enrolled (MA, 158; NHW, 85; and other, 14). Overall quality of communication score was better among surrogates of MA patients than NHW individuals after adjustment for demographics, stroke severity, and patient survival though the ethnic difference was attenuated (β, 0.47 [95% CI, -0.17 to 1.12]; P=0.15) after adjustment for trust in the medical profession and frequency of personal prayer. High CollaboRATE scale scores were more common among surrogates of MA patients than NHW individuals (unadjusted odds ratio, 1.75 [95% CI, 1.04-2.95]). This association persisted after adjustment for demographic and clinical factors though there was an interaction between patient age and ethnicity (P=0.04), suggesting that this difference was primarily in older patients. CONCLUSIONS Surrogate decision-makers of MA patients generally reported better outcomes on validated measures of quality of communication and shared decision-making than NHW individuals. Further study of outcomes among diverse populations of stroke surrogate decision-makers may help to identify sources of strength and resiliency that may be broadly applicable.
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Affiliation(s)
| | - Carmen Ortiz
- Stroke Program, University of Michigan Medical School, Ann Arbor, USA
| | - Rebecca J. Lank
- University of Iowa Carver College of Medicine, Iowa City, USA
| | - Guanghao Zhang
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, USA
| | - Xu Shi
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, USA
| | - Erin Case
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, USA
| | - Lewis B. Morgenstern
- Stroke Program, University of Michigan Medical School, Ann Arbor, USA
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, USA
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Lank RJ, Morgenstern LB, Ortiz C, Case E, Zahuranec DB. Barriers to Surrogate Application of Patient Values in Medical Decisions in Acute Stroke: Qualitative Study in a Biethnic Community. Neurocrit Care 2024; 40:215-224. [PMID: 37131090 PMCID: PMC10620105 DOI: 10.1007/s12028-023-01724-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/27/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND The objective of this study was to identify barriers to surrogate decision-maker application of patient values on life-sustaining treatments after stroke in Mexican American (MA) and non-Hispanic White (NHW) patients. METHODS We conducted a qualitative analysis of semistructured interviews with stroke patient surrogate decision-makers completed approximately 6 months after hospitalization. RESULTS Forty-two family surrogate decision-makers participated (median age: 54.5 years; female: 83%; patients were MA [60%] and NHW [36%], and 50% were deceased at the time of the interview). We identified three primary barriers to surrogates' applications of patient values and preferences when making decisions on life-sustaining treatments: (1) a minority of surrogates had no prior discussion of what the patient would want in the event of a serious medical illness, (2) surrogates struggled to apply prior known values and preferences to the actual decisions made, and (3) surrogates felt guilt or burden, often even in the setting of some knowledge of patient values or preferences. The first two barriers were seen to a similar degree in MA and NHW participants, though guilt or burden was reported more commonly among MA (28%) than NHW (13%) participants. Maintaining patient independence (e.g., ability to live at home, avoid a nursing home, make their own decisions) was the most important priority for decision-making for both MA and NHW participants; however, MA participants were more likely to list spending time with family as an important priority (24% vs. 7%). CONCLUSIONS Stroke surrogate decision-makers may benefit from (1) continued efforts to make advance care planning more common and more relevant, (2) assistance in how to apply their knowledge of patient values to actual treatment decisions, and (3) psychosocial support to reduce emotional burden. Barriers to surrogate application of patient values were generally similar in MA and NHW participants, though the possibility of greater guilt or burden among MA surrogates warrants further investigation and confirmation.
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Affiliation(s)
- Rebecca J Lank
- Stroke Program, University of Michigan, Ann Arbor, MI, USA
- University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Lewis B Morgenstern
- Stroke Program, University of Michigan, Ann Arbor, MI, USA
- Department of Epidemiology, School of Public Health, University of Michigan, Cardiovascular Center Rm 3392 1500 E Medical Center Dr., Ann Arbor, MI, USA
| | - Carmen Ortiz
- Stroke Program, University of Michigan, Ann Arbor, MI, USA
| | - Erin Case
- Stroke Program, University of Michigan, Ann Arbor, MI, USA
- Department of Epidemiology, School of Public Health, University of Michigan, Cardiovascular Center Rm 3392 1500 E Medical Center Dr., Ann Arbor, MI, USA
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Kim SH, Jang JH, Kim YZ, Kim KH, Nam TM. Recent Trends in the Withdrawal of Life-Sustaining Treatment in Patients with Acute Cerebrovascular Disease : 2017-2021. J Korean Neurosurg Soc 2024; 67:73-83. [PMID: 37454676 PMCID: PMC10788555 DOI: 10.3340/jkns.2023.0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/07/2023] [Accepted: 07/12/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVE The Act on Life-Sustaining Treatment (LST) decisions for end-of-life patients has been effective since February 2018. An increasing number of patients and their families want to withhold or withdraw from LST when medical futility is expected. This study aimed to investigate the status of the Act on LST decisions for patients with acute cerebrovascular disease at a single hospital. METHODS Between January 2017 and December 2021, 227 patients with acute cerebrovascular diseases, including hemorrhagic stroke (n=184) and ischemic stroke (n=43), died at the hospital. The study period was divided into the periods before and after the Act. RESULTS The duration of hospitalization decreased after the Act was implemented compared to before (15.9±16.1 vs. 11.2±18.6 days, p=0.127). The rate of obtaining consent for the LST plan tended to increase after the Act (139/183 [76.0%] vs. 27/44 [61.4%], p=0.077). Notably, none of the patients made an LST decision independently. Ventilator withdrawal was more frequently performed after the Act than before (52/183 [28.4%] vs. 0/44 [0%], p<0.001). Conversely, the rate of organ donation decreased after the Act was implemented (5/183 [2.7%] vs. 6/44 [13.6%], p=0.008). Refusal to undergo surgery was more common after the Act was implemented than before (87/149 [58.4%] vs. 15/41 [36.6%], p=0.021) among the 190 patients who required surgery. CONCLUSION After the Act on LST decisions was implemented, the rate of LST withdrawal increased in patients with acute cerebrovascular disease. However, the decision to withdraw LST was made by the patient's family rather than the patient themselves. After the execution of the Act, we also observed an increased rate of refusal to undergo surgery and a decreased rate of organ donation. The Act on LST decisions may reduce unnecessary treatments that prolong end-of-life processes without a curative effect. However, the widespread application of this law may also reduce beneficial treatments and contribute to a decline in organ donation.
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Affiliation(s)
- Seung Hwan Kim
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Ji Hwan Jang
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Young Zoon Kim
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Kyu Hong Kim
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Taek Min Nam
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
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9
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Zhang L, Albert GP, Pieters TA, McHugh DC, Asemota AO, Roberts DE, Hwang DY, Bender MT, George BP. Association of Do-Not-Resuscitate orders and in-hospital mortality among patients undergoing cranial neurosurgery. J Clin Neurosci 2023; 118:26-33. [PMID: 37857061 DOI: 10.1016/j.jocn.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 09/21/2023] [Accepted: 10/10/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Previous studies identified pre-existing DNR orders as a predictor of mortality after surgery. We sought to evaluate mortality of patients receiving cranial neurosurgery with DNR orders placed at the time of, or within 24 h of admission. METHODS We performed a retrospective cohort study using the California State Inpatient Database, January 2018 to December 2020. We used International Classification of Diseases, 10th Revision (ICD-10) codes to identify emergent hospitalizations with principal diagnosis of brain injury, including traumatic brain injury [TBI], ischemic stroke [IS], intracerebral hemorrhage [ICH], subarachnoid hemorrhage [SAH], or malignant brain tumor [mBT]. We used procedure and Diagnosis Related Group codes to identify cranial neurosurgery. Patients with DNR were one-to-one matched to non-DNR controls based on diagnosis (exact matching), age, sex, Elixhauser comorbidity index, and organ failure (coarsened matching). The primary outcome was inpatient mortality. RESULTS In California, 30,384 patients underwent cranial neurosurgery, 2018-2020 (n = 3,112, 10% DNR). DNR patients were older, more often female, more often White, with greater comorbidity and organ system dysfunction. There were 2,505 patients with DNR orders 1:1 matched to controls. Patients with DNR had greater inpatient mortality (56% vs. 23%, p < 0.001; Hazard Ratio 3.11, 95% CI 2.50-3.86), received tracheostomy (Odds Ratio [OR] 0.37, 95% CI 0.24-0.57) and gastrostomy less (OR 0.48, 95% CI 0.39-0.58) compared to controls. Multivariable analysis of the unmatched cohort demonstrated similar results. CONCLUSION Patients undergoing cranial neurosurgery with early or pre-existing DNR have high inpatient mortality compared to clinically similar non-DNR patients; 1 in 2 died during their hospitalization.
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Affiliation(s)
- Lan Zhang
- University of Rochester Medical Center, Departments of Neurology and Neurosurgery, Rochester, NY, United States
| | - George P Albert
- University of Rochester Medical Center, Departments of Neurology and Neurosurgery, Rochester, NY, United States
| | - Thomas A Pieters
- University of Massachusetts Memorial Health, Department of Neurosurgery, Worcester, MA, United States
| | - Daryl C McHugh
- University of Rochester Medical Center, Departments of Neurology and Neurosurgery, Rochester, NY, United States
| | - Anthony O Asemota
- University of Texas Southwestern Medical Center, Department of Neurosurgery, Dallas, TX, United States
| | - Debra E Roberts
- University of Rochester Medical Center, Departments of Neurology and Neurosurgery, Rochester, NY, United States
| | - David Y Hwang
- University of North Carolina School of Medicine, Department of Neurology, Chapel Hill, NC, United States
| | - Matthew T Bender
- University of Rochester Medical Center, Departments of Neurology and Neurosurgery, Rochester, NY, United States
| | - Benjamin P George
- University of Rochester Medical Center, Departments of Neurology and Neurosurgery, Rochester, NY, United States.
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Steinberg A, Fischhoff B. Cognitive Biases and Shared Decision Making in Acute Brain Injury. Semin Neurol 2023; 43:735-743. [PMID: 37793424 DOI: 10.1055/s-0043-1775596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Many patients hospitalized after severe acute brain injury are comatose and require life-sustaining therapies. Some of these patients make favorable recoveries with continued intensive care, while others do not. In addition to providing medical care, clinicians must guide surrogate decision makers through high-stakes, emotionally charged decisions about whether to continue life-sustaining therapies. These consultations require clinicians first to assess a patient's likelihood of recovery given continued life-sustaining therapies (i.e., prognosticate), then to communicate that prediction to surrogates, and, finally, to elicit and interpret the patient's preferences. At each step, both clinicians and surrogates are vulnerable to flawed decision making. Clinicians can be imprecise, biased, and overconfident when prognosticating after brain injury. Surrogates can misperceive the choice and misunderstand or misrepresent a patient's wishes, which may never have been communicated clearly. These biases can undermine the ability to reach choices congruent with patients' preferences through shared decision making (SDM). Decision science has extensively studied these biases. In this article, we apply that research to improving SDM for patients who are comatose after acute brain injury. After introducing SDM and the medical context, we describe principal decision science results as they relate to neurologic prognostication and end-of-life decisions, by both clinicians and surrogates. Based on research regarding general processes that can produce imprecise, biased, and overconfident prognoses, we propose interventions that could improve SDM, supporting clinicians and surrogates in making these challenging decisions.
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Affiliation(s)
- Alexis Steinberg
- Department of Critical Care Medicine, Neurology, and Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Baruch Fischhoff
- Department of Engineering and Public Policy, Institute for Politics and Strategy, Carnegie Mellon University, Pittsburgh, Pennsylvania
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Hoda W, Bharati SJ. Palliative care in neurology patients. Int Anesthesiol Clin 2023; 61:73-79. [PMID: 37249177 DOI: 10.1097/aia.0000000000000403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Wasimul Hoda
- Department of Superspeciality Anaesthesia, Rajendra Institute of Medical Sciences (RIMS), Ranchi, Jharkhand, India
| | - Sachidanand J Bharati
- Department of Onco-Anaesthesia & Palliative Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, Delhi, India
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Greenway MRF, Robinson MT. Palliative care approaches to acute stroke in the hospital setting. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:13-27. [PMID: 36599505 DOI: 10.1016/b978-0-12-824535-4.00010-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Stroke is a prevalent neurologic condition that portends a high risk of morbidity and mortality such that patients impacted by stroke and their caregivers can benefit from palliative care at the time of diagnosis and throughout the disease trajectory. Clinicians who care for stroke patients should be adept at establishing rapport with patients and caregivers, delivering serious news, responding to emotions, discussing prognosis, and establishing goals of care efficiently in an acute stroke setting. Aggressive stroke care can be integrated with a palliative approach to care that involves aligning the available treatment options with a patient's values and goals of care. Reassessing the goals throughout the hospitalization provides an opportunity for continued shared decision-making about the intensity of poststroke interventions. The palliative needs for stroke patients may increase over time depending on the severity of disease, poststroke complications, stroke-related symptoms, and treatment intensity preferences. If the decision is made to transition the focus of care to comfort, the support of an interdisciplinary palliative care or hospice team can be beneficial to the patient, family members, and surrogate decision makers.
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Affiliation(s)
| | - Maisha T Robinson
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States; Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, United States.
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Non-Neurological Complications after Mechanical Thrombectomy for Acute Ischemic Stroke: A Retrospective Single-Center Study. Crit Care Res Pract 2022; 2022:5509081. [PMID: 36590829 PMCID: PMC9803559 DOI: 10.1155/2022/5509081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 11/26/2022] [Accepted: 12/03/2022] [Indexed: 12/25/2022] Open
Abstract
Introduction The global burden of stroke is high and mechanical thrombectomy is the cornerstone of the treatment. Incidences of acute non-neurological-complications are poorly described. Improve knowledge about these complications may allow to better prevent, detect and/or manage them. The aim is to identify risk markers of death or poor evolution. Method We conducted a retrospective single-center study to analyzed the incidence of non-neurologicalcomplications after mechanical thrombectomy in acute ischemic stroke. Patients who had experienced a stroke and undergone thrombectomy were identified using a registry in which we prospectively collected data from each patient admitted to our hospital with a diagnosis of stroke. Quantitative and qualitative variables were analyses. The association between studied variables and hospital death was assessed using simple logistic regression models. Result 361 patients were reviewed but 16 were excluded due to a lack of medical information. Between 2012 and 2019, 345 patients were included. The median admission NIHSS score was 15. Seven percent of the patients died in the ICU. The following independent risk markers of death in the ICU were identified by logistic regression: respiratory complication, hypotension, infectious complication, and hyperglycemia. Conclusion In this large retrospective study of stroke, respiratory complications and pulmonary infections represented the most important non-neurological adverse events encountered in the ICU and associated with a risk of death.
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Shlobin NA, Clark JR, Campbell JM, Bernstein M, Jahromi BS, Potts MB. Ethical Considerations in Surgical Decompression for Stroke. Stroke 2022; 53:2673-2682. [PMID: 35703095 DOI: 10.1161/strokeaha.121.038493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stroke is a major cause of morbidity and mortality. Neurosurgical decompression is often considered for the treatment of malignant infarcts and intraparenchymal hemorrhages, but this treatment can be frought with ethical dilemmas. In this article, the authors outline the primary principles of bioethics and their application to stroke care, provide an overview of key ethical issues and special situations in the neurosurgical management of stroke, and highlight methods to improve ethical decision-making for patients with stroke. Understanding these ethical principles is essential for stroke care teams to deliver appropriate, timely, and ethical care to patients with stroke.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. (N.A.S., J.R.C., B.S.J., M.B.P.)
| | - Jeffrey R Clark
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. (N.A.S., J.R.C., B.S.J., M.B.P.)
| | | | - Mark Bernstein
- Division of Neurosurgery, Department of Surgery, University of Toronto, University Health Network, Ontario, Canada (M.B.)
| | - Babak S Jahromi
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. (N.A.S., J.R.C., B.S.J., M.B.P.).,Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL. (B.S.J., M.B.P.).,Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL. (B.S.J., M.B.P.)
| | - Matthew B Potts
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. (N.A.S., J.R.C., B.S.J., M.B.P.).,Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL. (B.S.J., M.B.P.).,Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL. (B.S.J., M.B.P.)
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Pérez de la Ossa N, Abilleira S, Jovin TG, García-Tornel Á, Jimenez X, Urra X, Cardona P, Cocho D, Purroy F, Serena J, San Román Manzanera L, Vivanco-Hidalgo RM, Salvat-Plana M, Chamorro A, Gallofré M, Molina CA, Cobo E, Davalos A, Ribo M. Effect of Direct Transportation to Thrombectomy-Capable Center vs Local Stroke Center on Neurological Outcomes in Patients With Suspected Large-Vessel Occlusion Stroke in Nonurban Areas: The RACECAT Randomized Clinical Trial. JAMA 2022; 327:1782-1794. [PMID: 35510397 PMCID: PMC9073661 DOI: 10.1001/jama.2022.4404] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE In nonurban areas with limited access to thrombectomy-capable centers, optimal prehospital transport strategies in patients with suspected large-vessel occlusion stroke are unknown. OBJECTIVE To determine whether, in nonurban areas, direct transport to a thrombectomy-capable center is beneficial compared with transport to the closest local stroke center. DESIGN, SETTING, AND PARTICIPANTS Multicenter, population-based, cluster-randomized trial including 1401 patients with suspected acute large-vessel occlusion stroke attended by emergency medical services in areas where the closest local stroke center was not capable of performing thrombectomy in Catalonia, Spain, between March 2017 and June 2020. The date of final follow-up was September 2020. INTERVENTIONS Transportation to a thrombectomy-capable center (n = 688) or the closest local stroke center (n = 713). MAIN OUTCOMES AND MEASURES The primary outcome was disability at 90 days based on the modified Rankin Scale (mRS; scores range from 0 [no symptoms] to 6 [death]) in the target population of patients with ischemic stroke. There were 11 secondary outcomes, including rate of intravenous tissue plasminogen activator administration and thrombectomy in the target population and 90-day mortality in the safety population of all randomized patients. RESULTS Enrollment was halted for futility following a second interim analysis. The 1401 enrolled patients were included in the safety analysis, of whom 1369 (98%) consented to participate and were included in the as-randomized analysis (56% men; median age, 75 [IQR, 65-83] years; median National Institutes of Health Stroke Scale score, 17 [IQR, 11-21]); 949 (69%) comprised the target ischemic stroke population included in the primary analysis. For the primary outcome in the target population, median mRS score was 3 (IQR, 2-5) vs 3 (IQR, 2-5) (adjusted common odds ratio [OR], 1.03; 95% CI, 0.82-1.29). Of 11 reported secondary outcomes, 8 showed no significant difference. Compared with patients first transported to local stroke centers, patients directly transported to thrombectomy-capable centers had significantly lower odds of receiving intravenous tissue plasminogen activator (in the target population, 229/482 [47.5%] vs 282/467 [60.4%]; OR, 0.59; 95% CI, 0.45-0.76) and significantly higher odds of receiving thrombectomy (in the target population, 235/482 [48.8%] vs 184/467 [39.4%]; OR, 1.46; 95% CI, 1.13-1.89). Mortality at 90 days in the safety population was not significantly different between groups (188/688 [27.3%] vs 194/713 [27.2%]; adjusted hazard ratio, 0.97; 95% CI, 0.79-1.18). CONCLUSIONS AND RELEVANCE In nonurban areas in Catalonia, Spain, there was no significant difference in 90-day neurological outcomes between transportation to a local stroke center vs a thrombectomy-capable referral center in patients with suspected large-vessel occlusion stroke. These findings require replication in other settings. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02795962.
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Affiliation(s)
- Natalia Pérez de la Ossa
- Department of Neurology, Stroke Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Sònia Abilleira
- Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Tudor G. Jovin
- Neurological Institute, Cooper University Hospital, Camden, New Jersey
| | - Álvaro García-Tornel
- Department of Neurology, Stroke Unit, Hospital Universitari Vall d’Hebrón, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Xavier Jimenez
- Emergency Medical Services of Catalonia, Barcelona, Spain
| | - Xabier Urra
- Department of Neurology, Stroke Unit, Hospital Clínic, Barcelona, Spain
| | - Pere Cardona
- Department of Neurology, Stroke Unit, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Dolores Cocho
- Neurology Department, Hospital Granollers, Granollers, Spain
| | - Francisco Purroy
- Department of Neurology, Stroke Unit, Hospital Arnau de Vilanova, Lleida, Spain
| | - Joaquin Serena
- Department of Neurology, Stroke Unit, Hospital Josep Trueta, Girona, Spain
| | | | - Rosa Maria Vivanco-Hidalgo
- Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Mercè Salvat-Plana
- Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Angel Chamorro
- Department of Neurology, Stroke Unit, Hospital Clínic, Barcelona, Spain
| | - Miquel Gallofré
- Stroke Programme, Catalan Health Department, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - Carlos A. Molina
- Department of Neurology, Stroke Unit, Hospital Universitari Vall d’Hebrón, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Erik Cobo
- Statistics and Operational Research, Universitat Politècnica de Catalunya, Barcelona, Spain
| | - Antoni Davalos
- Department of Neurology, Stroke Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Marc Ribo
- Department of Neurology, Stroke Unit, Hospital Universitari Vall d’Hebrón, Universitat Autonoma de Barcelona, Barcelona, Spain
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16
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De Georgia M. The intersection of prognostication and code status in patients with severe brain injury. J Crit Care 2022; 69:153997. [PMID: 35114602 DOI: 10.1016/j.jcrc.2022.153997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 12/27/2021] [Accepted: 01/18/2022] [Indexed: 11/16/2022]
Abstract
Accurately estimating the prognosis of brain injury patients can be difficult, especially early in their course. Prognostication is important because it largely determines the care level we provide, from aggressive treatment for patients we predict could have a good outcome to withdrawal of treatment for those we expect will have a poor outcome. Accurate prognostication is required for ethical decision-making. However, several studies have shown that prognostication is frequently inaccurate and variable. Overly optimistic prognostication can lead to false hope and futile care. Overly pessimistic prognostication can lead to therapeutic nihilism. Overlapping is the powerful effect that cognitive biases, in particular code status, can play in shaping our perceptions and the care level we provide. The presence of Do Not Resuscitate orders has been shown to be associated with increased mortality. Based on a comprehensive search of peer-reviewed journals using a wide range of key terms, including prognostication, critical illness, brain injury, cognitive bias, and code status, the following is a review of prognostic accuracy and the effect of code status on outcome. Because withdrawal of treatment is the most common cause of death in the ICU, a clearer understanding of this intersection of prognostication and code status is needed.
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Affiliation(s)
- Michael De Georgia
- University Hospitals Cleveland Medical Center, Cleveland, OH, United States of America.
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17
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Brown K, El Husseini N, Grimley R, Ranta A, Kass-Hout T, Kaplan S, Kaufman BG. Alternative Payment Models and Associations With Stroke Outcomes, Spending, and Service Utilization: A Systematic Review. Stroke 2021; 53:268-278. [PMID: 34727742 DOI: 10.1161/strokeaha.121.033983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Stroke contributes an estimated $28 billion to US health care costs annually, and alternative payment models aim to improve outcomes and lower spending over fee-for-service by aligning economic incentives with high value care. This systematic review evaluates historical and current evidence regarding the impacts of alternative payment models on stroke outcomes, spending, and utilization. Included studies evaluated alternative payment models in 4 categories: pay-for-performance (n=3), prospective payments (n=14), shared savings (n=5), and capitated payments (n=14). Pay-for-performance models were not consistently associated with improvements in clinical quality indicators of stroke prevention. Studies of prospective payments suggested that poststroke spending was shifted between care settings without consistent reductions in total spending. Shared savings programs, such as US Medicare accountable care organizations and bundled payments, were generally associated with null or decreased spending and service utilization and with no differences in clinical outcomes following stroke hospitalizations. Capitated payment models were associated with inconsistent effects on poststroke spending and utilization and some worsened clinical outcomes. Shared savings models that incentivize coordination of care across care settings show potential for lowering spending with no evidence for worsened clinical outcomes; however, few studies evaluated clinical or patient-reported outcomes, and the evidence, largely US-based, may not generalize to other settings.
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Affiliation(s)
- Kelby Brown
- Duke University School of Medicine, Durham, NC (K.B., N.E.H., S.K.).,Margolis Center for Health Policy Duke University, Durham, NC (K.B., B.G.K.)
| | - Nada El Husseini
- Duke University School of Medicine, Durham, NC (K.B., N.E.H., S.K.).,Department of Neurology, Duke University, Durham, NC (N.E.H.)
| | - Rohan Grimley
- School of Medicine, Griffith University, Birtinya, Queensland, Australia (R.G.)
| | - Annemarei Ranta
- University of Otago School of Medicine, Wellington, New Zealand (A.R.)
| | - Tareq Kass-Hout
- Department of Neurology, The University of Chicago Pritzker School of Medicine, Chicago, IL (T.K.-H.)
| | - Samantha Kaplan
- Duke University School of Medicine, Durham, NC (K.B., N.E.H., S.K.)
| | - Brystana G Kaufman
- Margolis Center for Health Policy Duke University, Durham, NC (K.B., B.G.K.).,Population Health Sciences, Duke University School of Medicine, Durham NC (B.G.K.).,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, NC (B.G.K.)
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18
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Ruiz A, Longstreth WT, Tirschwell DL, Creutzfeldt CJ. What defines success following reperfusion after mechanical thrombectomy for older patients in the real world? J Neurol 2021; 269:2214-2218. [PMID: 34674008 DOI: 10.1007/s00415-021-10859-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 10/15/2021] [Accepted: 10/18/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Amber Ruiz
- Department of Neurology, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359775, Seattle, WA, 98104, USA
| | - W T Longstreth
- Department of Neurology, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359775, Seattle, WA, 98104, USA
| | - David L Tirschwell
- Department of Neurology, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359775, Seattle, WA, 98104, USA
| | - Claire J Creutzfeldt
- Department of Neurology, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359775, Seattle, WA, 98104, USA.
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19
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Riesinger R, Altmann K, Lorenzl S. Involvement of Specialist Palliative Care in a Stroke Unit in Austria-Challenges for Families and Stroke Teams. Front Neurol 2021; 12:683624. [PMID: 34630274 PMCID: PMC8492896 DOI: 10.3389/fneur.2021.683624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 08/09/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose: Severe stroke poses vast challenges. Appropriate goals of care according to individual preferences and values have to be developed under time restrictions—often impeded by limited ability to communicate and the need for decisions by surrogates. The aim of our study was to explore the decision-making process and the involvement of specialist palliative care in the acute phase of severe stroke. Methods: Twenty patients suffering from severe ischemic stroke treated in an Austrian acute inpatient stroke unit were included in a prospective study. Their families were interviewed with a questionnaire (FS-ICU 24), which covered satisfaction with care and decision-making. With a second questionnaire, decision-making processes within the stroke team were investigated. Results: A palliative approach and early integration of specialist palliative care in severe ischemic stroke results in individualized therapeutic goals, including withholding therapeutic or life-sustaining measures, especially in patients with pre-existing illness. Conclusions: Family members benefit from understandable and consistent information, emotional support, and a professional team identifying their needs. Stroke unit professionals need skills as well as knowledge and strategies in order to make decisions and provide treatment at the end-of-life, when there may be ethical or legal issues. Close cooperation with specialist palliative care services supports both treatment teams and families with communication and decision-making for patients with severe ischemic stroke.
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Affiliation(s)
- Renate Riesinger
- Department of Palliative Care, Hospital Barmherzige Schwestern, Ried im Innkreis, Austria
| | - Klaus Altmann
- Department of Neurology, Hospital Barmherzige Schwestern, Ried im Innkreis, Austria
| | - Stefan Lorenzl
- Institute of Nursing Science and Practice, Paracelsus Medical University, Salzburg, Austria.,Ludwig-Maximilians-University, Munich, Germany.,Department of Neurology, Klinikum Agatharied, Hausham, Germany
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20
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Rutz Voumard R, Dugger KM, Kiker WA, Barber J, Borasio GD, Curtis JR, Jox RJ, Creutzfeldt CJ. Goal-Concordant Care After Severe Acute Brain Injury. Front Neurol 2021; 12:710783. [PMID: 34603183 PMCID: PMC8485029 DOI: 10.3389/fneur.2021.710783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/13/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Patients with severe acute brain injury (SABI) lack decision-making capacity, calling on families and clinicians to make goal-concordant decisions, aligning treatment with patient's presumed goals-of-care. Using the family perspective, this study aimed to (1) compare patient's goals-of-care with the care they were receiving in the acute setting, (2) identify patient and family characteristics associated with goal-concordant care, and (3) assess goals-of-care 6 months after SABI. Methods: Our cohort included patients with SABI in our Neuro-ICU and a Glasgow Coma Scale Score <12 after day 2. Socio-demographic and clinical characteristics were collected through surveys and chart review. At enrollment and again at 6 months, each family was asked if the patient would prefer medical care focused on extending life vs. care focused on comfort and quality of life, and what care the patient is currently receiving. We used multivariate regression to examine the characteristics associated with (a) prioritized goals (comfort/extending life/unsure) and (b) goal concordance. Results: Among 214 patients, families reported patients' goals-of-care to be extending life in 118 cases (55%), comfort in 71 (33%), and unsure for 25 (12%), while care received focused on extending life in 165 cases (77%), on comfort in 23 (11%) and families were unsure in 16 (7%). In a nominal regression model, prioritizing comfort over extending life was significantly associated with being non-Hispanic White and having worse clinical severity. Most patients who prioritized extending life were receiving family-reported goal-concordant care (88%, 104/118), while most of those who prioritized comfort were receiving goal-discordant care (73%, 52/71). The only independent association for goal concordance was having a presumed goal of extending life at enrollment (OR 23.62, 95% CI 10.19–54.77). Among survivors at 6 months, 1 in 4 family members were unsure about the patient's goals-of-care. Conclusion: A substantial proportion of patients are receiving unwanted aggressive care in the acute setting after SABI. In the first days, such aggressive care might be justified by prognostic uncertainty. The high rate of families unsure of patient's goals-of-care at 6 months suggests an important need for periodic re-evaluation of prognosis and goals-of-care in the post-acute setting.
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Affiliation(s)
- Rachel Rutz Voumard
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, United States.,Department of Palliative and Supportive Care, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Kaley M Dugger
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, United States
| | - Whitney A Kiker
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, United States.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, United States
| | - Jason Barber
- Department of Neurosurgery, Harborview Medical Center, University of Washington, Seattle, WA, United States
| | - Gian Domenico Borasio
- Department of Palliative and Supportive Care, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - J Randall Curtis
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, United States.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, United States
| | - Ralf J Jox
- Department of Palliative and Supportive Care, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland.,Institute of Humanities in Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Claire J Creutzfeldt
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, United States.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, United States
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21
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Levy SA, Pedowitz E, Stein LK, Dhamoon MS. Healthcare Utilization for Stroke Patients at the End of Life: Nationally Representative Data. J Stroke Cerebrovasc Dis 2021; 30:106008. [PMID: 34330019 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 05/20/2021] [Accepted: 07/10/2021] [Indexed: 10/20/2022] Open
Abstract
Objectives Stroke and post-stroke complications are associated with high morbidity, mortality, and cost. Our objective was to examine healthcare utilization and hospice enrollment for stroke patients at the end of life. Materials and methods The 2014 Nationwide Readmissions Database is a national database of > 14 million admissions. We used validated ICD-9 codes to identify fatal ischemic stroke, summarized demographics and hospitalization characteristics, and examined healthcare use within 30 days before fatal stroke admission. We used de-identified 2014 Medicare hospice data to identify stroke and non-stroke patients admitted to hospice. Results Among IS admissions in 2014 (n = 472,969), 22652 (4.8%) had in-hospital death. 28.2% with fatal IS had two or more hospitalizations in 2014. Among those with fatal IS admission, 13.0% were admitted with cerebrovascular disease within 30 days of fatal IS admission. Half of stroke patients discharged to hospice from the Medicare dataset were hospitalized with cerebrovascular disease within the thirty days prior to hospice enrollment. Within the study year, 6.9% of hospice enrollees had one or more emergency room visits, 31.7% had one or more inpatient encounters, and 5.2% had one or more nursing facility encounters (compared to 21.4%, 70.6%, and 27.2% respectively in the 30-day period prior to enrollment). Conclusions High rates of readmission prior to fatal stroke may indicate opportunity for improvement in acute stroke management, secondary prevention, and palliative care involvement as encouraged by AHA/ASA guidelines. For patients who are expected to survive 6 months or less, hospice may offer goal-concordant services for patients and caregivers who desire comfort-focused care.
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Affiliation(s)
- Sarah A Levy
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, Annenberg 301B, New York 10029, United States.
| | - Elizabeth Pedowitz
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, United States.
| | - Laura K Stein
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, Annenberg 301B, New York 10029, United States.
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave, Annenberg 301B, New York 10029, United States.
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22
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Lim JX, Vedicherla SV, Chan SKS, Primalani NK, Tan AJL, Saffari SE, Lee L. Decompressive craniectomy for internal carotid artery and middle carotid artery infarctions: a long-term comparative outcome study. Neurosurg Focus 2021; 51:E10. [PMID: 34198256 DOI: 10.3171/2021.4.focus21123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Malignant internal carotid artery (ICA) infarction is an entirely different disease entity when compared with middle cerebral artery (MCA) infarction. Because of an increased area of infarction, it is assumed to have a poorer prognosis; however, this has never been adequately investigated. Decompressive craniectomy (DC) for malignant MCA infarction has been shown to improve mortality rates in several randomized controlled trials. Conversely, aggressive surgical decompression for ICA infarction has not been recommended. The authors sought to compare the functional outcomes and survival between patients with ICA infarctions and those with MCA infarctions after DC in the largest series to date to investigate this assumption. METHODS A multicenter retrospective review of 154 consecutive DCs for large territory cerebral infarctions performed from 2005 to 2020 were analyzed. Patients were divided into ICA and MCA groups depending on the territory of infarction. Variables, including age, sex, medical comorbidities, laterality of the infarction, preoperative neurological status, primary stroke treatment, and the time from stroke onset to DC, were recorded. Univariable and multivariable analyses were performed for the clinical exposures for functional outcomes (modified Rankin Scale [mRS] score) on discharge and at the 1- and 6-month follow-ups, and for mortality, both inpatient and at the 1-year follow-up. A favorable mRS score was defined as 0-2. RESULTS There were 67 patients (43.5%) and 87 patients (56.5%) in the ICA and MCA groups, respectively. Univariable analysis showed that the ICA group had a comparably favorable mRS (OR 0.15 [95% CI 0.18-1.21], p = 0.077). Inpatient mortality (OR 1.79 [95% CI 0.79-4.03], p = 0.16) and 1-year mortality (OR 2.07 [95% CI 0.98-4.37], p = 0.054) were comparable between the groups. After adjustment, a favorable mRS score at 6 months (OR 0.17 [95% CI 0.018-1.59], p = 0.12), inpatient mortality (OR 1.02 [95% CI 0.29-3.57], p = 0.97), and 1-year mortality (OR 0.94 [95% CI 0.41-2.69], p = 0.88) were similar in both groups. The overall survival, plotted using the Cox proportional hazard regression, did not show a significant difference between the ICA and MCA groups (HR 0.581). CONCLUSIONS Unlike previous smaller studies, this study found that patients with malignant ICA infarction had a functional outcome and survival that was similar to those with MCA infarction after DC. Therefore, DC can be offered for malignant ICA infarction for life-saving purposes with limited functional recovery.
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Affiliation(s)
- Jia Xu Lim
- 1Department of Neurosurgery, National Neuroscience Institute; and
| | | | | | | | - Audrey J L Tan
- 1Department of Neurosurgery, National Neuroscience Institute; and
| | | | - Lester Lee
- 1Department of Neurosurgery, National Neuroscience Institute; and.,3Duke-NUS Medical School, Singapore
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23
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Adapting to a New Normal After Severe Acute Brain Injury: An Observational Cohort Using a Sequential Explanatory Design. Crit Care Med 2021; 49:1322-1332. [PMID: 33730742 PMCID: PMC8282680 DOI: 10.1097/ccm.0000000000004947] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Treatment decisions following severe acute brain injury need to consider patients' goals-of-care and long-term outcomes. Using family members as respondents, we aimed to assess patients' goals-of-care in the ICU and explore the impact of adaptation on survivors who did not reach the level of recovery initially considered acceptable. DESIGN Prospective, observational, mixed-methods cohort study. SETTING Comprehensive stroke and level 1 trauma center in Pacific Northwest United States. PARTICIPANTS Family members of patients with severe acute brain injury in an ICU for greater than 2 days and Glasgow Coma Scale score less than 12. MEASUREMENTS AND MAIN RESULTS At enrollment, we asked what level of physical and cognitive recovery the patient would find acceptable. At 6 months, we assessed level of recovery through family surveys and chart review. Families of patients whose outcome was below that considered acceptable were invited for semistructured interviews, examined with content analysis. RESULTS For 184 patients, most family members set patients' minimally acceptable cognitive recovery at "able to think and communicate" or better (82%) and physical recovery at independence or better (66%). Among 170 patients with known 6-month outcome, 40% had died in hospital. Of 102 survivors, 33% were able to think and communicate, 13% were independent, and 10% died after discharge. Among survivors whose family member had set minimally acceptable cognitive function at "able to think and communicate," 64% survived below that level; for those with minimally acceptable physical function at independence, 80% survived below that. Qualitative analysis revealed two key themes: families struggled to adapt to a new, yet uncertain, normal and asked for support and guidance with ongoing treatment decisions. CONCLUSIONS AND RELEVANCE Six months after severe acute brain injury, most patients survived to a state their families initially thought would not be acceptable. Survivors and their families need more support and guidance as they adapt to a new normal and struggle with persistent uncertainty.
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24
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Pires Monteiro S, Voogd E, Muzzi L, De Vecchis G, Mossink B, Levers M, Hassink G, Van Putten M, Le Feber J, Hofmeijer J, Frega M. Neuroprotective effect of hypoxic preconditioning and neuronal activation in a in vitro human model of the ischemic penumbra. J Neural Eng 2021; 18:036016. [PMID: 33724235 DOI: 10.1088/1741-2552/abe68a] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE In ischemic stroke, treatments to protect neurons from irreversible damage are urgently needed. Studies in animal models have shown that neuroprotective treatments targeting neuronal silencing improve brain recovery, but in clinical trials none of these were effective in patients. This failure of translation poses doubts on the real efficacy of treatments tested and on the validity of animal models for human stroke. Here, we established a human neuronal model of the ischemic penumbra by using human induced pluripotent stem cells and we provided an in-depth characterization of neuronal responses to hypoxia and treatment strategies at the network level. APPROACH We generated neurons from induced pluripotent stem cells derived from healthy donor and we cultured them on micro-electrode arrays. We measured the electrophysiological activity of human neuronal networks under controlled hypoxic conditions. We tested the effect of different treatment strategies on neuronal network functionality. MAIN RESULTS Human neuronal networks are vulnerable to hypoxia reflected by a decrease in activity and synchronicity under low oxygen conditions. We observe that full, partial or absent recovery depend on the timing of re-oxygenation and we provide a critical time threshold that, if crossed, is associated with irreversible impairments. We found that hypoxic preconditioning improves resistance to a second hypoxic insult. Finally, in contrast to previously tested, ineffective treatments, we show that stimulatory treatments counteracting neuronal silencing during hypoxia, such as optogenetic stimulation, are neuroprotective. SIGNIFICANCE We presented a human neuronal model of the ischemic penumbra and we provided insights that may offer the basis for novel therapeutic approaches for patients after stroke. The use of human neurons might improve drug discovery and translation of findings to patients and might open new perspectives for personalized investigations.
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Affiliation(s)
- Sara Pires Monteiro
- Department of Clinical Neurophysiology, University of Twente, 7522 NB Enschede, The Netherlands
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25
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Lank RJ, Shafie-Khorassani F, Zhang X, Ortiz C, Kim S, Case E, Creutzfeldt CJ, Morgenstern LB, Zahuranec DB. Advance Care Planning and Transitions to Comfort Measures after Stroke. J Palliat Med 2020; 24:1191-1196. [PMID: 33370167 DOI: 10.1089/jpm.2020.0587] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background: Advance care planning (ACP) is recommended to align treatment with patient goals, although there has been little study of the impact of ACP on in-hospital stroke treatment. Objective: To examine the association between ACP and transitions to comfort measures after stroke. Design: Prospective cohort study. Setting/Subjects: Hospitalized stroke patients 45 years and older and surrogate decision makers from a population-based study in Corpus Christi, TX. Measurements: Surrogates were interviewed to assess presence of patient prestroke ACP, categorized as none, informal conversations only, or formal documentation. Patient records were reviewed for time from admission to transition to comfort measures only (CMO) (defined as in-hospital comfort measures or discharge with hospice services). Cox proportional-hazards models assessed the relationship between ACP and time to transition to CMO. Results: Of 148 included stroke patients, 37% transitioned to CMO (median time five days). For ACP, 44% had only informal conversations, 38% had formal documentation (98% of which also reported informal conversations), and 18% had neither. After adjustment for age, severity, and baseline disability, informal conversations alone (hazard ratio [HR] 3.55; 95% confidence interval [CI]: 1.35-9.33) and formal documentation (HR 2.85; 95% CI: 1.05-7.72) were associated with earlier transition to comfort measures compared to no ACP. There was no difference between formal documentation and informal conversations on time to comfort measures (HR 0.80, 95% CI: 0.40-1.63). Conclusions: There was no additional association of formal ACP documentation over informal conversations on time to transition to comfort measures after stroke. Further study of formal ACP is warranted.
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Affiliation(s)
- Rebecca J Lank
- Stroke Program, University of Michigan, Ann Arbor, Michigan, USA
| | - Fatema Shafie-Khorassani
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Xingyu Zhang
- Department of Systems, Populations and Leadership, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
| | - Carmen Ortiz
- Stroke Program, University of Michigan, Ann Arbor, Michigan, USA
| | - Sehee Kim
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Erin Case
- Department of Epidemiology, School of Public Health University of Michigan, Ann Arbor, Michigan, USA
| | | | - Lewis B Morgenstern
- Stroke Program, University of Michigan, Ann Arbor, Michigan, USA.,Department of Epidemiology, School of Public Health University of Michigan, Ann Arbor, Michigan, USA
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Yip HK, Lee MS, Li YC, Shao PL, Chiang JY, Sung PH, Yang CH, Chen KH. Dipeptidyl Peptidase-4 deficiency effectively protects the brain and neurological function in rodent after acute Hemorrhagic Stroke. Int J Biol Sci 2020; 16:3116-3132. [PMID: 33162819 PMCID: PMC7645992 DOI: 10.7150/ijbs.42677] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 03/05/2020] [Indexed: 11/05/2022] Open
Abstract
This study tested the hypothesis that abrogated dipeptidyl peptidase-4 (DPP4) activity played a crucial role on reducing stroke volume and preserving neurological function in rodent after acute hemorrhagic stroke (AHS). Animals (n=6/each group) were categorized into group 1 (sham-control of F344 rat), group 2 (sham-control of DPP4-deficiency rat), group 3 [AHS by right cerebral injection of autologous blood (100 µL) in F344 rat], group 4 (AHS + sitagliptin/600 mg/kg 3 h prior to and at 3 h then once per day after AHS) and group 5 (AHS in DPP4-deficiency rat). The results of corner test showed the neurological function was significantly improved from days 3, 7, and 14 in groups 4 and 5 than in group 3 (all p<0.001). By days 1 and 14 after AHS procedure, the circulating levels of SDF-1α and GLP-1 were significantly increased from groups 1/2 to group 5 (all p<0.001), whereas circulating DPP4 activity was significantly increased in group 3 than other groups (all p<0.001). The brain ischemic area (BIA) was highest in group 3, lowest in groups 1/2 and significantly lower in group 5 than in group 4 (all p<0.0001). The protein expressions of oxidative-stress/inflammatory/apoptotic/cell-proliferation signaling, and the cellular expressions of inflammatory/DNA-damaged biomarkers exhibited a similar pattern to BIA among the groups (all p<0.01). In conclusion, deprivation of DPP4 activity protected the brain from AHS damage and preserved neurological function.
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Affiliation(s)
- Hon-Kan Yip
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.,Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan.,Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan.,Department of Medical Research, China Medical University Hospital, China Medical University, Taichung 40402, Taiwan.,Department of Nursing, Asia University, Taichung, 41354, Taiwan.,Division of Cardiology, Department of Internal Medicine, Xiamen Chang Gung Hospital, Xiamen 361028, Fujian, China
| | - Mel S Lee
- Department of Orthopedics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Yi-Chen Li
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Pei-Lin Shao
- Department of Nursing, Asia University, Taichung, 41354, Taiwan
| | - John Y Chiang
- Department of Computer Science and Engineering, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Pei-Hsun Sung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Chien-Hui Yang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Kuan-Hung Chen
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
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Anderson N, Janarious A, Liu S, Flanagan LA, Stradling D, Yu W. Language disparity is not a significant barrier for time-sensitive care of acute ischemic stroke. BMC Neurol 2020; 20:363. [PMID: 33008325 PMCID: PMC7532579 DOI: 10.1186/s12883-020-01940-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 09/23/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Language barriers were reported to affect timely access to health care and outcome. The aim of this study was to investigate the effect of language disparity on quality benchmarks of acute ischemic stroke therapy. METHODS Consecutive patients with acute ischemic stroke at the University of California Irvine Medical Center from 2013 to 2016 were studied. Patients were categorized into 3 groups according to their preferred language: English, Spanish, and other languages. Quality benchmarks and outcomes of the 3 language groups were analyzed. RESULTS Of the 928 admissions, 69.7% patients recorded English as preferred language, as compared to 17.3% Spanish and 13.0% other languages. There was no significant difference in the rate of receiving intravenous thrombolysis (24.3, 22.1 and 21.0%), last-known-well to door time, door-to-imaging time, door-to-needle time, and hospital length of stay among the 3 language groups. In univariate analysis, the other languages group had lower chance of favorable outcomes than the English-speaking group (26.3% vs 40.4, p < 0.05) while the Spanish-speaking group had lower mortality rate than English-speaking group (3.1% vs 7.7%, p = 0.05). After adjusting for age and initial NIHSS scores, multivariate regression models showed no significant difference in favorable outcomes and mortality between different language groups. CONCLUSION We demonstrate no significant difference in quality benchmarks and outcome of acute ischemic stroke among 3 different language groups. Our results suggest that limited English proficiency is not a significant barrier for time-sensitive stroke care at Comprehensive Stroke Center.
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Affiliation(s)
- Noriko Anderson
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Afra Janarious
- Department of Neurology, University of California, Irvine, CA, USA
| | - Shimeng Liu
- Department of Neurology, University of California, Irvine, CA, USA
| | - Lisa A Flanagan
- Department of Neurology, University of California, Irvine, CA, USA
| | - Dana Stradling
- Department of Neurology, University of California, Irvine, CA, USA
| | - Wengui Yu
- Department of Neurology, University of California, Irvine, CA, USA. .,, Orange, CA, USA.
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Reinink H, Konya B, Geurts M, Kappelle LJ, van der Worp HB. Treatment Restrictions and the Risk of Death in Patients With Ischemic Stroke or Intracerebral Hemorrhage. Stroke 2020; 51:2683-2689. [PMID: 32757755 DOI: 10.1161/strokeaha.120.029788] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Do-not-resuscitate (DNR) orders in the first 24 hours after intracerebral hemorrhage have been associated with an increased risk of early death. This relationship is less certain for ischemic stroke. We assessed the relation between treatment restrictions and mortality in patients with ischemic stroke and in patients with intracerebral hemorrhage. We focused on the timing of treatment restrictions after admission and the type of treatment restriction (DNR order versus more restrictive care). METHODS We retrospectively assessed demographic and clinical data, timing and type of treatment restrictions, and vital status at 3 months for 622 consecutive stroke patients primarily admitted to a Dutch university hospital. We used a Cox regression model, with adjustment for age, sex, comorbidities, and stroke type and severity. RESULTS Treatment restrictions were installed in 226 (36%) patients, more frequently after intracerebral hemorrhage (51%) than after ischemic stroke (32%). In 187 patients (83%), these were installed in the first 24 hours. Treatment restrictions installed within the first 24 hours after hospital admission and those installed later were independently associated with death at 90 days (adjusted hazard ratios, 5.41 [95% CI, 3.17-9.22] and 5.36 [95% CI, 2.20-13.05], respectively). Statistically significant associations were also found in patients with ischemic stroke and in patients with just an early DNR order. In those who died, the median time between a DNR order and death was 520 hours (interquartile range, 53-737). CONCLUSIONS The strong relation between treatment restrictions (including DNR orders) and death and the long median time between a DNR order and death suggest that this relation may, in part, be causal, possibly due to an overall lack of aggressive care.
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Affiliation(s)
- Hendrik Reinink
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Brain Center, Utrecht University, the Netherlands (H.R., B.K., M.G., L.J.K., H.B.v.d.W.)
| | - Burak Konya
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Brain Center, Utrecht University, the Netherlands (H.R., B.K., M.G., L.J.K., H.B.v.d.W.)
| | - Marjolein Geurts
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Brain Center, Utrecht University, the Netherlands (H.R., B.K., M.G., L.J.K., H.B.v.d.W.).,Department of Neurology, Erasmus Medical Center, University Medical Center Rotterdam, the Netherlands (M.G.)
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Brain Center, Utrecht University, the Netherlands (H.R., B.K., M.G., L.J.K., H.B.v.d.W.)
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Brain Center, Utrecht University, the Netherlands (H.R., B.K., M.G., L.J.K., H.B.v.d.W.)
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Sutter R, Meyer-Zehnder B, Baumann SM, Marsch S, Pargger H. Advance Directives in the Neurocritically Ill: A Systematic Review. Crit Care Med 2020; 48:1188-1195. [PMID: 32697490 DOI: 10.1097/ccm.0000000000004388] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine the frequency of advance directives or directives disclosed by healthcare agents and their influence on decisions to withdraw/withhold life-sustaining care in neurocritically ill adults. DATA SOURCES PubMed, Embase, and Cochrane databases. STUDY SELECTION Screening was performed using predefined search terms to identify studies describing directives of neurocritically ill patients from 2000 to 2019. The review was registered prior to the screening process (International Prospective Register of Systematic Reviews identification number 149185). DATA EXTRACTION Data were collected using standardized forms. Primary outcomes were the frequency of directives and associated withholding/withdrawal of life-sustaining care. DATA SYNTHESIS Out of 721 articles, 25 studies were included representing 35,717 patients. The number of studies and cohort sizes increased over time. A median of 39% (interquartile range, 14-72%) of patients had directives and/or healthcare agents. The presence of directives was described in patients with stroke, status epilepticus, neurodegenerative disorders, neurotrauma, and neoplasms, with stroke patients representing the largest subgroup. Directives were more frequent among patients with neurodegenerative disorders compared with patients with other illnesses (p = 0.043). In reference to directives, care was adapted in 71% of European, 50% of Asian, and 42% of American studies, and was withheld or withdrawn more frequently over time with a median of 58% (interquartile range, 39-89%). Physicians withheld resuscitation in reference to directives in a median of 24% (interquartile range, 22-70%). CONCLUSIONS Studies regarding the use and translation of directives in neurocritically ill patients are increasing. In reference to directives, care was adapted in up to 71%, withheld or withdrawn in 58%, and resuscitation was withheld in every fourth patient, but the quality of evidence regarding their effects on critical care remains weak and the risk of bias high. The limited number of patients having directives is worrisome and studies aiming to increase the use and translation of directives are scarce. Efforts need to be made to increase the perception, use, and translation of directives of the neurocritically ill.
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Affiliation(s)
- Raoul Sutter
- Department of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Department of Anesthesiology, University Hospital Basel, Basel, Switzerland
| | | | | | - Stephan Marsch
- Department of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Hans Pargger
- Department of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
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30
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Wartenberg KE, Hwang DY, Haeusler KG, Muehlschlegel S, Sakowitz OW, Madžar D, Hamer HM, Rabinstein AA, Greer DM, Hemphill JC, Meixensberger J, Varelas PN. Gap Analysis Regarding Prognostication in Neurocritical Care: A Joint Statement from the German Neurocritical Care Society and the Neurocritical Care Society. Neurocrit Care 2020; 31:231-244. [PMID: 31368059 PMCID: PMC6757096 DOI: 10.1007/s12028-019-00769-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background/Objective Prognostication is a routine part of the delivery of neurocritical care for most patients with acute neurocritical illnesses. Numerous prognostic models exist for many different conditions. However, there are concerns about significant gaps in knowledge regarding optimal methods of prognostication. Methods As part of the Arbeitstagung NeuroIntensivMedizin meeting in February 2018 in Würzburg, Germany, a joint session on prognostication was held between the German NeuroIntensive Care Society and the Neurocritical Care Society. The purpose of this session was to provide presentations and open discussion regarding existing prognostic models for eight common neurocritical care conditions (aneurysmal subarachnoid hemorrhage, intracerebral hemorrhage, acute ischemic stroke, traumatic brain injury, traumatic spinal cord injury, status epilepticus, Guillain–Barré Syndrome, and global cerebral ischemia from cardiac arrest). The goal was to develop a qualitative gap analysis regarding prognostication that could help inform a future framework for clinical studies and guidelines. Results Prognostic models exist for all of the conditions presented. However, there are significant gaps in prognostication in each condition. Furthermore, several themes emerged that crossed across several or all diseases presented. Specifically, the self-fulfilling prophecy, lack of accounting for medical comorbidities, and absence of integration of in-hospital care parameters were identified as major gaps in most prognostic models. Conclusions Prognostication in neurocritical care is important, and current prognostic models are limited. This gap analysis provides a summary assessment of issues that could be addressed in future studies and evidence-based guidelines in order to improve the process of prognostication.
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Affiliation(s)
- Katja E Wartenberg
- Neurocritical Care and Stroke Unit, Department of Neurology, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - David Y Hwang
- Department of Neurology, Yale School of Medicine, P.O. Box 208018, New Haven, CT, 06520-8018, USA
| | - Karl Georg Haeusler
- Department of Neurology, Universitätsklinikum Würzburg, Josef-Schneider-Strasse 11, 97080, Würzburg, Germany
| | - Susanne Muehlschlegel
- Department of Neurology, Anesthesiology and Surgery, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
| | - Oliver W Sakowitz
- Neurosurgery Center Ludwigsburg-Heilbronn, RKH Klinikum Ludwigsburg, Posilipostrasse 4, 71640, Ludwigsburg, Germany
| | - Dominik Madžar
- Department of Neurology, University of Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Hajo M Hamer
- Department of Neurology, University of Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | | | - David M Greer
- Department of Neurology, Boston University Medical Center, 72 East Concord St, Boston, MA, 02118, USA
| | - J Claude Hemphill
- Department of Neurology, University of California San Francisco, 1001 Potrero Ave, San Francisco, CA, 94110, USA
| | - Juergen Meixensberger
- Department of Neurosurgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Panayiotis N Varelas
- Department of Neurology and Neurosurgery, Henry Ford Hospital, 2799 W. Grand Blvd Neurosurgery - K-11, Detroit, MI, 48202, USA
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31
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Skolarus LE, Feng C, Burke JF. Exploring Factors Contributing to Race Differences in Poststroke Disability. Stroke 2020; 51:1813-1819. [PMID: 32404036 DOI: 10.1161/strokeaha.119.027700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Cross sectional analyses have found large race differences in poststroke disability, yet these analyses do not account for prestroke disability, hospitalization factors, postacute care, transitions, or mortality. In this context, we explore mortality, nursing home placement, and disability in a longitudinal analysis of older stroke survivors who survived at least 90 days poststroke. Methods- A prospective cohort of black or white stroke survivors from the National Health and Aging Trends Study (2009-2016) linked to Medicare were used. Disability was assessed during in-person interviews with validated scales (0-7). We used cox proportional hazards models to separately assess mortality and nursing home admission adjusting for age, sex, sociodemographics (marital status, education, income, insurance status, social network size), comorbidities, hospitalization factors, postacute care, and 90-day readmissions. To estimate racial differences in disability, we used a multilevel linear regression model initially adjusting for age and sex and then compared with a model adjusted for sociodemographics, comorbidities, hospitalization factors, postacute care, and 90-day readmissions. Results- There were 282 stroke survivors, of which 76 (12.6%) were black. There were no race differences in long-term mortality (hazard ratio for black, 1.2 [95% CI, 0.7-2.2]; P=0.5) or nursing home placement (hazard ratio for black, 0.7 [95% CI, 0.2-2.4]; P=0.5). The largest race differences in disability were observed immediately prestroke, estimated age- and sex-adjusted activity limitations were (2.6 [2.0-3.2] in blacks versus 1.4 [1.0-1.8] in whites, mean difference, 1.2 [0.5-1.9], P<0.001) and immediately poststroke (2.6 [2.0-3.3] in blacks versus 1.7 [1.2-2.1] in whites, mean difference, 1.0 [0.2-1.7], P<0.01). Full adjustment did not substantially change the associations between race and disability. Conclusions- Race differences in nursing home placement, long-term mortality, sociodemographics, comorbidities, hospitalization factors, postacute care, and readmissions are unlikely to be large contributors to race differences in poststroke disability. Further research is needed to understand the drivers of race differences in poststroke disability.
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Affiliation(s)
- Lesli E Skolarus
- From the Department of Neurology, University of Michigan, Ann Arbor (L.E.S., C.F., J.F.B.)
| | - Chunyang Feng
- From the Department of Neurology, University of Michigan, Ann Arbor (L.E.S., C.F., J.F.B.)
| | - James F Burke
- From the Department of Neurology, University of Michigan, Ann Arbor (L.E.S., C.F., J.F.B.).,Department of Neurology, Ann Arbor VA, MI (J.F.B.)
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Rezaei F, Reamazannezhad N, Douki MF, Shayadeh FS, Nejati E, Ahmadian Z. Nursing care (palliative medicine) in patients with neuropsychiatric disorders. J Family Med Prim Care 2020; 9:25-30. [PMID: 32110560 PMCID: PMC7014906 DOI: 10.4103/jfmpc.jfmpc_701_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/27/2019] [Accepted: 12/12/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Palliative medicine is a special status focusing on the quality of life of patients suffering from special or advanced diseases. Palliative medicine can be helpful at any stage of the disease, including the diagnosis. Thus, the present study aims at reviewing the application of palliative care in mental disorders. METHOD In the present study, as many as 1,149 studies were found in the period of 1985 to 2018 by searching on different websites including Medline, Embase, ProQuest, Global Health, GoogleScholar, and Scopus. As many as 53 studies having to do with mental disorders were found, and more specifically, as many as 36 articles related to palliative medicine were applied. FINDINGS Reviewing the related literature indicates that the care needs of mental disorders patients are quite complicated. The findings indicated that predicting the complications of the disease, as well as advanced planning in terms of caring for these patients, are of significant importance. The findings indicated that over the last decade two palliative care models have been developed: integrative and consultative. CONCLUSION With the growth development of palliative care in developed countries, the knowledge of palliative care can be shared with the nurses and practitioners of neurological diseases, and this knowledge can be applied to palliate and reduce the pains and sufferings of the patients and their families.
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Affiliation(s)
- Fatemeh Rezaei
- Department of Nursing and Midwifery, Golestan University of Medical Sciences, Golestan, Babol, Iran.,Department of Nursing, Islamic Azad University, Babol Branch, Babol, Iran
| | | | | | | | - Elahe Nejati
- Department of Nursing, Yahyanejad Hospital, Babol, Iran
| | - Zaynab Ahmadian
- Department of Nursing, Nursing and Midwifery School, Islamic Azad University, Babol Branch, Babol, Iran
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Soluble ST2 is a Useful Biomarker for Grading Cerebral-Cardiac Syndrome in Patients after Acute Ischemic Stroke. J Clin Med 2020; 9:jcm9020489. [PMID: 32054047 PMCID: PMC7074380 DOI: 10.3390/jcm9020489] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 01/28/2020] [Accepted: 02/07/2020] [Indexed: 01/06/2023] Open
Abstract
This study tested whether the soluble (s)ST2 is a superb biomarker predictive of moderate to severe cerebral-cardiac syndrome (CCS) (defined as coexisting National Institute of Health Stroke Scale (NIHSS) >8 and left-ventricular ejection fraction (LVEF) <60%) in patients after acute ischemic stroke (IS). Between November 2015 and October 2017, a total of 99 IS patients were prospectively enrolled and categorized into three groups based on NIHSS, i.e., group 1 (NIHSS ≤ 8, n = 66), group 2 (NIHSS = 9-15, n = 14) and group 3 (NIHSS ≥ 16, n = 19), respectively. Blood samples were collected immediately after hospitalization, followed by transthoracic echocardiographic examination. The results showed that the flow cytometric analysis for assessment of inflammatory biomarkers of TLR2+/CD14+cells, TLR4+/CD14+cells, Ly6g+/CD14+cells, and MPO+/CD14+cells, and ELISA assessment for circulatory level of sST2 were significantly higher in groups 2/3 than in group 1 (all p < 0.01). However, these parameters did not show significant differences between groups 2 and 3 (all p > 0.05). The LVEF was significantly lower in group 3 than in group 1 (p < 0.001), but it displayed no difference between groups 1/2 or between groups 2/3. These inflammatory biomarkers ((TLR2+/CD14+cells// TLR4+/CD14+cells// MPO+/CD14+cells) and sST2)) were significantly positively correlated to NIHSS and strongly negatively correlated to LVEF (all p < 0.05). Multivariate analysis demonstrated that both MPO/CD14+cells >20% (p = 0.027) and sST2 ≥ 17,600 (p = 0.004) were significantly and independently predictive of moderate-severe CCS after acute IS. Receiver operating characteristic curve analysis demonstrated that sST2 was the most powerful predictor of CCS with a sensitivity of 0.929 and a specificity of 0.731 (p < 0.001). In conclusion, sST2 is a useful biomarker for prediction of CCS severity in patients after acute IS.
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Virani K, Hu S, Christian C, Simpkin W, Phillips S, Shankar JJS. Endovascular Thrombectomy for Stroke Effectiveness Study—An Audit From a Small Tertiary Care Center. Can Assoc Radiol J 2020; 71:63-67. [DOI: 10.1177/0846537119885668] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Purpose: Endovascular thrombectomy (EVT) treatment for acute ischemic stroke is now recommended as a standard of care. However, implementing EVT in routine clinical practice poses many challenges, even in countries with advanced health-care systems. The aim of the current study is to delineate if EVT at our institution is an effective treatment for acute ischemic stroke. Methods: All patients who underwent EVT at our institution between December 2011 and July 2017 were retrospectively assessed from our prospective registry. Clinical and imaging (including the Alberta Stroke Program Early CT [ASPECT] score, single-phase computed tomography angiography, and computed tomography perfusion) criteria were utilized to determine EVT suitability. Primary outcomes included modified Rankin score (mRS) at 90 days and recanalization determined by the modified Treatment in Cerebral Infarction score. Effectiveness was assessed by comparing our cohort with patients receiving EVT in the ESCAPE (Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke) trial. Results: Eighty-eight patients presented to our hospital after a median of 87 minutes last seen normal. Of these, median ASPECT score was 9. A majority (72%) also received intravenous alteplase. Successful recanalization (≥TICI 2b) was achieved in 79%. At 90 days, 48% (36/75) were functionally independent (mRS score of 0-2) and 28% (21/75) were disabled (mRS score of 3-5); 24% (18/75) died (mRS of 6) within 90 days. Conclusions: An audit of our initial experience with EVT for the treatment of acute ischemic stroke in a small tertiary care center yielded similar results compared to the ESCAPE trial, which is encouraging for implementing this treatment in routine clinical practice.
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Affiliation(s)
- Karim Virani
- Division of Neuroradiology, Department of Radiology, Dalhousie University & Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Sherry Hu
- Division of Neurology, Department of Medicine, Dalhousie University & Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Christine Christian
- Queen Elizabeth II Health Sciences Centre, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Wendy Simpkin
- Queen Elizabeth II Health Sciences Centre, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Stephen Phillips
- Division of Neuroradiology, Department of Radiology, Dalhousie University & Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Jai Jai Shiva Shankar
- Division of Neuroradiology, Department of Radiology, Dalhousie University & Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Department of Radiology, University of Manitoba, Winnipeg, Manitoba, Canada
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McCracken DJ, Lovasik BP, McCracken CE, Frerich JM, McDougal ME, Ratcliff JJ, Barrow DL, Pradilla G. The Intracerebral Hemorrhage Score: A Self-Fulfilling Prophecy? Neurosurgery 2020; 84:741-748. [PMID: 29762777 DOI: 10.1093/neuros/nyy193] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 04/17/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The ICH Score has become the standard for risk-stratification of 30-d mortality in patients with intracerebral hemorrhage (ICH), but treatment has evolved over the last 17 yr since its inception. We sought to determine if the ICH Score remains an accurate predictor of 30-d mortality in these high acuity patients. OBJECTIVE To determine the role the ICH Score has on mortality in current treatment of patients. METHODS A retrospective review of 554 patients treated for acute, spontaneous ICH at 2 large academic institutions between 2010 and 2014 was carried out. Surgical intervention in the form of external ventricular drain or craniotomy was performed when indicated. All patients were managed medically until discharge or death. RESULTS Over half (53.6%) of the patients presented with ICH of the basal ganglia/thalamus and the majority (71%) presented with ICH Scores of 0 to 2. Overall mortality was 25.1%. Observed mortality in moderate grade ICH Score patients (3 and 4) was lower than expected (49% vs 72%, P < .001) and (71% vs 97%, P < .001) when compared to the original ICH Score results. Despite differences in ICH and intraventricular hemorrhage volume, and Glasgow Coma Scale there was no difference in surgical intervention (12.2% vs 11.8%, P = .94) between the two groups. Withdrawal of care was instituted in 56.6% of all patients who died and increased with ICH Score. CONCLUSION In our cohort, the original ICH score did not accurately predict the mortality rate. Patient survival exceeded ICH Score-predicted mortality regardless of surgical intervention. Reevaluation of predictive scores could be useful to aid in more accurate prognoses.
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Affiliation(s)
- D Jay McCracken
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Brendan P Lovasik
- Department of Biostatistics and Bioinformatics, Emory University School of Medicine, Atlanta, Georgia
| | - Courtney E McCracken
- Department of Biostatistics and Bioinformatics, Emory University School of Medicine, Atlanta, Georgia
| | - Jason M Frerich
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Margaret E McDougal
- Department of Biostatistics and Bioinformatics, Emory University School of Medicine, Atlanta, Georgia
| | - Jonathan J Ratcliff
- Department of Emergency Medicine and Neurology, Emory University, Atlanta, Georgia
| | - Daniel L Barrow
- Department of Neurosurgery, Emory University, Atlanta, Georgia
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Abstract
Stroke is a sudden, unexpected illness with an uncertain prognosis for functional recovery. Ethical issues in the care of patients with stroke include assessment of decision-making capacity when cognition or communication is impaired, prognostication, evaluation of quality of life, withdrawal or withholding of life-sustaining treatment, and how to optimize surrogate decision making. Skilled communication between clinicians and patients or their surrogates promotes shared decision making and may prevent ethical conflict. Nurses with an understanding of the ethics of stroke care play an important role in the care of patients with stroke and their families.
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Abstract
BACKGROUND Although the efficacy of endovascular thrombectomy (EVT) for acute ischemic stroke caused by intracranial anterior circulation large vessel occlusion (LVO) is proven, demonstration of local effectiveness is critical for health system planning and resource allocation because of the complexity and cost of this treatment. METHODS Using our prospective registry, we identified all patients who underwent EVT for out-of-hospital LVO stroke from February 1, 2013 through January 31, 2017 (n = 44), and matched them 1:1 in a hierarchical fashion with control patients not treated with EVT based on age (±5 years), prehospital functional status, stroke syndrome, severity, and thrombolysis administration. Demographics, in-hospital mortality, discharge disposition from acute care, length of hospitalization, and functional status at discharge from acute care and at follow-up were compared between cases and controls. RESULTS For EVT-treated patients (median age 66, 50% women), the median onset-to-recanalization interval was 247 min, and successful recanalization was achieved in 30/44 (91%). Alteplase was administered in 75% of cases and 57% of controls (p = 0.07). In-hospital mortality was 11% among the cases and 36% in the control group (p = 0.006); this survival benefit persisted during follow-up (p = 0.014). More EVT patients were discharged home from acute care (50% vs. 18%, p = 0.002). Among survivors, there were nonsignificant trends in favor of EVT for median length of hospitalization (14 vs. 41 days, p = 0.11) and functional independence at follow-up (51% vs. 32%, p = 0.079). CONCLUSION EVT improved survival and decreased disability. This demonstration of single-center effectiveness may help facilitate expansion of EVT services in similar health-care jurisdictions.
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Timing of Direct Enteral Tube Placement and Outcomes after Acute Stroke. J Stroke Cerebrovasc Dis 2019; 28:104401. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104401] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/14/2019] [Accepted: 09/08/2019] [Indexed: 11/22/2022] Open
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Pneumonia in acute ischemic stroke patients requiring invasive ventilation: Impact on short and long-term outcomes. J Infect 2019; 79:220-227. [PMID: 31238051 DOI: 10.1016/j.jinf.2019.06.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/06/2019] [Accepted: 06/20/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To describe the epidemiology and prognostic impact of pneumonia in acute ischemic stroke patients requiring invasive mechanical ventilation. METHODS Retrospective analysis from a prospective multicenter cohort study of critically ill patients with acute ischemic stroke requiring invasive mechanical ventilation at admission. Impact of pneumonia was investigated using Cox regression for 1-year mortality, and competing risk survival models for ICU mortality censored at 30-days. RESULTS We included 195 patients. Stroke was supratentorial in 62% and 64% of patients had a Glasgow coma scale score <8 on admission. Mortality at day-30 and 1 year were 56%, and 70%, respectively. Post-stroke pneumonia was identified in 78 (40%) patients, of which 46/78 (59%) episodes were present at ICU admission. Post-stroke pneumonia was associated with an increase in 1-year mortality (adjusted HR 1.49, 95%CI [1.01-2.20]). Post-stroke pneumonia was not associated with ICU mortality but was associated with a 1.6-fold increase in ICU length of stay (CSHR 0.62 [0.39-0.99], p = 0.06). CONCLUSIONS In ischemic stroke patients requiring invasive ventilation, pneumonia occurred in 40% of cases and was associated with a 49% increase in 1-year mortality. Post-stroke pneumonia did not impact day-30 mortality but increased ICU length of stay.
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Fahlström A, Tobieson L, Redebrandt HN, Zeberg H, Bartek J, Bartley A, Erkki M, Hessington A, Troberg E, Mirza S, Tsitsopoulos PP, Marklund N. Differences in neurosurgical treatment of intracerebral haemorrhage: a nation-wide observational study of 578 consecutive patients. Acta Neurochir (Wien) 2019; 161:955-965. [PMID: 30877470 PMCID: PMC6484090 DOI: 10.1007/s00701-019-03853-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 02/13/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Supratentorial intracerebral haemorrhage (ICH) carries an excessive mortality and morbidity. Although surgical ICH treatment can be life-saving, the indications for surgery in larger cohorts of ICH patients are controversial and not well defined. We hypothesised that surgical indications vary substantially among neurosurgical centres in Sweden. OBJECTIVE In this nation-wide retrospective observational study, differences in treatment strategies among all neurosurgical departments in Sweden were evaluated. METHODS Patient records, neuroimaging and clinical outcome focused on 30-day mortality were collected on each operated ICH patient treated at any of the six neurosurgical centres in Sweden from 1 January 2011 to 31 December 2015. RESULTS In total, 578 consecutive surgically treated ICH patients were evaluated. There was a similar incidence of surgical treatment among different neurosurgical catchment areas. Patient selection for surgery was similar among the centres in terms of patient age, pre-operative level of consciousness and co-morbidities, but differed in ICH volume, proportion of deep-seated vs. lobar ICH and pre-operative signs of herniation (p < .05). Post-operative patient management strategies, including the use of ICP-monitoring, CSF-drainage and mechanical ventilation, varied among centres (p < .05). The 30-day mortality ranged between 10 and 28%. CONCLUSIONS Although indications for surgical treatment of ICH in the six Swedish neurosurgical centres were homogenous with regard to age and pre-operative level of consciousness, important differences in ICH volume, proportion of deep-seated haemorrhages and pre-operative signs of herniation were observed, and there was a substantial variability in post-operative management. The present results reflect the need for refined evidence-based guidelines for surgical management of ICH.
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Affiliation(s)
- Andreas Fahlström
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala University Hospital, SE-751 85, Uppsala, Sweden.
| | - Lovisa Tobieson
- Department of Neurosurgery and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Henrietta Nittby Redebrandt
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Skane University Hospital, Lund, Sweden
| | - Hugo Zeberg
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Jiri Bartek
- Department of Medicine and Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Andreas Bartley
- Department of Clinical Neuroscience, Neurosurgery, University of Gothenburg, Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria Erkki
- Department of Clinical Neuroscience, Neurosurgery, Umeå University, Umeå University Hospital, Umeå, Sweden
| | - Amel Hessington
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala University Hospital, SE-751 85, Uppsala, Sweden
| | - Ebba Troberg
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Skane University Hospital, Lund, Sweden
| | - Sadia Mirza
- Department of Medicine and Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Parmenion P Tsitsopoulos
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala University Hospital, SE-751 85, Uppsala, Sweden
| | - Niklas Marklund
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala University Hospital, SE-751 85, Uppsala, Sweden
- Department of Neurosurgery and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Skane University Hospital, Lund, Sweden
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Kosminsky L, Shah NY, Chang P. Prognosis after Stroke #374. J Palliat Med 2019; 22:593-594. [DOI: 10.1089/jpm.2019.0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Monteiro NF, Cipriano P, Freire E. Palliative approach in acute neurological events: a five-year study. ACTA ACUST UNITED AC 2019; 64:833-836. [PMID: 30673005 DOI: 10.1590/1806-9282.64.09.832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 01/13/2018] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Acute neurological illness often results in severe disability. Five-year life expectancy is around 40%; half the survivors become completely dependent on outside help. OBJECTIVE Evaluate the symptoms of patients admitted to a Hospital ward with a diagnosis of stroke, subarachnoid hemorrhage or subdural hematoma, and analyze the role of an In-Hospital Palliative Care Support Team. MATERIAL AND METHODS Retrospective, observational study with a sample consisting of all patients admitted with acute neurological illness and with a guidance request made to the In-Hospital Palliative Care Support Team of a tertiary Hospital, over 5 years (2012-2016). RESULTS A total of 66 patients were evaluated, with an age median of 83 years old. Amongst them, there were 41 ischaemic strokes, 12 intracranial bleedings, 12 subdural hematomas, and 5 subarachnoid hemorrhages. The median of delay between admission and guidance request was 14 days. On the first evaluation by the team, the GCS score median was 6/15 and the Palliative Performance Scale (PPS) median 10%. Dysphagia (96.8%) and bronchorrhea (48.4%) were the most prevalent symptoms. A total of 56 patients had a feeding tube (84.8%), 33 had vital sign monitoring (50.0%), 24 were hypocoagulated (36.3%), 25 lacked opioid or anti-muscarinic therapy for symptom control (37,9%); 6 patients retained orotracheal intubation, which was removed. In-hospital mortality was 72.7% (n=48). DISCUSSION AND CONCLUSION Patients were severely debilitated, in many cases futile interventions persisted, yet several were under-medicated for symptom control. The delay between admission and collaboration request was high. Due to the high morbidity associated with acute neurological illness, palliative care should always be timely provided.
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Affiliation(s)
- Nuno Ferreira Monteiro
- . Internal Medicine Resident at the Egas Moniz Hospital, Hospital Centre of West Lisbon, Lisboa, Portugal
| | - Patrícia Cipriano
- . Internal Medicine Resident at Medicine of the Cascais Hospital, Cascais, Portugal
| | - Elga Freire
- . Graduate Assistant in Internal Medicine, Coordinator of the In-hospital Team for Palliative Care Support of the Santo António Hospital, Porto Hospital Centre, Porto, Portugal
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Chauhan N, Ali SF, Hannawi Y, Hinduja A. Utilization of Hospice Care in Patients With Acute Ischemic Stroke. Am J Hosp Palliat Care 2018; 36:28-32. [DOI: 10.1177/1049909118796796] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: A significant percentage of terminally ill patients are discharged to hospice care following a devastating stroke. Objective: We sought to determine the factors associated with hospital discharge to hospice care in a large cohort of patients with stroke. Methods: Using the institutional Get With The Guidelines-Stroke database, all consecutive patients with acute ischemic stroke (AIS) who were alive at discharge, from January 2009 until July 2015, were analyzed. Univariate and multivariable statistical analyses were performed to determine the factors associated with discharge to hospice care. Results: Of 2446 patients with AIS, 3.4% died and were excluded of remaining 2363 patients, and 4.2% were discharged to hospice care. Univariate analysis identified patients who were discharged to hospice care to be older, caucasian, Medicare or private insurance, have atrial fibrillation, heart failure and less often had diabetes mellitus or smoked. Altered mentation at presentation and urinary tract infection were more common in patients discharged to hospice. On multivariable analysis, patients transferred to hospice care were older (odds ratio [OR]: 1.04, 95% confidence interval [CI]: 1.01-1.07; P < .001), had a high National Institute of Health Stroke Scale (NIHSS; OR: 1.15, 95% CI: 1.10-1.20; P < .001), and altered mental status at presentation (OR: 2.42, 95% CI: 1.29-4.55; P < .001). Conclusion: In our study, elderly patients with high NIHSS and altered mental status were identified as factors associated with transition to hospice care following AIS. Prospective studies on the optimal timing of initiation of these consults are needed.
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Affiliation(s)
- Nabeel Chauhan
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Syed F. Ali
- Department of Neurology, University of Arkansas or Medical Sciences, Little Rock, AR, USA
| | - Yousef Hannawi
- Division of Cerebrovascular and Neurocritical Care, Department of Neurology, Ohio State University, Columbus, OH, USA
| | - Archana Hinduja
- Division of Cerebrovascular and Neurocritical Care, Department of Neurology, Ohio State University, Columbus, OH, USA
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Leblanc G, Boutin A, Shemilt M, Lauzier F, Moore L, Potvin V, Zarychanski R, Archambault P, Lamontagne F, Léger C, Turgeon AF. Incidence and impact of withdrawal of life-sustaining therapies in clinical trials of severe traumatic brain injury: A systematic review. Clin Trials 2018; 15:398-412. [PMID: 29865897 DOI: 10.1177/1740774518771233] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Most deaths following severe traumatic brain injury follow decisions to withdraw life-sustaining therapies. However, the incidence of the withdrawal of life-sustaining therapies and its potential impact on research data interpretation have been poorly characterized. The aim of this systematic review was to assess the reporting and the impact of withdrawal of life-sustaining therapies in randomized clinical trials of patients with severe traumatic brain injury. Methods We searched Medline, Embase, Cochrane Central, BIOSIS, and CINAHL databases and references of included trials. All randomized controlled trials published between January 2002 and August 2015 in the six highest impact journals in general medicine, critical care medicine, and neurocritical care (total of 18 journals) were considered for eligibility. Randomized controlled trials were included if they enrolled adult patients with severe traumatic brain injury (Glasgow Coma Scale ≤ 8) and reported data on mortality. Our primary objective was to assess the proportion of trials reporting the withdrawal of life-sustaining therapies in a publication. Our secondary objectives were to describe the overall mortality rate, the proportion of deaths following the withdrawal of life-sustaining therapies, and to assess the impact of the withdrawal of life-sustaining therapies on trial results. Results From 5987 citations retrieved, we included 41 randomized trials (n = 16,364, ranging from 11 to 10,008 patients). Overall mortality was 23% (range = 3%-57%). Withdrawal of life-sustaining therapies was reported in 20% of trials (8/41, 932 patients in trials) and the crude number of deaths due to the withdrawal of life-sustaining therapies was reported in 17% of trials (7/41, 884 patients in trials). In these trials, 63% of deaths were associated with the withdrawal of life-sustaining therapies (105/168). An analysis carried out by imputing a 4% differential rate in instances of withdrawal of life-sustaining therapies between study groups yielded different results and conclusions in one third of the trials. Conclusion Data on the withdrawal of life-sustaining therapies are incompletely reported in randomized controlled trials of patients with severe traumatic brain injury. Given the high proportion of deaths due to the withdrawal of life-sustaining therapies in severe traumatic brain injury patients, and the potential of this medical decision to influence the results of clinical trials, instances of withdrawal of life-sustaining therapies should be systematically reported in clinical trials in this group of patients.
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Affiliation(s)
- Guillaume Leblanc
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Amélie Boutin
- 3 Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Michèle Shemilt
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - François Lauzier
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada.,4 Department of Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Lynne Moore
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,3 Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Véronique Potvin
- 2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Ryan Zarychanski
- 5 Department of Internal Medicine, Sections of Critical Care Medicine, Haematology and Medical Oncology, Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Patrick Archambault
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada.,6 Department of Family and Emergency Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - François Lamontagne
- 7 Department of Medicine, Faculty of Medicine, University of Sherbrooke, Sherbrooke, QC, Canada.,8 Centre de recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada
| | - Caroline Léger
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Alexis F Turgeon
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
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Chen KH, Chen CH, Wallace CG, Yuen CM, Kao GS, Chen YL, Shao PL, Chen YL, Chai HT, Lin KC, Liu CF, Chang HW, Lee MS, Yip HK. Intravenous administration of xenogenic adipose-derived mesenchymal stem cells (ADMSC) and ADMSC-derived exosomes markedly reduced brain infarct volume and preserved neurological function in rat after acute ischemic stroke. Oncotarget 2018; 7:74537-74556. [PMID: 27793019 PMCID: PMC5342685 DOI: 10.18632/oncotarget.12902] [Citation(s) in RCA: 172] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 10/14/2016] [Indexed: 12/16/2022] Open
Abstract
We tested the hypothesis that combined xenogenic (from mini-pig) adipose-derived mesenchymal stem cell (ADMSC) and ADMSC-derived exosome therapy could reduce brain-infarct zone (BIZ) and enhance neurological recovery in rat after acute ischemic stroke (AIS) induced by 50-min left middle cerebral artery occlusion. Adult-male Sprague-Dawley rats (n = 60) were divided equally into group 1 (sham-control), group 2 (AIS), group 3 [AIS-ADMSC (1.2×106 cells)], group 4 [AIS-exosome (100μg)], and group 5 (AIS-exosome-ADMSC). All therapies were provided intravenously at 3h after AIS procedure. BIZ determined by histopathology (by day-60) and brain MRI (by day-28) were highest in group 2, lowest in group 1, higher in groups 3 and 4 than in group 5, but they showed no difference between groups 3 and 4 (all p < 0.0001). By day-28, sensorimotor functional results exhibited an opposite pattern to BIZ among the five groups (p < 0.005). Protein expressions of inflammatory (inducible nitric oxide synthase/tumor necrosis factor-α/nuclear factor-κB/interleukin-1β/matrix metalloproteinase-9/plasminogen activator inhibitor-1/RANTES), oxidative-stress (NOX-1/NOX-2/oxidized protein), apoptotic (caspase-3/ Poly-ADP-ribose polymerase), and fibrotic (Smad3/transforming growth factor-β) biomarkers, and cellular expressions of brain-damaged (γ-H2AX+/ XRCC1-CD90+/p53BP1-CD90+), inflammatory (CD11+/CD68+/glial fibrillary acid protein+) and brain-edema (aquaporin-4+) markers showed a similar pattern of BIZ among the groups (all n < 0.0001). In conclusion, xenogenic ADMSC/ADMSC-derived exosome therapy was safe and offered the additional benefit of reducing BIZ and improving neurological function in rat AIS.
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Affiliation(s)
- Kuan-Hung Chen
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Department of Biological Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Chih-Hung Chen
- Department of Internal Medicine, Division of General Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | | | - Chun-Man Yuen
- Department of Surgery, Division of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Gour-Shenq Kao
- Department of Internal Medicine, Division of Cardiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yi-Ling Chen
- Department of Internal Medicine, Division of Cardiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Pei-Lin Shao
- Department of Nursing, Asia University, Taichung, Taiwan
| | - Yung-Lung Chen
- Department of Internal Medicine, Division of Cardiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Han-Tan Chai
- Department of Internal Medicine, Division of Cardiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kun-Chen Lin
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chu-Feng Liu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsueh-Wen Chang
- Department of Biological Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Mel S Lee
- Department of Orthopedics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hon-Kan Yip
- Department of Internal Medicine, Division of Cardiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Department of Nursing, Asia University, Taichung, Taiwan.,Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan
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Yang B, Du S, Lu Y, Jia S, Zhao M, Bai J, Li P, Wu H. Influence of paeoniflorin and menthol on puerarin transport across MDCK and MDCK-MDR1 cells as blood–brain barrier in vitro model. J Pharm Pharmacol 2017; 70:349-360. [DOI: 10.1111/jphp.12853] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 10/24/2017] [Indexed: 12/20/2022]
Abstract
Abstract
Objective
Our objective of this research was (1) to investigate the transport characteristics of puerarin through MDCK-MDR1 and MDCK cells and (2) to evaluate the effects of paeoniflorin and menthol on puerarin transport so as to (3) explore the enhancement mechanism.
Methods
The cytotoxicity of drugs on MDCK and MDCK-MDR1 was evaluated by the MTT assay, and the transport studies were performed in both directions. The membrane fluidity was evaluated by fluorescence recovery after photobleaching, and the membrane potential was estimated by the accumulation of DiBAC4(3) in the cells.
Key findings
Puerarin showed relatively poor absorption and purely passive diffusion. However, the efflux ratio of puerarin was <2 in MDCK-MDR1 models, which suggested puerarin was not P-gp substrates so as to the P-glycoprotein activity determination of puerarin. With the existence of menthol, the transcellular transport of puerarin increased and puerarin transport significantly increased when co-administrated with paeoniflorin and menthol.
Conclusions
The enhancing effect of paeoniflorin and menthol may be attributed to the significant enhancement on cell membrane fluidity, the decrease in membrane potential. Immunostaining results indicated that menthol behaved as transport enhancer by disassembly effect on tight junction integrity.
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Affiliation(s)
- Bing Yang
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Shouying Du
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Yang Lu
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Shan Jia
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Mengdi Zhao
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Jie Bai
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Pengyue Li
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
| | - Huichao Wu
- School of Chinese Materia Medica, Beijing University of Chinese Medicine, Beijing, China
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47
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de Kort FAS, Geurts M, de Kort PLM, van Tuijl JH, van Thiel GJMW, Kappelle LJ, van der Worp HB. Advance directives, proxy opinions, and treatment restrictions in patients with severe stroke. BMC Palliat Care 2017; 16:52. [PMID: 29137615 PMCID: PMC5686946 DOI: 10.1186/s12904-017-0234-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 11/09/2017] [Indexed: 11/15/2022] Open
Abstract
Background Patients with severe stroke often do not have the capacity to participate in discussions on treatment restrictions because of a reduced level of consciousness, aphasia, or another cognitive disorder. We assessed the role of advance directives and proxy opinions in the decision-making process of incapacitated patients. Methods Sixty patients with severe functional dependence (Barthel Index ≤6) at day four after ischemic stroke or intracerebral hemorrhage were included in a prospective two-center cohort study. The decision-making process with respect to treatment restrictions was assessed by means of a semi-structured questionnaire administered to the treating physician at the day of inclusion. Results Forty-nine patients (82%) did not have the capacity to participate in the decision-making process. In eight patients, there was no discussion on treatment restrictions and full care was installed. In 41 patients, the decision whether to install treatment restrictions was discussed with proxies. One patient had a written advance directive. In the remaining 40 patients, proxies based their opinion on previously expressed wishes of the patient (18 patients) or advised in the best interest of the patient (22 patients). In 36 of 41 patients, treatment restrictions were installed after agreement between physician and proxy. At six months, 23 of 49 patients had survived. In only three of them the decision on treatment restrictions was based on previously expressed wishes. Remarkably, two of these survivors could not recall any of their alleged previously expressed wishes. Conclusions Treatment restrictions were installed in the majority of incapacitated patients after stroke. Proxy opinions frequently served as the best way to respect the patients’ autonomy, but their accuracy remains unclear. Electronic supplementary material The online version of this article (10.1186/s12904-017-0234-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Floor A S de Kort
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marjolein Geurts
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Paul L M de Kort
- Department of Neurology, Elisabeth-Twee Steden ziekenhuis, Tilburg, the Netherlands
| | - Julia H van Tuijl
- Department of Neurology, Elisabeth-Twee Steden ziekenhuis, Tilburg, the Netherlands
| | - Ghislaine J M W van Thiel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
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48
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Robinson MT, Holloway RG. Palliative Care in Neurology. Mayo Clin Proc 2017; 92:1592-1601. [PMID: 28982489 DOI: 10.1016/j.mayocp.2017.08.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 07/25/2017] [Accepted: 08/07/2017] [Indexed: 12/12/2022]
Abstract
Palliative medicine is a specialty that focuses on improving the quality of life for patients with serious or advanced medical conditions, and it is appropriate at any stage of disease, including at the time of diagnosis. Neurologic conditions tend to have high symptom burdens, variable disease courses, and poor prognoses that affect not only patients but also their families and caregivers. Patients with a variety of neurologic conditions such as Parkinson disease, dementia, amyotrophic lateral sclerosis, brain tumors, stroke, and acute neurologic illnesses have substantial unmet needs that can be addressed through a combination of primary and specialty palliative care. The complex needs of these patients are ideally managed with a comprehensive approach to care that addresses the physical, psychological, social, and spiritual aspects of care in an effort to reduce suffering. Early discussions about prognosis, goals of care, and advance care planning are critical as they can provide guidance for treatment decisions and allow patients to retain a sense of autonomy despite progressive cognitive or functional decline. With the rapid growth in palliative care across the United States, there are opportunities to improve the palliative care knowledge of neurology trainees, the delivery of palliative care to patients with neurologic disease by both neurologists and nonneurologists, and the research agenda for neuropalliative care.
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Affiliation(s)
| | - Robert G Holloway
- Department of Neurology, University of Rochester Medical Center, Rochester, NY
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49
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Predictive accuracy of physicians' estimates of outcome after severe stroke. PLoS One 2017; 12:e0184894. [PMID: 28961255 PMCID: PMC5621670 DOI: 10.1371/journal.pone.0184894] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 09/01/2017] [Indexed: 12/21/2022] Open
Abstract
Introduction End-of-life decisions after stroke should be guided by accurate estimates of the patient’s prognosis. We assessed the accuracy of physicians’ estimates regarding mortality, functional outcome, and quality of life in patients with severe stroke. Methods Treating physicians predicted mortality, functional outcome (modified Rankin scale (mRS)), and quality of life (visual analogue scale (VAS)) at six months in patients with major disabling stroke who had a Barthel Index ≤6 (of 20) at day four. Unfavorable functional outcome was defined as mRS >3, non-satisfactory quality of life as VAS <60. Patients were followed-up at six months after stroke. We compared physicians’ estimates with actual outcomes. Results Sixty patients were included, with a mean age of 72 years. Of fifteen patients who were predicted to die, one actually survived at six months (positive predictive value (PPV), 0.93; 95% CI, 0.66–0.99). Of thirty patients who survived, one was predicted to die (false positive rate (FPR), 0.03; 95%CI 0.00–0.20). Of forty-six patients who were predicted to have an unfavorable outcome, four had a favorable outcome (PPV, 0.93; 95% CI, 0.81–0.98; FPR, 0.30; 95% CI; 0.08–0.65). Prediction of non-satisfactory quality of life was less accurate (PPV, 0.63; 95% CI, 0.26–0.90; FPR, 0.18; 95% CI 0.05–0.44). Conclusions In patients with severe stroke, treating physicians’ estimation of the risk of mortality or unfavorable functional outcome at six months is relatively inaccurate. Prediction of quality of life is even more imprecise.
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50
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Singh T, Peters SR, Tirschwell DL, Creutzfeldt CJ. Palliative Care for Hospitalized Patients With Stroke: Results From the 2010 to 2012 National Inpatient Sample. Stroke 2017; 48:2534-2540. [PMID: 28818864 PMCID: PMC5571885 DOI: 10.1161/strokeaha.117.016893] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 07/14/2017] [Accepted: 07/14/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Substantial variability exists in the use of life-prolonging treatments for patients with stroke, especially near the end of life. This study explores patterns of palliative care utilization and death in hospitalized patients with stroke across the United States. METHODS Using the 2010 to 2012 nationwide inpatient sample databases, we included all patients discharged with stroke identified by International Classification of Diseases-Ninth Revision codes. Strokes were subclassified as ischemic, intracerebral, and subarachnoid hemorrhage. We compared demographics, comorbidities, procedures, and outcomes between patients with and without a palliative care encounter (PCE) as defined by the International Classification of Diseases-Ninth Revision code V66.7. Pearson χ2 test was used for categorical variables. Multivariate logistic regression was used to account for hospital, regional, payer, and medical severity factors to predict PCE use and death. RESULTS Among 395 411 patients with stroke, PCE was used in 6.2% with an increasing trend over time (P<0.05). We found a wide range in PCE use with higher rates in patients with older age, hemorrhagic stroke types, women, and white race (all P<0.001). Smaller and for-profit hospitals saw lower rates. Overall, 9.2% of hospitalized patients with stroke died, and PCE was significantly associated with death. Length of stay in decedents was shorter for patients who received PCE. CONCLUSIONS Palliative care use is increasing nationally for patients with stroke, especially in larger hospitals. Persistent disparities in PCE use and mortality exist in regards to age, sex, race, region, and hospital characteristics. Given the variations in PCE use, especially at the end of life, the use of mortality rates as a hospital quality measure is questioned.
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Affiliation(s)
- Tarvinder Singh
- From the Department of Neurology, Harborview Medical Center, University of Washington, Seattle.
| | - Steven R Peters
- From the Department of Neurology, Harborview Medical Center, University of Washington, Seattle
| | - David L Tirschwell
- From the Department of Neurology, Harborview Medical Center, University of Washington, Seattle
| | - Claire J Creutzfeldt
- From the Department of Neurology, Harborview Medical Center, University of Washington, Seattle
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