Estimates of outcomes up to ten years after stroke: analysis from the prospective South London Stroke Register

Prevalence, predictors, and patterns of patient reported non-motor outcomes six months after stroke: a prospective cohort study

Background

Adverse non-motor outcomes have a major impact on patients and caregivers after stroke, but knowledge of their prevalence, predictors and patterns across multiple health domains remains limited; we therefore aimed to obtain these data in a large observational prospective cohort study.

Methods

We included data from the Stroke Investigation Group in North and Central London (SIGNAL) registry based at the University College London Hospitals (UCLH) Comprehensive Stroke Service which serves a multi-ethnic population of ∼1.6 million people. In adult patients diagnosed with acute stroke due to cerebral ischaemia or intracerebral haemorrhage (ICH) from January 2017 to January 2020 we evaluated non-motor outcomes (anxiety, depression, fatigue, sleep disturbance, social participation, pain, bowel dysfunction, bladder dysfunction, mood problems, communication problems, activities of daily living (ADL), memory and thinking problems) at 6-month follow-up. We evaluated baseline predictors in multivariable logistic regression, and correlations between domains using kappa statistics.

Findings

Follow-up was complete for 3080 of 3338 (92.3%) eligible surviving patients (2534 ischaemic stroke, 547 with ICH; mean age 71.2 years, 1379 (44.8%) female, 1774 (59.3%) white). The most prevalent adverse non-motor outcomes were fatigue 1756 (57%), reduced social participation 1694 (55%), sleep disturbance 1663 (54%), and constipation 1355 (44%). The rates of adverse non-motor outcomes in ⩾ 1, ⩾ 2, ⩾ 3, ⩾ 4, and ⩾ 5 domains were 2310 (75%), 1571 (51%), 1519 (49%), 1232 (40%), and 801 (26%), respectively. Factors associated with adverse non-motor outcomes included stroke due to ICH, stroke severity, previous stroke, or history of cardiovascular disease. We identified moderate correlations between fatigue and sleep disturbance (kappa = 0.72); memory and thinking impairment and reduced ADL (kappa = 0.68); and communication problems and ADL (kappa = 0.70).

Interpretation

Adverse non-motor outcomes are highly prevalent and often multiple at 6-months after stroke: 75% have at least one affected domain; fatigue, sleep disturbance, and reduced social participation each affect over 50% of survivors, and 26% of patients report ≥5 adverse outcomes. Our findings suggest an urgent need to better detect and mitigate these outcomes to improve quality of life after stroke.

Funding

The National Institute for Health and Care Research (NIHR) UCLH Biomedical Research Centre.

Riding waves to improve functioning: a quantitative evaluation of a Surf Week in individuals with chronic phase brain injury with six months follow-up

PURPOSE

Environmental enrichment seems to enable people in the chronic phase of acquired brain injury (ABI) to experience new functional abilities and motor/coping strategies and consequently to become more adaptable which might prevent/reverse functional decline. This study describes the influence of a five-days Surf Week program on participants on physical function, self-efficacy, functional balance performance and self-perceived recovery.

MATERIALS AND METHODS

A multiple-baseline single-case design was used. Adults participating in the Surf Week in chronic phase of ABI were eligible to participate. Participants completed a battery of tests monitoring physical function, self-efficacy, functional balance performance and self-perceived recovery. This battery was repeated 5 times over a 1-year period, two times pre-Surf Week, three times post-Surf Week. Visual data inspection with two non-overlap methods were used to determine if patients showed sustained improvement in outcomes post-intervention.

RESULTS

A moderate to strong indication for improvements on physical function, functional balance performance and self-perceived recovery exists till six months follow-up. No indication was observed on self-efficacy till six months follow-up.

CONCLUSIONS

A five-days Surf Week is a physically, cognitively and socially intensive stimulating activity that can positively challenge individuals after ABI and seems to improve physical functioning, functional balance performance and self-perceived recovery.

Association Between Leisure-Time Physical Activity and All-Cause Mortality Among Stroke Survivors: Findings From National Health and Nutrition Examination Survey

BACKGROUND

Stroke is the second leading cause of death and the third leading cause of disability globally. But little is known about the optimal level of physical activity for stroke survivors. Therefore, we aimed to analyze the dose-response relationship between leisure-time physical activity (LTPA) and all-cause mortality in stroke survivors.

METHODS

One-thousand six hundred and sixty-four stroke survivors form from the 1999 to 2018 National Health and Nutrition Examination Surveys were classified into 6 groups: 0, 1 to 149, 150 to 299, 300 to 599, 600 to 899, and ≥900 minutes per week (based on the Global Physical Activity Questionnaire). Cox proportional hazards regression models with different adjustments of covariates were used to investigate the association between LTPA and all-cause mortality.

RESULTS

Except for stroke survivors with LTPA levels ranging from 600 to 899 minutes per week (P = .055), there was a significant difference in survival rates among stroke survivors with different levels of LTPA compared with those without LTPA. Stroke survivors engaging in LTPA levels exceeding 900 minutes per week exhibited the greatest benefit compared with stroke survivors who did not engage in LTPA (hazard ratio = 0.225; 95% confidence interval, 0.122-0.414).

CONCLUSIONS

Our research findings add to the expanding evidence base that highlights the favorable connection between LTPA and decreased risk of all-cause mortality among individuals who have survived a stroke. Our study emphasizes the significance of incorporating physical activity interventions into the poststroke care regimen and underscores the potential advantages of personalized activity guidance.

Prestroke Physical Activity Matters for Functional Limitations: A Longitudinal Case-Control Study of 12,860 Participants

OBJECTIVE

In the chronic phase after a stroke, limitations in basic activities of daily living (ADLs) and instrumental activities of daily living (IADLs) initially plateau before steadily increasing. The benefits of prestroke physical activity on these limitations remain unclear. To clarify this relationship, the effect of physical activity on the long-term evolution of functional limitations in a cohort of people with stroke compared to a cohort of matched adults without stroke was examined.

METHODS

Longitudinal data from 2143 people with stroke and 10,717 adults without stroke aged 50 years and older were drawn from a prospective cohort study based on the Survey of Health, Ageing and Retirement in Europe (2004-2022; eight data collection waves). Physical activity was assessed in the prestroke wave. Functional limitations were assessed in the poststroke waves. Each person with stroke was matched with five adults without stroke who had similar propensity scores computed on the basis of key covariates, including baseline age, sex, body mass index, limitations in ADLs and IADLs, chronic conditions, and country of residence, before any of the participants from either cohort had experienced a stroke.

RESULTS

Results showed an interaction between stroke status and physical activity on ADL limitations (b = -0.076; 95% CI = -0.142 to -0.011), with the beneficial effect of physical activity being stronger in people with stroke (b = -0.345; 95% CI = -0.438 to -0.252) than in adults without stroke (b = -0.269; 95% CI = -0.269 to -0.241).

CONCLUSION

The beneficial effect of prestroke physical activity on ADL limitations after stroke is stronger than its effect in matched adults without stroke followed for a similar number of years.

IMPACT

Physical activity, an intervention within the physical therapist's scope of practice, is effective in reducing the risk of functional dependence after stroke. Moreover, prestroke levels of physical activity can inform the prognosis of functional dependence in people with stroke.

Factors and prediction model associated with resumption of social outings in stroke survivors 6 months after onset: a multicenter prospective study

OBJECTIVES

To identify factors associated with the resumption of social outings 6 months after stroke onset and develop a simple clinically practical prediction model.

MATERIALS AND METHODS

Participants were recruited from first-ever stroke survivors admitted to three rehabilitation wards, and resumption of social outings 6 months after stroke onset was assessed using the Japanese version of the Frenchay Activities Index. The association of physical and cognitive functions with activities of daily living at admission to the rehabilitation ward and resumption of social outings 6 months after stroke onset was examined using logistic regression and decision trees.

RESULTS

Notably, 63.2% of the 57 stroke survivors who participated in this study had lower Frenchay Activities Index scores for social outings 6 months after stroke onset than before. Logistic regression analysis revealed that attention deficit and grooming on the Functional Independence Measure (FIMTM) were significantly associated with decreased social outing scores 6 months after stroke onset. A decision tree model was created to predict the resumption of social outings using the presence or absence of attention disorders and FIMTM grooming score (>2 or ≤ 2).

CONCLUSIONS

The results of this study suggest that attention deficit and beyond a certain level of independence in grooming (FIMTM >2) at admission to the rehabilitation ward are associated with recovery to the pre-stroke level of social outings 6 months after stroke onset. The decision tree created in this study holds promise as a simple model to predict the resumption of social outings among stroke survivors.

Effect of Early Rehabilitation Services After Discharge on Social Activity Among Chronic Stroke Survivors: A Multicenter Prospective Study

BACKGROUND

Social inactivity after a stroke leads to adverse outcomes, making social activity after discharge important for chronic stroke survivors. This study aimed to investigate the effects of early rehabilitation services after discharge on social activity among chronic stroke survivors.

METHODS

The participants were prospectively recruited from 3 convalescent hospitals. Receipt of early rehabilitation services after discharge for chronic stroke survivors was defined as the utilization of day care or home-based rehabilitation services by the Japanese long-term care insurance system. Social activity was assessed using the Frenchay Activities Index (FAI) premorbid and at 3, 6, and 12 months after discharge. In this study, the outcome was defined as the change in the FAI score from 3 to 12 months after discharge. Multivariate regression analysis was performed to examine the effect of access to rehabilitation on changes in FAI.

RESULTS

Ninety stroke survivors (age 67.2±11.6 years, 52 male) were enrolled. The FAI showed improvements by 27.4% and 1.4% from 3 to 12 months after discharge in the rehabilitation and nonrehabilitation groups, respectively. Multivariate regression analysis showed that access to rehabilitation after discharge was positively associated with the FAI change from 3 to 12 months after discharge (B=30.3, β=0.38, 95% confidence interval=11.13-49.47, P=0.002).

CONCLUSIONS

Early rehabilitation services after discharge were significantly associated with increased social activity.

Pre-stroke physical activity matters for functional limitations: A longitudinal case-control study of 12,860 participants

Objective

In the chronic phase after a stroke, limitations in activities of daily living (ADLs) and instrumental ADL (IADLs) initially plateau before steadily increasing. The benefits of pre-stroke physical activity on these limitations remain unclear. To clarify this relationship, we examined the effect of physical activity on the long-term evolution of functional limitations in a cohort of stroke survivors and compared it to a cohort of matched stroke-free adults.

Methods

Longitudinal data from 2,143 stroke survivors and 10,717 stroke-free adults aged 50 years and older were drawn from a prospective cohort study based on the Survey of Health, Ageing and Retirement in Europe (2004-2022; 8 data collection waves). Physical activity was assessed in the pre-stroke wave. Functional limitations were assessed in the post-stroke waves. Each stroke survivor was matched with 5 stroke-free adults who had similar propensity scores computed on the basis of key covariates, including baseline age, sex, body mass index, limitations in ADL and IADL, chronic conditions and country of residence, before any of the participants from either cohort had experienced a stroke.

Results

Results showed an interaction between stroke status and physical activity on ADL limitations (b = -0.076; 95% CI = -0.142 to -0.011), with the effect of physical activity being stronger in stroke survivors (b = -0.345, 95% CI = -0.438 to -0.252) than in stroke-free adults (b = -0.269, 95% CI = -0.269 to -0.241).

Conclusion

The beneficial effect of pre-stroke physical activity on ADL limitations after stroke is stronger than its effect in matched stroke-free adults followed for a similar number of years.

Impact

Physical activity, an intervention within the physical therapist's scope of practice, is effective in reducing the risk of functional dependence after stroke. Moreover, pre-stroke levels of physical activity can inform the prognosis of functional dependence in stroke survivors.

Adipokines and stroke: A systematic review and meta-analysis of disease risk and patient outcomes

Obesity is reported to increase stroke risk, with adipocyte-derived cytokines or adipokines implicated as mediators. However, the relationship between adipokines and stroke is not well clarified. Thus, we aimed to evaluate the association of adipokines with stroke using fully adjusted risk estimates that incorporated body mass index in a meta-analysis. Data from 52 studies (62,428 patients) were pooled in a random-effects meta-analysis. Adiponectin was independently associated with a lower risk of pre-existing stroke (adjusted odds ratio: 0.64 [95% confidence interval: 0.46-0.88], p < 0.01), whereas leptin (1.08 [1.00-1.17], p = 0.04), resistin (1.06 [1.04-1.08], p < 0.01) and visfatin (1.04 [1.01-1.07], p = 0.01) are associated with a higher risk of stroke, but none with incident stroke. Adipokines independently associated with an ischaemic stroke subtype were adiponectin (0.48 [0.30-0.77], p < 0.01), leptin (1.10 [1.01-1.20], p = 0.04), and resistin (1.06 [1.04-1.08], p < 0.01). Fatty acid-binding protein-4 (FABP-4) independently predicted 6-month poor functional outcomes in stroke patients (adjusted hazard ratio: 1.09 [1.06-1.12], p < 0.01); whereas both FABP-4 (1.17 [1.03-1.34], p = 0.01) and visfatin (1.24 [1.00-1.55], p = 0.05) were predictive of 6-month mortality. Adipokines are associated with a greater risk of pre-existing stroke, but not with the relationship with incident stroke. Adipokines, such as FABP-4 and visfatin, may serve as biomarkers of stroke severity and worsening of stroke outcomes.

Efficacy of diaphragmatic breathing exercise on respiratory, cognitive, and motor function outcomes in patients with stroke: a systematic review and meta-analysis

Background

Stroke disrupts the functions carried out by the brain such as the control of movement, sensation, and cognition. Disruption of movement control results in hemiparesis that affects the function of the diaphragm. Impaired function of the diaphragm can in turn affect many outcomes such as respiratory, cognitive, and motor function. The aim of this study is to carry out a systematic review and meta-analysis to determine the efficacy of diaphragmatic breathing exercise on respiratory, cognitive, and motor outcomes after stroke.

Method

The study was registered in PROSPERO (CRD42023422293). PubMED, Embase, Web of Science (WoS), PEDro, Scopus, and CENTRAL databases were searched until September 2023. Only randomized controlled trials comparing diaphragmatic breathing exercise with a control were included. Information on the study authors, time since stroke, mean age, height, weight, sex, and the protocols of the experimental and control interventions including intensity, mean scores on the outcomes such as respiratory, cognitive, and motor functions were extracted. Cochrane risks of bias assessment tool and PEDro scale were used to assess the risks of bias and methodological quality of the studies. Narrative synthesis and meta-analysis were used to summarize the results, which were then presented in tables, risk-of-bias graph, and forest plots. The meta-analysis was carried out on respiratory function [forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC, peak expiratory flow (PEF)] and motor function (trunk impairment, and internal and external oblique muscles activity).

Results

Six studies consisting of 151 participants were included. The results of the meta-analyses showed that diaphragmatic breathing exercise is only superior to the control at improving respiratory function, FVC (MD = 0.90, 95% CI = 0.76 to 1.04, P < 0.00001), FEV1 (MD = 0.32, 95% CI = 0.11 to 0.52, P = 0.002), and PEF (MD = 1.48, 95% CI = 1.15 to 1.81, P < 0.00001).

Conclusion

There is limited evidence suggesting that diaphragmatic breathing exercise may help enhance respiratory function, which may help enhance recovery of function post stroke.

Systematic Review Registration

PROSPERO, identifier CRD42023422293.

Predictive value of functional disability scales among stroke survivors: A long-term mortality evaluation in a Brazilian stroke cohort

OBJECTIVE

To assess the influence of two functional scales- Modified Rankin Scale (m-RS) and Modified Katz Index (m-Katz Index) on long-term mortality in a stroke cohort.

MATERIAL AND METHODS

Among 760 stroke survivors (median age: 66 (IQR:56-75), 56.4 % women) m-Katz Index and m-RS scales applied at 1 and 6 months after stroke, were investigated in relation to 12-years of all-cause mortality. Kaplan-Meier survival curves were computed, and time-varying covariate Cox regression models were fitted to calculate hazard ratios (HRs) with 95 % confidence intervals (CIs) in all sample and by sex. The prognostic ability of the fitted models was computed for each model by six different measures.

RESULTS

After 12 years of follow-up (median survival time: 7.3 years), 311 participants died. Overall survival curves show lower survival rates among those with the highest levels of disability/dependence (all log-rank p-values <0.0001). These findings were confirmed in all regression models for both sexes, particularly in men who had higher levels of dependence on Activities of Daily Living (ADLs) by m-Katz Index and severe disability by m-RS and presented the highest HR of dying (HR: 3.34 (95 %CI: 2.27-4.92) and HR: 4.94 (95 % CI: 3.15-7.75), respectively).

CONCLUSIONS

Both the m-Katz Index and the m-RS scale were good predictors of long-term mortality, which is of importance for guiding the functional rehabilitation of stroke patients. Besides, high levels of disability and dependence were implicated with high mortality risks, regardless of sex.

Longitudinal relationships between depressive symptoms and cognitive function after stroke: A cross-lagged panel design

OBJECTIVE

Stroke is a leading cause of mortality and disability. This study aimed to investigate the temporal and directional relationships between post-stroke depressive symptoms and cognitive impairment using a cross-lagged panel design. Depressive symptoms and cognitive impairment are two common post-stroke complications. However, the precise underlying mechanism remains unclear despite their close relationship. Therefore, elucidating the causal relationship between these two issues is of great clinical significance for improving the poor prognosis of stroke.

METHODS

This study employed a hospital-based multicenter prospective cohort design. A total of 610 patients with ischemic stroke were eligible. Depressive symptoms (measured using the seventeen-item Hamilton Rating Scale for Depression) and cognitive function (measured using the Montreal Cognitive Assessment) were assessed at baseline and the 12-month follow-up. Spearman's correlation was used to examine the correlation between cognitive function and depressive symptoms. Additionally, a cross-lagged panel analysis was employed to elucidate the causal relationship between these factors after adjusting for potential covariates.

RESULTS

The results of a four-iteration cross-lagged panel analysis substantiated a bidirectional relationship between post-stroke depressive symptoms and cognitive function over time. Specifically, higher scores for early depressive symptoms were associated with lower scores for later cognitive function; additionally, higher baseline cognitive function scores were associated with lower depressive symptom scores at a later point.

CONCLUSION

This study establishes a reciprocally causal long-term relationship between depressive symptoms and cognitive function after an ischemic stroke. Therefore, interventions aimed at improving cognitive function and ameliorating depressive symptoms may positively affect both cognition and mood.

TRIAL REGISTRATION

ChiCTR-ROC-17013993.

Post-stroke limitations in daily activities: experience from a tertiary care hospital in Ethiopia

BACKGROUND

The disability of stroke patients remains an important global health problem; yet information on the extent of restriction from basic and instrumental activities of daily living is limited, particularly in lower-and middle-income (LMIC) countries. Therefore, we examined the issue under the caption, since it is the first step in planning several rehabilitation services.

METHOD

A facility-based cross-sectional study was done to assess the magnitude and predictors of post-stroke limitations in basic activities of daily living (BADL) using the Barthel Index (BI) scale and instrumental activities of daily living (IADL) using the Frenchay Activities Index (FAI) scale among patients who visited Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia, Neurology Clinic from April-October, 2022. All patients having a diagnosis of stroke for more than six months duration were enrolled. Descriptive and inferential statistical analyses were done, and measures of estimated crude and adjusted odds ratio with 95% CI were constructed and a p-value less than 0.05 was considered statistically significant. The results are presented in figures and tables.

RESULTS

A total of 150 stroke patients were enrolled in the present study. The mean age of participants was 53 (14.9) years with slight male preponderance (51.3%). Ischemic stroke was present in 106 (70.7%) of them, while 44 (29.3%) had hemorrhagic stroke. Of this, 57 (38%) and 115 (79.3%) of them had limitations in basic and instrumental ADL, respectively. Comorbid cardiac disease (AOR = 6.9; 95%CI = 1.3-37.5) and regular substance use (AOR = 11.1; 95%CI = 1.1-115) were associated with limitations in BADL, while an increase in age (AOR = 1.1; 95%CI = 1.04-1.15) was associated with severe limitations in BADL. Initial stroke severity (AOR = 7.3; 95%CI = 1.2-44.7) was associated with limitations in IADL, whereas depression (AOR = 5.1; 95%CI = 1.1-23.2) was identified as a predictor of severe limitation in IADL.

CONCLUSION

Limitation in activities of daily living (ADL) after stroke is common among Ethiopian patients. Therefore, screening for post-stroke limitations in daily activities is essential for further management and rehabilitative plans.

Role of age and sex in the association between BMI and functional limitations in stroke patients: Cross-sectional analysis in three European and US cohorts

BACKGROUND

A U- or J-shaped association between BMI and different post-stroke outcomes is suggested. Thus, the aim is to evaluate the association between BMI with ADL, IADL and mobility limitations in the ageing post-stroke population at different ages, as well as the differences in this association by sex.

METHODS

A total of 5,468 participants with stroke and 21,872 without stroke over 50 years of age were assessed for the number of limitations in basic or instrumental activities of daily living (ADL/IADL) as well as mobility tasks. The association between BMI at the interview (continuous time-dependent variable) and the level of limitations was assessed using a linear mixed model stratified by sex and stroke status.

RESULTS

The association between BMI and ADL/IADL and mobility limitations were found to be significant in both men and women regardless of stroke status (p<0.001 for all). The association differs between those who have suffered a stroke and those who have not (p<0.001 for all). In ADL/IADL limitations, men with stroke showed a transition from an inverted J-shape to a U-shape association with age. In women, the BMI showed a less pronounced association between BMI and ADL/IADL limitations compared to men but with similar trends. A effect of sex was observed in the association between BMI and mobility, with women with and without stroke showing a linear association that differed from the inverted J-shaped or U-shaped association of men.

CONCLUSION

Our results suggest that BMI is associated with limitations in ADL, IADL and mobility in stroke patients. In addition, this association differs between men and women and is also influenced by age.

Cohort profile: The South London Stroke Register - a population-based register measuring the incidence and outcomes of stroke

PURPOSE

The South London Stroke Register (SLSR) is a population-based cohort study, which was established in 1995 to study the causes, incidence, and outcomes of stroke. The SLSR aims to estimate incidence, and acute and long term needs in a multi-ethnic inner-city population, with follow-up durations for some participants exceeding 20 years.

PARTICIPANTS

The SLSR aims to recruit residents of a defined area within Lambeth and Southwark who experience a first stroke. More than 7700 people have been registered since inception, and >2750 people continue to be followed up. At the 2011 census, the source population was 357,308.

FINDINGS TO DATE

The SLSR was instrumental in highlighting the inequalities in risk and outcomes in the UK, and demonstrating the dramatic improvements in care quality and outcomes in recent decades. Data from the SLSR informed the UK National Audit Office in its 2005 report criticising the poor state of stroke care in England. For people living in the SLSR area the likelihood of being treated in a stroke unit increased from 19% in 1995-7 to 75% in 2007-9. The SLSR has investigated health inequalities in stroke incidence and outcome. SLSR analyses have demonstrated that lower socioeconomic status was associated with poorer outcome, and that Black people and younger people have not experienced the same improvements in stroke incidence as other groups.

FUTURE PLANS

As part of an NIHR Programme Grant for Applied Research, from April 2022 the SLSR has expanded to recruit ICD-11 defined stroke (including those with <24 h symptoms where there are neuroimaging findings), and have expanded the follow up interviews to collect more detailed information on quality of life, cognition, and care needs. Additional data items will be added over the Programme based on feedback from patients and other stakeholders.

Prevalence and Outcomes of Depression, Obstructive Sleep Apnea, and Concurrent Anxiety (DOCA) in Stroke Survivors: Insights From a Nationwide Study

BACKGROUND

Many individuals will also experience psychological side effects after a stroke episode, such as symptoms of depression, anxiety (generalized anxiety disorder (GAD)), and/or specific phobias, considerably decreasing their quality of life (QOL).

OBJECTIVE

This study aimed to evaluate the prevalence of depression, obstructive sleep apnea (OSA), and concurrent anxiety (DOCA) and their outcomes (morbidity, disability (All Patient Refined Diagnosis Related Group (APRDRG) - loss of function), and discharge disposition) among acute ischemic stroke (AIS) hospitalizations.

METHODS

A cross-sectional study used the National Inpatient Sample (NIS) from 2003-2017. Adults with hospitalizations with AIS were extracted, and DOCA was identified using ICD-9/10-CM codes. Weighted analysis using a chi-square test and mixed-effect multivariable survey logistic regression was used to assess the prevalence and role of DOCA in predicting outcomes.

RESULTS

Out of 5,690,773 AIS hospitalizations, 2.7%, 3.1%, and 4.4% had depression, OSA, and GAD, respectively. In AIS patients, females had a higher prevalence of depression (3.4% vs. 2.3%) and GAD (5.9% vs. 3.0%) and a quality of life lower prevalence of OSA (2.2% vs 4.4%) in comparison to males (p<0.0001). Caucasians had a higher prevalence of depression, OSA, and GAD in comparison to others (African Americans/Hispanics/Asians/Native Americans). Depressed patients had a higher prevalence of morbidity (9% vs. 8% vs 5% vs. 7%), disability (46% vs. 46% vs. 35% vs. 37%), transfer to non-home (69% vs. 58% vs. 61% vs. 63%) in comparison with OSA, GAD, and non-DOCA patients, respectively (p<0.0001). Depression was associated with a 40% higher chance of severe disability (aOR 1.40; 95% CI 1.38-41), morbidity (1.36; 1.33-1.38), and discharge to non-home (1.54; 1.52-1.56). OSA and GAD had higher odds of non-home discharge amongst post-AIS hospitalizations.

CONCLUSION

DOCA is associated with poor outcomes among post-AIS patients. Prompt recognition by screening and timely management of DOCA may mitigate the adverse outcomes.

Timing and Dose of Constraint-Induced Movement Therapy after Stroke: A Systematic Review and Meta-Regression

The aim of this study is to investigate the effects of constraint-induced movement therapy on stroke patients who had intact cognition and some voluntary finger extension and to identify optimal protocols to apply this therapy method. We searched PubMed, Cochrane Library, and Embase for randomized controlled trials conducted prior to January 2022. The outcomes included the Motor Activity Log, Fugl-Meyer Assessment, and Wolf Motor Function Test. The inverse variance method fixed-effect model as well as the DerSimonian and Laird estimator random-effects model were applied, and the mean difference was calculated with 95% confidence interval to measure continuous outcomes. Six randomized controlled trials involving a total of 169 patients with stroke were enrolled. Compared with conventional rehabilitation methods, there was no significant effect of constraint-induced movement therapy when evaluated by the Motor Activity Log, including the amount of use (random-effect, standardized mean difference 0.65; 95%, confidence interval: −0.23–1.52) and quality of movement (random-effect, standardized mean difference 0.60; 95% confidence interval: −0.19–1.39). However, among patients with chronic stroke symptoms, meta-regression analyses showed better performance with a constraint time of at least 6 h per day and 6 h training per week when assessing the amount of use (p = 0.0035) and quality of movement (p = 0.0031). Daily intervention time did not lead to a significant difference in functional upper limb performance. An efficient protocol of constraint-induced movement therapy designed as 6 h of training per week with 6 h constraint per day could bring significant stroke symptom improvement to patients with chronic stroke.

An intervention to support stroke survivors and their carers in the longer term: results of a cluster randomised controlled feasibility trial (LoTS2Care)

BACKGROUND

To address the limited provision of longer-term stroke care, we conducted a programme of research (LoTS2Care) to develop and test an intervention to form part of a replicable longer-term care strategy. New Start, a programme of facilitated self-management, was developed to be delivered at 6 months post-stroke by trained facilitators. Here, we report the findings from the final workstream of this programme, which aimed to evaluate the feasibility and acceptability of implementing a future definitive cluster randomised controlled trial of the developed intervention (New Start) to support stroke survivors and their carers in the longer term.

METHODS

A feasibility cluster randomised controlled trial was conducted in English and Welsh NHS stroke services. Stroke services (clusters) were randomised on a 1:1 basis to implement New Start or continue with usual care only. Community-dwelling stroke survivors between 4 and 6 months post-stroke were invited to participate in the trial by post. Outcome measures were collected via post at 3, 6 and 9 months after recruitment. Recruitment and follow-up rates, delivery and uptake of the intervention, data collection feasibility (including postal outcome measures of health and disability, mental well-being at 3, 6, and 9 months post-recruitment) and safety were assessed.

RESULTS

Ten stroke services were recruited. A total of 1127 stroke survivors were screened for participation, and 269 were registered (New Start, n = 145; usual care, n = 124). Retention was high with 239 (89%) stroke survivors being available for follow-up at 9 months, and high return rates of postal questionnaires were achieved (80.3% at 9 months). Intervention training was successfully delivered, and New Start was offered to 95.2% of trial participants in the intervention arm. Uptake was variable, however, ranging from 11.8 to 75.0%. There were no safety concerns.

CONCLUSIONS

Stroke service recruitment and longer-term stroke survivor postal recruitment and outcome data collection are feasible; however, refinement of intervention targeting and delivery is required prior to undertaking a definitive trial.

TRIAL REGISTRATION

ISRCTN38920246. Registered 22 June 2016 ( http://www.isrctn.com/ISRCTN38920246 ).

Quality of life: predictors and outcomes after stroke in a Brazilian public hospital

BACKGROUND

Some scales are applied after stroke to measure functional independence but qualify of life (QoL) is sometimes neglected in this scenario.

OBJECTIVE

To analyze predictors and outcomes of QoL after stroke using a validated scale in our population.

METHODS

Our study included patients who had their first ischemic stroke and were followed in the outpatient clinic for at least 6 months from stroke index. Disability status was assessed using the modified Rankin scale (mRS), the Barthel index (BI), and the Lawton and Brody scale. Quality of life was assessed by a stroke-specific QoL (SSQoL) scale. Statistical significance was accepted for p < 0.05. The estimated measure of association was the odds ratio (OR) for which 95% confidence intervals (95%Cis) were presented.

RESULTS

Of 196 patients studied, the median age was 60.4 (±13.4) years, and 89 (45.40%) of the patients were female. In a stepwise model considering risk factors, basic activities of daily living scales, satisfaction with life, and outcomes, we found four independent variables related to a poor QoL after stroke, namely hypertension, non-regular rehabilitation, not returning to work, and medical complications. The National Institutes of Health stroke scale (NIHSS) score at admission ≥ 9 was also an independent clinical marker. Approximately 30% of all participants had a negative score under 147 points in the SSQoL.

CONCLUSIONS

Our results showed that QoL after stroke in a developing country did not seem to differ from those of other countries, although there is a gap in rehabilitation programs in our public system. The functional scales are important tools, but they have failed to predict QoL, in some patients, when compared with specific scales.

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

PURPOSE

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

MATERIAL AND METHOD

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

RESULTS

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

CONCLUSION

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

Incidence, lethality, and post-stroke functional status in different Brazilian macro-regions: The SAMBA study (analysis of stroke in multiple Brazilian areas)

Background

Stroke is the second leading cause of death in Brazil. The social and financial burden of stroke is remarkable; however, the epidemiological profile remains poorly understood.

Objective

The aim of this study was to report the incidence, lethality, and functional status at 30 and 90 days post-stroke in the cities of different Brazilian macro-regions.

Methods

This is an observational, prospective, and population-based study, led in Canoas (South), Joinville (South, reference center), Sertãozinho (Southeast), and Sobral (Northeast) in Brazil. It was developed according to the three-step criteria recommended by the World Health Organization to conduct population-based studies on stroke. Using different sources, all hospitalized and ambulatory patients with stroke were identified and the same criteria were kept in all cities. All first events were included, regardless of sex, age, or type of stroke. Demographic and risk factor data were collected, followed by biochemical, electrocardiographic, and radiological test results. Functional status and lethality were obtained using the mRankin scale through telephonic interview (validated Brazilian version).

Results

In 1 year, 932 stroke cases were registered (784 ischemic stroke, 105 hemorrhagic stroke, and 43 subarachnoid hemorrhage). The incidence rates per 100,000 inhabitants, adjusted for the world population, were 63 in Canoas, 106 in Joinville, 72 in Sertãozinho, and 96 in Sobral. The majority (70.8%) were followed for 90 days. Kaplan-Meier curves showed that 90-day survival was different among cities. Sobral, which has the lowest socioeconomic indexes, revealed the worst results in terms of lethality and functional status.

Conclusion

This study expands the knowledge of stroke epidemiology in Brazil, a middle-income country with enormous socioeconomic and cultural diversity. The discrepancy observed regarding the impact of stroke in patients from Joinville and Sobral highlights the need to improve the strategic allocation of resources to meet the health priorities in each location.

Moving from traditional to more advanced treatments in stroke care is cost-effective: A case study from Greece

OBJECTIVES

Stroke is the most common cause of disability in high-income countries. Several countries offer a limited range of advanced treatments with implications for outcomes, disability and costs. This study estimates the burden of disability that could have been avoided through the transition from traditional (no intravenous thrombolytic therapy (IVT), or endovascular thrombectomy (EVT)) to modern stroke treatments (treatment in stroke units, IVT and EVT). We perform a cost-effectiveness analysis comparing best practice with traditional stroke care, using Greece as a case study.

MATERIALS AND METHODS

A Markov model was used to calculate costs and Quality Adjusted Life Years (QALYs) for each treatment strategy, using a lifetime horizon. Data for model inputs were derived from meta-analyses of trials, and national and international cost databases. Sensitivity analyses were also performed to address potential uncertainty and test the robustness of the findings.

RESULTS

Incremental effectiveness comprised 0.22 QALYs per patient and year. Best practice was cost-effective for more than 90% of all iterations (ICER for the baseline scenario: €2,109.25/QALY). Sensitivity analysis demonstrated that the findings remain robust. Considering the stroke incidence in Greece, the annual additional cost to implement best practice was calculated to be between 0.07%-0.15% of the total health expenditure.

CONCLUSION

Best practice stroke treatment was cost-effective and affordable in a case study based on Greece. The results could be leveraged by including effects of preventive policies and rehabilitation. They also highlight the importance of adopting modern treatment strategies from a cost-effectiveness perspective, apart from the improved clinical outcomes.

Long-term determinants of death after stroke in Ghana: Analysis by stroke types & subtypes

BACKGROUND

Determinants of long-term mortality after stroke by mechanistic type and subtype are unknown in sub-Saharan Africa (SSA). Such data are crucial for targeting specific pathophysiologic pathways to improve stroke outcomes in the region.

PURPOSE

To evaluate rates and predictors of mortality up to 8 years after stroke, by type and subtype, in Ghana.

METHODS

We prospectively collected data on stroke patients presenting at a tertiary medical facility in Ghana between 2013 and 2018 who were followed up until October 31, 2021. Stroke diagnosis was confirmed using a Computerized Tomography scan; ischemic strokes were mechanistically typed using the TOAST classification while intracerebral hemorrhages were subtyped using the SMASH-U scheme. Demographic and clinical predictors of stroke mortality were evaluated using Cox proportional hazards regression modelling.

RESULTS

Of 564 patients encountered during the study period, data on vital status were available for 556 (98.6%) subjects at discharge and 442 (78.4%) on follow-up. Mean age was 61.1 ±15.1 years, and 223 (53.1%) were male. Mortality rates at 1, 3, 12, 36, 60 and 96 months were 37.5%, 43.2%, 49.7%, 57.4%, 62.9%, and 73.7% respectively. Three (3) factors remained significantly associated with risk of death namely age, adjusted hazard ratios (aHR) of 1.12 (95%CI: 1.04-1.20), no formal education 1.36 (95% CI: 1.02-1.81) and modified Rankin score 1.67 (95%CI: 1.42 - 1.98) for each unit rise. For ischemic stroke the four (4) factors associated with long-term mortality were low formal education, low monthly income, having diabetes mellitus and higher functional score on admission. For intracerebral hemorrhage, the two factors were increasing age and high functional score.

CONCLUSION

Stroke severity is the key predictor of long-term mortality after an index stroke in Ghana, regardless of the underlying pathophysiologic mechanism. Instituting acute stroke systems of care to facilitate timely reperfusion efforts may greatly improve long term survival outcomes after stroke in SSA.

Predictors of long-term return-to-work at five-year follow-up for mild-to-moderate subacute stroke patients enrolled in an early supported discharge program

BACKGROUND: Facilitating return-to-work (RTW) for working-age stroke survivors is a key component of stroke rehabilitation, however, research investigating the long-term outcomes of working-age stroke survivors is lacking. OBJECTIVE: To investigate the factors that influence long-term RTW for patients enrolled on a community-based early supported discharge (ESD) rehabilitation program in Singapore about five years post stroke. METHODS: Sixty-nine patients, aged between 18 and 60 years and were employed at the time of their hospitalization, were enrolled into the ESD program between 2012 and 2014. A prospective cohort design was adopted to examine the relationships between the factors— demographic, functional, personal, psychosocial factors and work related— and RTW at five-year follow-up. Details of RTW were collected through questionnaires via telephone follow-up. RESULTS: Sixty percent of the participants (n = 49) were selected for Cox and logistic regression analyses of RTW at five-year follow-up. The results indicated that having social problems is a negative predictor of RTW (OR 0.02; 95% CI 0.00–0.22) while being the breadwinner is a positive predictor of RTW (OR 13.79; 95% CI 2.46–77.52). The same factors were also significant in the time to RTW event at five-year follow-up, with a hazard ratio of 0.09 and 4.07, respectively. CONCLUSIONS: Early identification of the characteristics of stroke patients enrolled into an ESD program who have the potential to RTW would make interventions more targeted, increasing the likelihood of RTW.

Stroke Outcomes in Women: A Population-Based Cohort Study

BACKGROUND

Limited data are available on sex-related disparities in long-term outcomes after stroke. We estimated sex differences in various stroke long-term outcomes among survivors after stroke in a prospective 25-year follow-up study.

METHODS

Individuals recruited to the South London Stroke Register, an ongoing multi-ethnic urban-based population stroke register, from 1995 onward were included in the analyses (n=6687). The outcomes were death, subsequent stroke, activity of daily living, instrumental activity of daily living, cognitive impairment, depression, anxiety, and health-related quality of life. Kaplan-Meier curves were generated for mortality, stroke recurrence, and recurrence-free survival by sex and Cox proportional hazards model used to model sex differences up to 25 years. Generalized estimating equation were used to model sex differences in risk of self-reported stroke outcomes over 10 years poststroke outcomes, adjusting for age, preexisting activity of daily living, case-mix, stroke subtypes, and other potential confounding risk factors.

RESULTS

There were 49% women (mean age, 72 years; SD, 15.6) and 51% men (mean age, 67 years; SD, 14.3) in 6687 participants. Compared with men, women had 9% (95% CI, 3%-15%) lower covariate-adjusted risk of death and 6% (0%-13%) lower risk of stroke recurrence or death. Generally, women had significantly poorer outcomes in activity of daily living and anxiety than men, and the sex differences persisted to up to 5 years after stroke. Women also had poorer health-related quality of life in physical (β=-2.06 [95% CI, -3.01 to -1.10]) and mental domains (β=-1.48 [95% CI, -2.44 to -0.52]). Although not significant, there was a suggestive trend for poorer outcomes in cognitive impairment and depression in women. No significant difference in stroke recurrence were found between men and women.

CONCLUSIONS

Female patients with stroke tended to have better covariate-adjusted survival but poorer outcomes among survivors than male patients, with deficits persisting to up to 5 years poststroke.

Depression symptoms 6 years after stroke are associated with higher perceived impact of stroke, limitations in ADL and restricted participation

Late post-stroke depression symptoms are understudied. This study aimed to investigate depression symptoms 6 years after stroke, and associations with perceived impact of stroke, activities of daily living (ADL), and participation in social and everyday activities. Data was collected in a 6-year follow-up in a longitudinal study of stroke. Assessments included Hospital Anxiety and Depression Scale (HADS) for depression symptoms, Stroke Impact Scale 3.0. for perceived impact of stroke, Barthel Index for ADL, Frenchay Activities Index for participation in social and everyday activities. The research questions were addressed by bivariate analyses (with HADS-D ≥ 4 as cut-off), and hierarchical multiple regression analyses using continuous HADS-D scores. Forty percent of the 105 participants (57% men, age 30-91) showed depression symptoms (HADS-D ≥ 4). Depression symptoms were associated with higher perceived impact of stroke, more dependence in ADL, and more restrictions in participation in social and everyday activities. Most of those with depression symptoms had low scores on HADS, indicating that even mild depression symptoms might be relevant to identify and target in treatment and rehabilitation of long-term consequences of stroke.

Formal Health and Social Services That Directly and Indirectly Benefit Stroke Caregivers: A Scoping Review of Access and Use

Stroke can be a life altering event that necessitates considerable amounts of formal and informal care. The impacts of stroke often persist over time requiring ongoing support for stroke survivors. Family members provide the majority of care and experience many life changes as a result of their caregiving role including social, financial, employment and health impacts. Formal supports such as counselling, respite, and health promotion initiatives that directly benefit caregivers or benefit them indirectly through supporting the stroke survivor, are well-placed to help caregivers manage their caregiving role. However, to date little is known about formal service use by stroke caregivers and the factors that influence their service use. This scoping review provides a critique and synthesis of what is known about stroke caregivers’ access and use of formal services intended to support them. Findings suggest that while services are available, caregivers’ ability to use them are impacted by both facilitators and barriers. Facilitators included: sex, age, and having a higher household income (depending on services used). Barriers included: high cost, poor service quality and deficient knowledge/communication regarding service availability. This review highlights a significant gap in our knowledge of caregivers’ experience in accessing and using formal services.

Cost-Effectiveness of Endovascular Thrombectomy in Childhood Stroke: An Analysis of the Save ChildS Study

Background and Purpose

The Save ChildS Study demonstrated that endovascular thrombectomy (EVT) is a safe treatment option for pediatric stroke patients with large vessel occlusions (LVOs) with high recanalization rates. Our aim was to determine the long-term cost, health consequences and cost-effectiveness of EVT in this patient population.

Methods

In this retrospective study, a decision-analytic Markov model estimated lifetime costs and quality-adjusted life years (QALYs). Early outcome parameters were based on the entire Save ChildS Study to model the EVT group. As no randomized data exist, the Save ChildS patient subgroup with unsuccessful recanalization was used to model the standard of care group. For modeling of lifetime estimates, pediatric and adult input parameters were obtained from the current literature. The analysis was conducted in a United States setting applying healthcare and societal perspectives. Probabilistic sensitivity analyses were performed. The willingness-to-pay threshold was set to $100,000 per QALY.

Results

The model results yielded EVT as the dominant (cost-effective as well as cost-saving) strategy for pediatric stroke patients. The incremental effectiveness for the average age of 11.3 years at first stroke in the Save ChildS Study was determined as an additional 4.02 lifetime QALYs, with lifetime cost-savings that amounted to $169,982 from a healthcare perspective and $254,110 when applying a societal perspective. Acceptability rates for EVT were 96.60% and 96.66% for the healthcare and societal perspectives.

Conclusions

EVT for pediatric stroke patients with LVOs resulted in added QALY and reduced lifetime costs. Based on the available data in the Save ChildS Study, EVT is very likely to be a cost-effective treatment strategy for childhood stroke.

Pre-stroke Disability and Long-Term Functional Limitations in Stroke Survivors: Findings From More of 12 Years of Follow-Up Across Three International Surveys of Aging

Background

Almost 50% of the post-stroke disabled population already have a premorbid disability before stroke. These patients may be offered a different care pathway in the acute and subacute phase than those without pre-morbid disability. Therefore, the aim of this study was to assess the association of the severity of premorbid disability with change of limitations in basic and instrumental activities of daily living (ADL/IADL) 1 year after stroke and over the following decade.

Methods

Among 3,432 participants from HRS, SHARE and ELSA cohorts with a first stroke, ADL/IADL limitations were measured at 1-2 years prior to stroke, at 1 year post-stroke, and during the chronic phase. Modified Ranking Scale (P-mRS) was used to categorize the participants by level of premorbid disability (1-2 years pre-stroke). Change in ADL/IADL limitations by P-mRS level (0-1, 2-3, and 4-5) was assessed using a piecewise linear mixed model with a breakpoint set at 1 year post-stroke, stratified by median age groups.

Results

Increase in ADL limitations at 1 year post-stroke was less pronounced in P-mRS ≥2 (p < 0.005). After years of relative stability, limitations of ADL increased for all P-mRS levels (p = 0.003). In those aged ≥75 years at stroke event, the increase was similar irrespective of P-mRS (p = 0.090). There were no significant differences in IADL trajectories between P-mRS levels (p ≥ 0.127).

Conclusion

These results suggest similar trajectories of functional limitations between P-mRS levels up to 9 years post-stroke, highlighting the possible benefit of including patients with pre-morbid disability to certain treatments during the acute phase.

Long-Term Evolution of Functional Limitations in Stroke Survivors Compared With Stroke-Free Controls: Findings From 15 Years of Follow-Up Across 3 International Surveys of Aging

BACKGROUND AND PURPOSE

In the chronic phase 2 to 5 years poststroke, limitations in activities of daily living (ADL) and instrumental ADL (IADL) initially plateau before steady increasing. However, the impact of age and differences in initial levels of disability on the evolution of these limitations remains unclear. As such, this study aims to evaluate differences in long-term evolution of ADL/IADL limitations between stroke survivors and stroke-free population, and how limitations differ by initial level of disability for stroke survivors.

METHODS

Thirty-three thousand six hundred sixty participants (5610 first-ever stroke cases with no recurrence during follow-up and 28 050 stroke-free controls) aged ≥50 from the Health and Retirement Study, Survey of Health, Ageing and Retirement in Europe, and English Longitudinal Study of Ageing were assessed for number of ADL/IADL limitations during the poststroke chronic phase (for cases) and over follow-up years 1996 to 2018 (for controls). Three thousand seven hundred eighteen stroke cases were additionally categorized by disability level using the modified Rankin Scale score of 1 to 2 years poststroke. Evolution of ADL/IADL limitations was assessed in stroke cases and controls and by modified Rankin Scale score (0-1, 2-3, 4-5) using linear mixed models. Models were stratified by age group (50-74 and ≥75 years) and adjusted for baseline characteristics, health behaviors, BMI, and comorbidities.

RESULTS

Findings showed relative stability of ADL/IADL limitations during 3 to 6 years poststroke followed by an increase for both populations, which was faster for younger stroke cases, suggesting a differential age-effect (P<0.001). Disability level at 1 to 2 years poststroke influenced the evolution of limitations over time, especially for severe disability (modified Rankin Scale score, 4-5) associated with a reduction in limitations at 5 to 6 years poststroke.

CONCLUSIONS

Our findings showed that during the poststroke chronic phase functional limitations first plateau and then increase and the evolution differs by disability severity. These results highlight the importance of adaptive long-term health and social care measures for stroke survivors.

Survival and outcomes for stroke survivors living in care homes: a prospective cohort study

Background

Stroke survivors living in care homes require high levels of support with everyday living. The aims of this study were to describe the survival, health status and care received by stroke survivors living in care homes at 1-year post-stroke, compared with those in their own homes.

Methods

A total of 3,548 stroke survivors with a first ever stroke between 1998 and 2017 in the South London Stroke Register were identified for survival analysis. A total of 2,272 were included in the 1-year follow-up analysis. Cox regression and Kaplan–Meier plots were used to describe survival, stratified into four 5-year cohorts. Health status, medications and rehabilitation received at 1-year post-stroke were compared using descriptive statistics.

Results

Over the 20-year period, survival improved for stroke survivors discharged to their own home (P < 0.001) but not for those discharged to care homes (P = 0.75). Care home residents were highly disabled (median Barthel index: 6/20, interquartile range: 2–10). Rates of secondary stroke prevention medications at 1-year follow-up increased over time for care home residents, including antiplatelets from 12.3 to 38.1%, although still lower than for those in their own homes (56.3%). Speech and language problems were common in the care home population (40.0%), but only 16% had received speech and language therapy.

Conclusions

Rates of secondary stroke prevention prescribing increased over 20 years but remained lower in care home residents. The lower levels of rehabilitation received by stroke survivors in care homes, despite their higher levels of disability, suggest a gap in care and urgent need for restorative and/or preventative rehabilitation.

Adjusted productivity costs of stroke by human capital and friction cost methods: a Northern Finland Birth Cohort 1966 study

BACKGROUND

Productivity costs result from loss of paid and unpaid work and replacements due to morbidity and mortality. They are usually assessed in health economic evaluations with human capital method (HCM) or friction cost method (FCM). The methodology for estimating lost productivity is an area of considerable debate.

OBJECTIVE

To compare traditional and adjusted HCM and FCM productivity cost estimates among young stroke patients.

METHODS

The Northern Finland Birth Cohort 1966 was followed until the age of 50 to identify all 339 stroke patients whose productivity costs were estimated with traditional, occupation-specific and adjusted HCM and FCM models by using detailed, national register-based data on care, disability, mortality, education, taxation and labour market.

RESULTS

Compared to traditional HCM, taking into account occupational class, national unemployment rate, disability-free life expectancy and decline in work ability, the productivity cost estimate decreased by a third, from €255,960 to €166,050. When traditional FCM was adjusted for occupational class and national unemployment rate, the estimate more than doubled from €3,040 to €7,020. HCM was more sensitive to adjustments for discount rate and wage growth rate than FCM.

CONCLUSIONS

This study highlights the importance of adjustments of HCM and FCM. Routine register-based data can be used for accurate productivity cost estimates of health shocks.

Risk Prediction of Cognitive Decline after Stroke

BACKGROUND AND PURPOSE

Cognitive decline is one of the major outcomes after stroke. We have developed and evaluated a risk predictive tool of post-stroke cognitive decline and assessed its clinical utility.

METHODS

In this population-based cohort, 4,783 patients with first-ever stroke from the South London Stroke Register (1995-2010) were included in developing the model. Cognitive impairment was measured using the Mini Mental State Examination (cut off 24/30) and the Abbreviated Mental Test (cut off 8/10) at 3-months and yearly thereafter. A penalised mixed-effects linear model was developed and temporal-validated in a new cohort consisted of 1,718 stroke register participants recruited from (2011-2018). Prediction errors on discrimination and calibration were assessed. The clinical utility of the model was evaluated using prognostic accuracy measurements and decision curve analysis.

RESULTS

The overall predictive model showed good accuracy, with root mean squared error of 0.12 and R2 of 73%. Good prognostic accuracy for predicting severe cognitive decline was observed AUC: (88%, 95% CI [85-90]), (89.6%, 95% CI [86-92]), (87%, 95% CI [85-91]) at 3 months, one and 5 years respectively. Average predicted recovery patterns were analysed by age, stroke subtype, Glasgow-coma scale, and left-stroke and showed variability. DECISION: curve analysis showed an increased clinical benefit, particularly at threshold probabilities of above 15% for predictive risk of cognitive impairment.

CONCLUSIONS

The derived prognostic model seems to accurately screen the risk of post-stroke cognitive decline. Such prediction could support the development of more tailored management evaluations and identify groups for further study and future trials.

Current characteristics and early functional outcome of older stroke patients: a population-based study (Dijon Stroke Registry)

BACKGROUND

the ongoing growing and ageing population is associated with an increase in older patients suffering a stroke. We aimed to assess the current profile of these patients in a population-based setting.

METHODS

all patients with acute stroke were prospectively identified among residents of Dijon, France, between 2013 and 2017, using a population-based registry. Characteristics and early outcome of patients were compared according to age groups.

RESULTS

1,288 stroke cases were recorded (median age: 81.1 years, interquartile range: 66.1-86.7, 54% women). Patients aged 75-85 years and those >85 years accounted for 27.6 and 33.9% of overall cases. Increasing age was associated with a greater prevalence of vascular risk factors, pre-existing cognitive impairment and handicap, higher initial severity, more frequent cardioembolic ischemic stroke, post-stroke pulmonary infection and delirium. Only 41% of patients aged 75-85 years and 18% of those aged >85 years had a good early recovery. Compared with patients aged <75 years, patients aged 75-85 years [adjusted odds ratio (OR) = 2.61; 95% confidence interval (CI): 1.74-3.93, P < 0.001] and those aged >85 years (adjusted OR = 7.18; 95% CI: 4.58-11.3, P < 0.001) had an increased risk of poor post-stroke functional outcome. Among survivors, the proportion of patients discharged to home was 60% in age group <75 years, compared with 49% in patients aged 75-85 years and 29% in those aged >85 years. Thirty per cent of patients >85 years old required a long-term care institution.

CONCLUSION

the increasing burden of stroke in older people has major implications for future treatment strategies and need for dedicated care facilities.

Participation in social and leisure activities while re-constructing the self: understanding strategies used by stroke survivors from a long-term perspective

PURPOSE

To further understand social and leisure (SL) participation after stroke and how it can be supported in a long-term perspective, this study aims to deepen the understanding of strategies used by long-term stroke survivors in relation to SL activities.

MATERIALS AND METHODS

The study has a qualitative design, using a grounded theory approach, and is based on in-depth interviews with 10 persons who had a stroke 15 years ago and four of their family members.

RESULTS

The findings comprise nine different strategies used by the participants. These had two overarching purposes; to protect and re-construct the post-stroke self and to enable participation in valued SL activities despite challenges. The findings are summarized in one overarching theme: "Employing different strategies to balance costs and rewards of engagement in social and leisure activities".

CONCLUSIONS

Strategies for SL participation involves balancing different priorities in life and can change over time as they are continuously influenced by various personal and environmental conditions. These findings contribute to an improved understanding of why and how people hold on to activities, give up activities and find new activities after a stroke. It also highlights the need for a long-term perspective on stroke rehabilitation and support.IMPLICATIONS FOR REHABILITATIONRe-engagement in social and leisure activities after stroke is a long-term process and various types of support may be needed during different stages of recovery and adaptation.Successful rehabilitation interventions build on an understanding of each individual's priorities, goals and strategies and how these may change or manifest over time.Special attention should be given to the individual's perception of costs and benefits in relation to engagement in activities, and the role that it has for the person's identity.By providing knowledge and supporting the use of adequate coping strategies, rehabilitation professionals can help patients find a new and accepted post-stroke identity.

Impact of Sleep Duration on Depression and Anxiety After Acute Ischemic Stroke

Background: Abnormal sleep duration predicts depression and anxiety. We seek to evaluate the impact of sleep duration before stroke on the occurrence of depression and anxiety at 3 months after acute ischemic stroke (AIS). Methods: Nationally representative samples from the Third China National Stroke Registry were used to examine cognition and sleep impairment after AIS (CNSR-III-ICONS). Based on baseline sleep duration before onset of stroke as measured by using the Pittsburgh Sleep Quality Index (PSQI), 1,446 patients were divided into four groups: >7, 6-7, 5-6, and <5 h of sleep. Patients were followed up with the General Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) for 3 months. Poststroke anxiety (PSA) was defined as GAD-7 of ≥5 and poststroke depression (PSD) as PHQ-9 of ≥5. The association of sleep duration with PSA and PSD was evaluated using multivariable logistic regression. Results: The incidences of PSA and PSD were 11.2 and 17.6% at 3 months, respectively. Compared to a sleep duration of >7 h, 5-6 h, and <5 h of sleep were identified as risk factors of PSA [odds ratio (OR), 1.95; 95% confidence interval (CI), 1.24-3.07; P < 0.01 and OR, 3.41; 95% CI, 1.94-6.04; P < 0.01) and PSD (OR, 1.47; 95% CI, 1.00-2.17; P = 0.04 and OR, 3.05; 95% CI, 1.85-5.02; P < 0.01), while 6-7 h of sleep was associated with neither PSA (OR, 1.09; 95% CI, 0.71-1.67; P = 0.68) nor PSD (OR, 0.92; 95% CI, 0.64-1.30; P = 0.64). In interaction analysis, the impact of sleep duration on PSA and PSD was not affected by gender (P = 0.68 and P = 0.29, respectively). Conclusions: Sleep duration of shorter than 6 h was predictive of anxiety and depression after ischemic stroke.

Utilisation of follow-up rehabilitation services for stroke survivors: a scoping review protocol

INTRODUCTION

Stroke is a leading cause of death and disability and has been identified as a significant public health problem. Residual functional deficits negatively affect the stroke survivor's functional independence and quality of life. Rehabilitation is necessary for them to regain lost skills, relearn tasks and be independent again.

METHODOLOGY AND ANALYSIS

A scoping review will be conducted to map available literature on factors influencing utilisation of follow-up rehabilitation services for stroke survivors. Databases including PubMed, LISTA(EBSCO), Web of Science (Clarivate), Google Scholar, Scopus and Science Direct will be searched using keyword searches for articles. The review will include studies presenting evidence on outpatient stroke rehabilitation services, studies undertaken and published in English, including grey literature. Title and abstract screening will be done simultaneously. Two reviewers will independently conduct the abstract and full-text article screening as well as pilot the data extraction form. Thematic analysis will be used to analyse the findings.

ETHICS AND DISSEMINATION

This scoping review is part of a larger study approved by the University of KwaZulu Natal Biomedical Research Ethics Committee (Reference no. BREC/00000660/2019). The results will be disseminated through publication.

Longer-term health and social care strategies for stroke survivors and their carers: the LoTS2Care research programme including cluster feasibility RCT

Background

It is reported that the longer-term outcomes for stroke survivors are poor, with a range of unmet needs identified.

Objectives

The aims were to develop and test a longer-term stroke care strategy focused on improving the quality of life of stroke survivors and their carers by addressing unmet needs, and maintenance and enhancement of participation (i.e. involvement in life situations).

Design

Five overlapping workstreams were undertaken – (1) refinement of content by semistructured interviews with stroke survivors and their carers and by a review of the literature to inform content and delivery of the care strategy; (2) exploration of service models by national survey and focus groups with purposely selected services; (3) intervention development by interaction with a reference group of stroke survivors, carers, and health and social care professionals; (4) refinement and pilot implementation of the developed intervention in three stroke services (case studies); and (5) a cluster randomised controlled feasibility trial in 10 stroke services across England and Wales.

Setting

The intervention development work and feasibility trial were in stroke services (inclusive of primary, secondary, community and social care provision) across England and Wales.

Participants

Participants were stroke survivors resident in the community and their carers, and health and social care professionals in the included stroke services.

Data sources

Interviews with 28 stroke survivors and their carers at least 9 months post stroke ascertained their needs and the barriers to and facilitators of addressing those needs. Additional literature reviews identified 23 needs. No evidence-based interventions to address these needs were reported; self-management was highlighted as a possible delivery mechanism. In workstream 2, a national survey revealed that the most common model of stroke service provision was care up to 12 months post stroke, reported by 46 (40%) services. Thirty-five (30%) services provided care up to 6 months post stroke and 35 (30%) provided care beyond 12 months, thus identifying 6 months post stroke as an appropriate delivery point for a new intervention. Through focus groups in a range of services, stroke survivors’ perceived unmet needs and the barriers to and enablers of service provision were identified.

Intervention

Using information obtained in workstreams 1 and 2 and working closely with a stakeholder reference group, we developed an intervention based on the unmet needs prioritised by stroke survivors and their carers (workstream 3). In workstream 4, action groups (clinicians, stroke survivors and researchers) were established in three stroke services that led implementation in their service and contributed to the iterative refinement of the intervention, associated training programme and implementation materials. The intervention (called New Start) was delivered at 6 months post stroke. Key components were problem-solving self-management with survivors and carers, help with obtaining usable information, and helping survivors and their carers build sustainable, flexible support networks.

Results

A cluster randomised feasibility trial (workstream 5) was successfully implemented in 10 stroke services across England and Wales, with associated process and health economic evaluations. Five services were randomised to provide New Start, while five continued with usual care; 269 participants were recruited. Progression criteria – in terms of our pre-determined (red, amber, green) criteria for progress to a full trial: target stroke survivor recruitment rates were achieved, on average, across sites (24.1 per site over 6 months, green); 216 (80.3%) registered stroke survivors returned follow-up questionnaires at 9 months (84.1% in the intervention arm and 75.8% in the usual care arm, green); according to data reported by sites, overall, 95.2% of registered stroke survivors were offered at least one session of the intervention (green); all five intervention sites had at least two facilitators deemed competent, delivered the New Start intervention and provided it to stroke survivors (green). However, at some sites, there were concerns regarding the number of stroke survivors being offered, accepting and receiving the intervention. Only small differences in outcomes and costs were observed between the New Start and usual care groups, and considerable uncertainty around the cost-effectiveness remains.

Conclusions

We report a complex programme of work that has described the longer-term needs of stroke survivors and highlighted evidence and service gaps. Working closely with stroke survivors, an intervention was developed that has been refined in three services and feasibility tested in a cluster randomised controlled trial. Further refinement of the target population and optimisation of the intervention materials is required prior to a full randomised controlled trial evaluation.

Future work

Optimisation of the intervention, and clearer specification of recipients, are required prior to a full trial evaluation.

Trial registration

Current Controlled Trials ISRCTN38920246.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 3. See the NIHR Journals Library website for further project information.

Long-Term Survival After Decompressive Craniectomy for Malignant Brain Infarction: A 10-Year Nationwide Study

BACKGROUND

Decompressive craniectomy (DC) has been shown to be an effective treatment for malignant cerebral infarction (MCI). There are limited nationwide studies evaluating outcome after craniectomy for MCI.

OBJECTIVE

To describe the evolution in DC practices for MCI, long-term survival, and associated prognostic factors.

METHODS

We searched the French medico-administrative national database to retrieve patients who underwent DC between 2008 and 2017.

RESULTS

A total of 1841 cases of DC were performed over 10 years in 51 centers. Mean age at procedure was 50.9 years, 18% were above 60 years, and 64.4% were male. There was a significant increase in DC for MCI over the 10 years (p < 0.001), and the annual volume of procedures more than doubled (95/year vs. 243/year). Early survival at one week and one month was 86%, _95%CI (84.5, 87.6) and 79.7%, _95%CI (77.8, 81.5), respectively. Long-term survival at 1 and 5 years were 73.6%, _95%CI (71.6, 75.7) and 68.9%, _95%CI (66.5, 71.4), respectively. Patients below 60 years at the time of DC (HR = 0.5; _95%CI [0.4, 0.7], p < 0.001), DC being performed in a center with a high surgical activity (HR = 0.8; _95%CI [0.6, 0.9], p = 0.002), and the patients having unimpaired consciousness (HR = 0.6; _95%CI [0.5, 0.8], p < 0.001) were associated with increased survival in both univariate and adjusted Cox regressions. 18.7% of the survivors had a cranioplasty inserted within 3 months and 57.8% within 6 months. The probability of having a cranioplasty at one year was 75.6%, _95%CI (77.9, 73.1).

CONCLUSION

Over the past 10 years in France, DC has been increasingly performed for MCI regardless of age. However, in-hospital mortality remains considerable, as about one quarter of patients died within the first weeks. For those who survive beyond 6 months, the risk of death significantly decreases. Early mortality is especially high for comatose patients above 60 years operated in inexperienced centers. Most of those who remain in good functional status tend to undergo a cranioplasty within the year following DC.

Integrating consequences of stroke into everyday life - Experiences from a long-term perspective

BACKGROUND

Occupational engagement encompasses both objective and subjective aspects of occupation. Long-term follow-up studies indicate that stroke can have a negative impact on the ability to perform IADL. Less is known about the subjective experiences of occupational engagement and how engagement may evolve after stroke.

OBJECTIVE

To explore stroke survivors' experiences of occupational engagement and how engagement changed over time and across contexts.

MATERIAL AND METHODS

Repeat, semi-structured interviews 15-18 years post-stroke, analysed using thematic analysis. Eight out of nine participants were classified as having had a mild stroke at onset.

RESULTS

The analysis resulted in five themes that together formed the main theme 'It takes time - integrating consequences of stroke into everyday life by engaging in occupation, using internal resources and adapting to context'. This illustrated how occupational outcome was the result of a continuous process in which occupational engagement was a way of gradually integrating consequences of stroke into everyday life.

CONCLUSION AND SIGNIFICANCE

Occupational engagement plays an important part in the process of moving on with life and can serve as both goal and means of achieving desired outcomes after stroke. Interventions that focus on enabling opportunities for occupational engagement in valued occupations and support the use of abilities and internal resources can reduce the impact of stroke in everyday life.

A Dynamic Model for Predicting Survival up to 1 Year After Ischemic Stroke

BACKGROUND

This study developed and validated a dynamic prediction model for survival after ischaemic stroke up to 1 year.

METHODS

Patients with stroke (n = 425) who participated in a sub-study (2002-2004) from the South London Stroke Register (SLSR) were selected for model derivation. The model was developed using the extended Cox model with time-dependent covariates. The two temporal validation cohorts from SLSR included 1735 (1995-2002) and 2155 patients (2004-2016). The discrimination, calibration and clinical utility of the model were assessed.

RESULTS

Six strong predictors were used in the model, namely, age, sex, stroke subtype, stroke severity and pre-stroke and post-stroke disabilities. The c-statistics was 0.822 at 1 year in the derivation cohort. The model had a fair performance with prognostic accuracies of 77%-83% in the validation 1 cohort and 70%-75% in the validation 2 cohort. A good calibration was observed in the derivation cohort.

CONCLUSION

The proposed model can accurately predict survival up to 1 year after ischaemic stroke.

Predictors and prognoses of new onset post-stroke anxiety at one year in black Africans

BACKGROUND

There is relatively limited information on the risk factors and outcome of new onset Poststroke Anxiety (PSA) in Low- and Middle-Income Countries. We estimated incidence, cumulative incidence, risk factors and outcome of new onset anxiety in the first year of stroke among African stroke survivors.

METHODS

We analyzed the dataset of a completed clinical trial comprising patients enrolled to test an intervention designed to improve one-year blood pressure control among recent (≤ one month) stroke survivors in Nigeria. Anxiety was measured using the Hospital Anxiety and Depression Scale. Outcomes were assessed using the modified Rankin Scale (mRS), Community screening instrument for dementia (CSID) and Health Related Quality of Life in Stroke Patients (HRQOLISP-26).

RESULTS

Among 322 stroke survivors who were free of anxiety at baseline, we found a one-year cumulative incidence of 34% (95% CI = 28.6-39.3). Rates were 36.2% (95% CI =29.6-42.7) for men and 29.2% (95% CI =19.9-38.3) for women. In multivariate Cox regression analyses, haemorrhagic stroke type was associated with higher risk of new onset PSA (Hazard Ratio=1.52, 95% CI =1.01-2.29). New onset PSA was independently associated with cognitive [(mean difference (MD) in CSID scores=1.1, 95% C.I=0.2, 1.9)] and motor decline (MD in mRS scores= -0.2, 95% C.I= -0.4, -0.02), as well as poorer quality of life overtime (MD in total HRQOLISP-26 scores=3.6, 95% C.I=1.0, 6.2).

CONCLUSION

One in 3 stroke survivors in Nigeria had PSA at one year. Clinicians in SSA should pay special attention to survivors of haemorrhagic stroke as they are at higher risk of incident anxiety and therefore its consequences.

Twenty-Year Time Trends in Long-Term Case-Fatality and Recurrence Rates After Ischemic Stroke Stratified by Etiology

Background and Purpose:

Data on long-term survival and recurrence after stroke are lacking. We investigated time trends in ischemic stroke case-fatality and recurrence rates over 20-years stratified by etiological subtype according to the Trial of ORG 10172 in Acute Stroke Treatment classification within a population-based stroke register in Germany.

Methods:

Data was collected within the Erlangen Stroke Project, a prospective, population-based stroke register covering a source population of 105 164 inhabitants (2010). Case fatality and recurrence rates for 3 months, 1 year, and 5 years were estimated with Kaplan-Meier estimates. Sex-specific time trends for case-fatality and recurrence rates were estimated with Cox regression. We adjusted for age, sex, and year of event and stratified for etiological subtypes. A sensitivity analysis with competing risk analysis for time trends in recurrence were performed.

Results:

Between 1996 and 2015, 3346 patients with first ischemic stroke were included; age-standardized incidence per 100 000 was 75.8 in women and 131.6 in men (2015). Overall, 5-year survival probabilities were 50.4% (95% CI, 47.9–53.1) in women and 59.2% (95% CI, 56.4–62.0) in men; 5-year survival was highest in patients with first stroke due to small-artery occlusion (women, 71.8% [95% CI, 67.1–76.9]; men, 75.9% [95% CI, 71.3–80.9]) and lowest in cardioembolic stroke (women, 35.7% [95% CI, 31.0–41.1]; men, 47.8% [95% CI, 42.2–54.3]). Five-year recurrence rates were 20.1% (95% CI, 17.5–22.6) in women and 20.1% (95% CI, 17.5–22.7) in men; 5-year recurrence rate was lowest in women in stroke due to small artery occlusion 16.0% (95% CI, 11.7–20.1) and in men in large-artery atherosclerosis 16.6% (95% CI, 8.7–23.9); highest risk of recurrence was observed in undefined strokes (women, 22.3% [95% CI, 17.8–26.6]; men, 21.4% [95% CI, 16.7–25.9]). Cox regression revealed improvements in case-fatality rates over time with differences in stroke causes. No time trends in recurrence rates were observed.

Conclusions:

Long-term survival and recurrence varied substantially by first stroke cause. Survival probabilities improved over the past 2 decades; no major trends in stroke recurrence rates were observed.

Cognitive Function Is a Prognostic Factor for Mortality of Nursing Home Residents during a 3-Year Observational Period

Introduction

Assessing cognitive function could help to provide appropriate care for nursing home residents. The aim of the study was to identify the factors affecting cognitive function in nursing home residents in Poland and assess how it influenced the mortality rate during a 3-year observational period.

Methods

This study included 202 elderly individuals from a nursing home in 2015. The investigation included examination of cognitive function using the MMSE and bioelectrical impedance analysis. Collected data included sex, age, blood pressure (BP), heart rate, number of comorbidities, years spent in the nursing home, educational level, and cigarette-smoking.

Results

The mean MMSE score was 21.36 ± 6.35, which was negatively correlated with age and diastolic BP (p = 0.001 and p = 0.024, respectively) and positively correlated with body mass, BMI, fat-free mass, fat, muscle mass, and education level (p = 0.004, p = 0.004, p = 002, p = 0.049, p = 0.005, and p ˂ 0.001, respectively). Patients who died during the observational period had lower MMSE scores than those who survived (23.34 ± 5.68 vs. 20.16 ± 6.45; p < 0.001). Smokers had better MMSE results than nonsmokers (23.34 ± 5.98 vs. 20.08 ± 4.94; p < 0.001).

Discussion

Polish nursing home residents had mild cognitive impairment depending on their age, sex, educational level, and nutritional status. Lower MMSE score was a prognostic factor for mortality in the 3-year observational period.

Long-Term Outcomes in Stroke Patients with Cognitive Impairment: A Population-Based Study

This study assesses five year outcomes of patients with cognitive deficits within the first three months after stroke. Population-based data from the South London Stroke Register between 1995 and 2018 were studied. Cognitive function was assessed using the Abbreviated-Mental-Test or Mini-Mental-State-Examination. Multivariable Poisson regression models with robust standard errors were constructed, to evaluate relative risks (RRs) and associations between post-stroke deterioration in cognitive function during the first three months on dependency, mortality, depression and institutionalisation. A total of 6504 patients with first-ever strokes were registered with a mean age of 73 (SD: 13.2). During the first three months post-stoke, approximately one-third of these stroke survivors either cognitively improved (37%), deteriorated (30%) or remained unchanged (33%). Post-stroke cognitive impairment was associated with increases, in five years, of the risks of mortality, dependency, depression and being institutionalised by RRs 30% (95% confidence interval: 1.1–1.5), 90% (1.3–2.6), 60% (1.1–2.4) and 50% (1.1–2.3), respectively. Deterioration in cognitive function by 10% or more between seven days and three months was associated with an approximate two-fold increased risk in mortality, dependency, and being institutionalised after one year, compared to stable cognitive function; RRs 80% (1.1–3.0), 70% (1.2–2.4) and two-fold (1.3–3.2), respectively. Monitoring further change to maintain cognitive abilities should be a focus to improve outcomes.

Exploring Factors Contributing to Race Differences in Poststroke Disability

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.

Computerised speech and language therapy or attention control added to usual care for people with long-term post-stroke aphasia: the Big CACTUS three-arm RCT

BACKGROUND

People with aphasia may improve their communication with speech and language therapy many months/years after stroke. However, NHS speech and language therapy reduces in availability over time post stroke.

OBJECTIVE

This trial evaluated the clinical effectiveness and cost-effectiveness of self-managed computerised speech and language therapy to provide additional therapy.

DESIGN

A pragmatic, superiority, single-blind, parallel-group, individually randomised (stratified block randomisation, stratified by word-finding severity and site) adjunct trial.

SETTING

Twenty-one UK NHS speech and language therapy departments.

PARTICIPANTS

People with post-stroke aphasia (diagnosed by a speech and language therapist) with long-standing (> 4 months) word-finding difficulties.

INTERVENTIONS

The groups were (1) usual care; (2) daily self-managed computerised word-finding therapy tailored by speech and language therapists and supported by volunteers/speech and language therapy assistants for 6 months plus usual care (computerised speech and language therapy); and (3) activity/attention control (completion of puzzles and receipt of telephone calls from a researcher for 6 months) plus usual care.

MAIN OUTCOME MEASURES

Co-primary outcomes - change in ability to find treated words of personal relevance in a bespoke naming test (impairment) and change in functional communication in conversation rated on the activity scale of the Therapy Outcome Measures (activity) 6 months after randomisation. A key secondary outcome was participant-rated perception of communication and quality of life using the Communication Outcomes After Stroke questionnaire at 6 months. Outcomes were assessed by speech and language therapists using standardised procedures. Cost-effectiveness was estimated using treatment costs and an accessible EuroQol-5 Dimensions, five-level version, measuring quality-adjusted life-years.

RESULTS

A total of 818 patients were assessed for eligibility and 278 participants were randomised between October 2014 and August 2016. A total of 240 participants (86 usual care, 83 computerised speech and language therapy, 71 attention control) contributed to modified intention-to-treat analysis at 6 months. The mean improvements in word-finding were 1.1% (standard deviation 11.2%) for usual care, 16.4% (standard deviation 15.3%) for computerised speech and language therapy and 2.4% (standard deviation 8.8%) for attention control. Computerised speech and language therapy improved word-finding 16.2% more than usual care did (95% confidence interval 12.7% to 19.6%; p < 0.0001) and 14.4% more than attention control did (95% confidence interval 10.8% to 18.1%). Most of this effect was maintained at 12 months (n = 219); the mean differences in change in word-finding score were 12.7% (95% confidence interval 8.7% to 16.7%) higher in the computerised speech and language therapy group (n = 74) than in the usual-care group (n = 84) and 9.3% (95% confidence interval 4.8% to 13.7%) higher in the computerised speech and language therapy group than in the attention control group (n = 61). Computerised speech and language therapy did not show significant improvements on the Therapy Outcome Measures or Communication Outcomes After Stroke scale compared with usual care or attention control. Primary cost-effectiveness analysis estimated an incremental cost per participant of £732.73 (95% credible interval £674.23 to £798.05). The incremental quality-adjusted life-year gain was 0.017 for computerised speech and language therapy compared with usual care, but its direction was uncertain (95% credible interval -0.05 to 0.10), resulting in an incremental cost-effectiveness ratio of £42,686 per quality-adjusted life-year gained. For mild and moderate word-finding difficulty subgroups, incremental cost-effectiveness ratios were £22,371 and £28,898 per quality-adjusted life-year gained, respectively, for computerised speech and language therapy compared with usual care.

LIMITATIONS

This trial excluded non-English-language speakers, the accessible EuroQol-5 Dimensions, five-level version, was not validated and the measurement of attention control fidelity was limited.

CONCLUSIONS

Computerised speech and language therapy enabled additional self-managed speech and language therapy, contributing to significant improvement in finding personally relevant words (as specifically targeted by computerised speech and language therapy) long term post stroke. Gains did not lead to improvements in conversation or quality of life. Cost-effectiveness is uncertain owing to uncertainty around the quality-adjusted life-year gain, but computerised speech and language therapy may be more cost-effective for participants with mild and moderate word-finding difficulties. Exploring ways of helping people with aphasia to use new words in functional communication contexts is a priority.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN68798818.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 19. See the NIHR Journals Library website for further project information. The Tavistock Trust for Aphasia provided additional support to enable people in the control groups to experience the intervention after the trial had ended.

Prediabetes is associated with poor functional outcome in patients with intracerebral hemorrhage

INTRODUCTION

The association between prediabetes and functional outcome in cerebrovascular diseases is controversial. No study has explored the relationship between prediabetes and functional outcome in intracerebral hemorrhage patients. Our study aimed to explore the association between prediabetes and functional outcome in intracerebral hemorrhage patients 1 month poststroke.

METHODS

One hundred and fifty intracerebral hemorrhage patients were consecutively recruited within the first 24 hr after admission and were followed up for 1 month. Patients were divided into a diabetes mellitus group, a prediabetes group, and a nondiabetic group by fasting glucose levels, 2-hr postprandial blood glucose levels, and glycosylated hemoglobin levels. Patients with modified Rankin Scale scores >2 at 1 month were defined as having a poor functional outcome.

RESULTS

The prediabetes group had a higher risk of poor functional outcome than the nondiabetic group in intracerebral hemorrhage patients (37.9% vs. 9.8%, χ²  = 11.521, p = .001). According to the logistic regression analyses, prediabetes was associated with a poor functional outcome in intracerebral hemorrhage patients after adjusting for confounding factors (odds ratio = 6.167, 95% confidence interval = 1.403-27.102, p = .016).

CONCLUSIONS

Our findings show that prediabetes is associated with a poor functional outcome in intracerebral hemorrhage patients 1 month poststroke.

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

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

Long-term trends in death and dependence after ischaemic strokes: A retrospective cohort study using the South London Stroke Register (SLSR)

BACKGROUND

There have been reductions in stroke mortality over recent decades, but estimates by aetiological subtypes are limited. This study estimates time trends in mortality and functional dependence by ischaemic stroke (IS) aetiological subtype over a 16-year period.

METHODS AND FINDINGS

The study population was 357,308 in 2011; 50.4% were males, 56% were white, and 25% were of black ethnic backgrounds. Population-based case ascertainment of stroke was conducted, and all participants who had their first-ever IS between 2000 and 2015 were identified. Further classification was concluded according to the underlying mechanism into large-artery atherosclerosis (LAA), cardio-embolism (CE), small-vessel occlusion (SVO), other determined aetiologies (OTH), and undetermined aetiologies (UND). Temporal trends in survival rates were examined using proportional-hazards survival modelling, adjusted for demography, prestroke risk factors, case mix variables, and processes of care. We carried out additional regression analyses to explore patterns in case-fatality rates (CFRs) at 30 days and 1 year and to explore whether these trends occurred at the expense of greater functional dependence (Barthel Index [BI] < 15) among survivors. A total of 3,128 patients with first-ever ISs were registered. The median age was 70.7 years; 50.9% were males; and 66.2% were white, 25.5% were black, and 8.3% were of other ethnic groups. Between 2000-2003 and 2012-2015, the adjusted overall mortality decreased by 24% (hazard ratio [HR] per year 0.976; 95% confidence interval [CI] 0.959-0.993). Mortality reductions were equally noted in both sexes and in the white and black populations but were only significant in CE strokes (HR per year 0.972; 95% CI 0.945‒0.998) and in patients aged ≥55 years (HR per year 0.975; 95% CI 0.959‒0.992). CFRs within 30 days and 1 year after an IS declined by 38% (rate ratio [RR] per year 0.962; 95% CI 0.941‒0.984) and 37% (RR per year 0.963; 95% CI 0.949‒0.976), respectively. Recent IS was independently associated with a 23% reduced risk of functional dependence at 3 months after onset (RR per year 0.983; 95% CI 0.968-0.998; p = 0.002 for trend). The study is limited by small number of events in certain subgroups (e.g., LAA), which could have led to insufficient power to detect significant trends.

CONCLUSIONS

Both mortality and 3-month functional dependence after IS decreased by an annual average of around 2.4% and 1.7%, respectively, during 2000‒2015. Such reductions were particularly evident in strokes of CE origins and in those aged ≥55 years.