Medical complications experienced by first-time ischemic stroke patients during inpatient, tertiary level stroke rehabilitation

Development of insomnia in patients with stroke: A systematic review and meta-analysis

BACKGROUND AND AIM

Stroke is a serious threat to human life and health, and post-stroke insomnia is one of the common complications severely impairing patients' quality of life and delaying recovery. Early understanding of the relationship between stroke and post-stroke insomnia can provide clinical evidence for preventing and treating post-stroke insomnia. This study was to investigate the prevalence of insomnia in patients with stroke.

METHODS

The Web of Science, PubMed, Embase, and Cochrane Library databases were used to obtain the eligible studies until June 2023. The quality assessment was performed to extract valid data for meta-analysis. The prevalence rates were used a random-efect. I2 statistics were used to assess the heterogeneity of the studies.

RESULTS

Twenty-six studies met the inclusion criteria for meta-analysis, with 1,193,659 participants, of which 497,124 were patients with stroke.The meta-analysis indicated that 150,181 patients with stroke developed insomnia during follow-up [46.98%, 95% confidence interval (CI): 36.91-57.18] and 1806 patients with ischemic stroke (IS) or transient ischemic attack (TIA) developed insomnia (47.21%, 95% CI: 34.26-60.36). Notably, 41.51% of patients with the prevalence of nonclassified stroke developed insomnia (95% CI: 28.86-54.75). The incidence of insomnia was significantly higher in patients with acute strokes than in patients with nonacute strokes (59.16% vs 44.07%, P < 0.0001).Similarly, the incidence of insomnia was significantly higher in the patients with stroke at a mean age of ≥65 than patients with stroke at a mean age of <65 years (47.18% vs 40.50%, P < 0.05). Fifteen studies reported the follow-up time. The incidence of insomnia was significantly higher in the follow-up for ≥3 years than follow-up for <3 years (58.06% vs 43.83%, P < 0.05). Twenty-one studies used the Insomnia Assessment Diagnostic Tool, and the rate of insomnia in patients with stroke was 49.31% (95% CI: 38.59-60.06). Five studies used self-reporting, that the rate of insomnia in patients with stroke was 37.58% (95% CI: 13.44-65.63).

CONCLUSIONS

Stroke may be a predisposing factor for insomnia. Insomnia is more likely to occur in acute-phase stroke, and the prevalence of insomnia increases with patient age and follow-up time. Further, the rate of insomnia is higher in patients with stroke who use the Insomnia Assessment Diagnostic Tool.

Inpatient Rehabilitation Outcomes after Primary Severe Haemorrhagic Stroke: A Retrospective Study Comparing Surgical versus Non-Surgical Management

BACKGROUND

Haemorrhagic stroke, accounting for 10-20% of all strokes, often requires decompressive surgery as a life-saving measure for cases with massive oedema and raised intracranial pressure. This study was conducted to compare the demographics, characteristics and rehabilitation profiles of patients with severe haemorrhagic stroke who were managed surgically versus those who were managed non-surgically.

METHODS

A single-centre retrospective study of electronic medical records was conducted over a 3-year period from 1 January 2018 to 31 December 2020. The inclusion criteria were first haemorrhagic stroke, age of >18 years and an admission Functional Independence Measure (FIM™) score of 18-40 upon admission to the rehabilitation centre. The primary outcome measure was discharge FIM™. Secondary outcome measures included modified Rankin Scale (mRS), rehabilitation length of stay (RLOS) and complication rates.

RESULTS

A total of 107 patients' records were analysed; 45 (42.1%) received surgical intervention and 62 (57.9%) patients underwent non-surgical management. Surgically managed patients were significantly younger than non-surgical patients, with a mean age of [surgical 53.1 (SD 12) vs. non-surgical 61.6 (SD 12.3), p = 0.001]. Admission FIM was significantly lower in the surgical vs. non-surgical group [23.7 (SD6.7) vs. 26.71 (SD 7.4), p = 0.031). However, discharge FIM was similar between both groups [surgical 53.91 (SD23.0) vs. non-surgical 57.0 (SD23.6), p = 0.625). Similarly, FIM gain (surgical 30.1 (SD 21.1) vs. non-surgical 30.3 (SD 21.1), p = 0.094) and RLOS [surgical 56.2 days (SD 21.5) vs. non-surgical 52.0 days (SD 23.4), p = 0.134) were not significantly different between groups. The majority of patients were discharged home (surgical 73.3% vs. non-surgical 74.2%, p = 0.920) despite a high level of dependency.

CONCLUSIONS

Our findings suggest that patients with surgically managed haemorrhagic stroke, while older and more dependent on admission to rehabilitation, achieved comparable FIM gains, discharge FIM and discharge home rates after ~8 weeks of rehabilitation. This highlights the importance of rehabilitation, especially for surgically managed haemorrhagic stroke patients.

Frequency and reasons for unplanned transfer to the primary acute care service of inpatient rehabilitation glioblastoma multiforme patients

PURPOSE

To determine the percentage of and factors associated with unplanned transfer to the acute care service of glioblastoma multiforme acute rehabilitation inpatients.

METHODS

Retrospective review of glioblastoma multiforme acute rehabilitation inpatients admitted 4/1/2016-3/31/2020 at a National Cancer Institute Comprehensive Cancer Center.

RESULTS

One hundred thirty-nine consecutive admissions of unique glioblastoma multiforme acute rehabilitation inpatients were analyzed. Fifteen patients (10.7%, 95% confidence interval 6.5-17.1%) were transferred to the acute care service for unplanned reasons. The most common reasons for transfer back were neurosurgical complication 6/15(40%), neurologic decline due to mass effect 4/15(26.7%), and pulmonary embolism 2/15(13.3%). Older age (p = 0.010), infection prior to acute inpatient rehabilitation transfer (p = 0.020), and lower activity measure of post-acute care 6-click basic mobility scores (p = 0.048) were significantly associated with transfer to the acute care service. Patients who transferred to the acute care service had significantly lower overall survival than patients who did not transfer off (log-rank test p = 0.001).

CONCLUSION

Acute inpatient physiatrists should closely monitor patients for neurosurgical and neurologic complications. The variables significantly associated with transfer to the acute care service may help identify patients at increased risk for medical complications who may require closer observation.

Frequency and Characteristics of Medical Complications in Rehabilitation Settings: A Scoping Review

OBJECTIVE

To synthesize the available evidence on medical complications occurring in adult patients in subacute inpatient rehabilitation, and to describe the impact on subacute length of stay and readmission to acute care.

DESIGN

Scoping review.

SUBJECTS

Adult patients, within the inpatient rehabilitation environment, who experienced medical complications, clinical deterioration and/or the requirement of transfer to acute care.

METHODS

A systematic search of MEDLINE and CINAHL electronic databases was undertaken to identify primary research studies published in English and French during the period 2000-2021. Study reporting followed the standards indicated by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist (PRISMA-ScR).

RESULTS

A total of 47 studies were identified for inclusion. Key results included differences in the type and frequency of complications according to admission type, the proportion of patients experiencing at least 1 complication, and complications associated with transfer to acute care.

CONCLUSION

Patients admitted for inpatient rehabilitation are at high risk of medical complications and may not be medically stable during their admission, requiring care by clinicians with expertise in functional rehabilitation, and ongoing management by members of the multidisciplinary team with expertise in acute general medicine, infectious diseases and recognition and response to clinical deterioration.

Effectiveness of Public Education Campaigns for Stroke Symptom Recognition and Response in Non-Elderly Adults: A Systematic Review and Meta-Analysis

OBJECTIVES

The incidence of stroke is on the rise among younger adults. Stroke educational campaigns are often used to raise public knowledge of stroke warning signs and response actions, but their effectiveness in non-elderly adults is unclear. This study investigated the effectiveness of stroke campaigns in improving stroke symptom recognition and intention to call emergency medical services in adults aged < 65 years, and described the characteristics of public stroke education in this demographic group.

MATERIALS AND METHODS

Seven databases (Cochrane Library, CINAHL, Embase, Medline, PsycINFO, Scopus, and ProQuest Dissertations and Theses) were searched from inception to 24 January 2021. A meta-analysis was conducted to synthesize the effects of stroke education campaigns on stroke symptom recognition and intention to call emergency medical services in adults < 65 years. A narrative synthesis approach was used to explore the types of educational content and campaign best suited to this demographic group.

RESULTS

Thirteen studies from 2001 to 2019 were included in this review. Out of the thirteen studies, five were included in the meta-analysis to synthesize the effects of stroke education campaigns on symptom recognition and four were included for synthesizing the effects on intention to call emergency medical services. The estimated pooled risk ratio for post-campaign compared with pre-campaign in stroke symptom recognition and intention to call emergency medical services was 1.20 (95% CI: 1.07-1.36, p = 0.002) and 1.19 (95% CI: 1.11-1.28, p < 0.00001), respectively. Usage of acronyms in broadcast and digital media campaigns appears promising in enhancing recognition of and responsiveness to stroke symptoms.

CONCLUSIONS

Public stroke education campaigns were found to have a significant impact on stroke symptom recognition and intention to call emergency medical services. The evidence generated from this review could be applied to inform future campaigns targeted at younger adults.

Protein C Promotor Haplotypes Associated with Large-Artery Atherosclerosis Stroke in Iranian Population

Ischemic stroke (IS) is a complex disease regarding its risk factors; among those factors, genetics has an important role. Protein C (PC) is an important antithrombotic enzyme which its genetic variations disrupt the normal cascade of blood coagulation, resulting in thrombosis and increases the chance of stroke. Therefore, we aimed to investigate three single-nucleotide polymorphisms (SNPs) located in the core promoter of PC in order to find their role in this condition in the Iranian population. Blood samples from IS patients (n = 249) and healthy volunteers (n = 203) were collected. Biochemical analysis was performed. Genotyping was conducted on the extracted DNA from blood samples via the HRM technique. Bioinformatic investigations were used to assess how these SNPs may be involved in the IS. Smoking, hypertension, low-density lipoprotein cholesterol, and fasting blood glucose were significantly different between healthy and IS groups. rs1799809 and rs1799810 SNPs were significantly more frequent among IS patients. Also, among four identified haplotypes, CGT was found associated with IS (p = 0.001). It was also found that these SNPs may interfere with the binding of transcription factors to alter the expression of PC. Our data predict that SNPs at the core promoter of PC can affect the binding affinity of transcription factors which in turn reduces the expression of PC and increases the risk of IS.

Factors related to interrupted inpatient stroke rehabilitation due to acute care transfer or death

OBJECTIVES

To identify factors that are independently related to interrupted stroke rehabilitation due to acute care transfer or death.

METHODS

Medical records of stroke inpatients admitted from 2012 to 2017 were reviewed. Stroke inpatients with interrupted stroke rehabilitation due to acute care transfer or death were enrolled into the case group. Those without interruption admitted in the same month were randomly selected into the control group (case to control ratio of 1 : 5). Ten clinical factors were studied.

RESULTS

Among stroke inpatients, 3.2% were transferred to acute care facilities and 0.2% died. The most common causes of acute care transfer were respiratory tract infection, intracranial hemorrhage, recurrent ischemic stroke, ischemic heart disease, and seizure. Three factors were found to be significantly associated with interrupted stroke rehabilitation, i.e. presence of feeding tube, presence of anemia and age. Our results also revealed significant association between presence of feeding tube and respiratory tract infection (p = 0.005).

CONCLUSION

Feeding tube, anemia and old age were identified as independent predictors of interrupted stroke rehabilitation due to acute care transfer or death. Interventions to reduce severe complications should be implemented in order to prevent interruption of rehabilitation process and to reduce the patient transfer rate.

Frequency of and Reasons for Unplanned Transfers From the Inpatient Rehabilitation Facility in a Tertiary Hospital

OBJECTIVE

To characterize the patients in the inpatient rehabilitation facility who were transferred to acute care facilities and identify the frequency of and reasons for the unplanned transfer.

METHODS

Medical records of patients admitted to the inpatient rehabilitation facility from October 2017 to December 2018 were reviewed. Patients were categorized according to their diagnoses. The included patients were divided into the unplanned transfer and control groups based on whether they required to transfer to another department for acute care before completing an uninterrupted rehabilitation course. The groups were compared in terms of sex, age, length of stay, admission sources, and disease groups. The reasons for unplanned transfers were classified based on medical or surgical conditions.

RESULTS

Of the 1,378 patients were admitted to the inpatient rehabilitation facility, 1,301 satisfied inclusion criteria. Among them, 121 (9.3%) were unexpectedly transferred to the medical or surgical department. The unplanned transfer group had a higher age (69.54±12.53 vs. 64.39±15.32 years; p=0.001) and longer length of stay (85.69±66.08 vs. 37.81±31.13 days; p<0.001) than the control group. The top 3 reasons for unplanned transfers were infectious disease, cardiopulmonary disease, and orthopedic problem.

CONCLUSION

The unplanned transfer group had a significantly higher age and longer length of stay. The most common reason for the unplanned transfer was infectious disease. However, the proportions of those with orthopedic and neurological problems were relatively high. Therefore, further studies of these patient populations may help organize systematic strategies that are needed to reduce unplanned transfers to acute facilities for patients in rehabilitation facilities.

Management protocols and encountered complications among stroke patients admitted to stroke unit of Jimma university medical center, Southwest Ethiopia: Prospective observational study

Objectives

The number of stroke patients receiving recombinant tissue plasminogen activator (r-tPA) in developing world is extremely low. Pre-hospital delay, financial constraints and lack of infrastructure are the main barriers. Additionally, various medical, neurological and psychological complications are allied to stroke patients after the acute attack. Hence, the study was aimed to identify management protocols and encountered complications among stroke patients admitted to stroke unit of Jimma university medical center (JUMC).

Patients and methods

Prospective observational study was conducted at stroke unit of JUMC from March 10 to July 10, 2017. All eligible consecutive stroke patients of ≥18 years were included. Data was entered to Epi data version 3.1 and analyzed using SPSS version 20.

Results

A total of 116 eligible stroke patients were followed with mean age of 55.14 ± 14.04 years and males comprised of 62.9%. Using world health organization (WHO) criteria, 60 (51.7%) patients had ischemic while 56 (48.3%) had hemorrhagic stroke. During admission, 93 (80.2%) patients had developed at least one complication. The most complication was brain edema (increased intracranial pressure) detected in about one third of the patients (30.2%) followed by urinary incontinence (28.4%) and aspiration pneumonia (19.8%). Almost half of the patients (52.5%) had at least one past medication history. During hospitalization, 111(95.7%) of patients had received at least one medication and the median start time of the medications after hospital arrival was 15 h. The most common medication given for the patients during hospitalization were antiplatelets and statins for 63 (54.3%) patients. During discharge, about 78 (67.2%) patients had received medications and antihypertensives were the prominent medications prescribed for half of the discharged patients.

Conclusion

Both neurologic and medical complications were common in majority of stroke patients. But the management protocol for stroke patients was sub-optimal and lagging behind the recommended guidelines due to lack of skilled personnel, appropriate treatment and diagnostic agents. The clinical team involved in the care of stroke patients should make preparations to take preventive measures that will save a lot of lives.

The expression of microRNA 146a in patients with ischemic stroke: an observational study

Aim

We conducted the present prospective study to assess the level of microRNA (miRNA) 146a in patients with ischemic stroke and its correlation with patients' characteristics.

Methods

We conducted an observational study that included adult patients (≥18 years old) who presented within 24 hrs after the onset of the symptoms of acute ischemic stroke. In addition, age- and sex-matched healthy volunteers were included as control group. The primary outcome in the present study was the difference in miRNA 146a expression between patients with ischemic stroke and control group participants. The expression of miRNA 146a was measured using quantitative real-time PCR. Quantitative real-time PCR amplification and analysis were performed using Rotor-Gene Q thermal cycler.

Results

The present study included 44 patients with ischemic stroke and 22 matched controls. Regarding the primary outcome of the present study, the median expression of miRNA 146a in patients with ischemic stroke was -1.98 fold (IQR -27.1-3.9) compared to 1.75 fold (IQR -2.25-5.27) in control group (P<0.001). However, the subgroup analysis showed that the expression of miRNA 146a was significantly downregulated in comatosed patients only (P<0.001). The expression of miRNA 146a correlated negatively with Glasgow Coma Scale score in comatose patients (r=-0.352, P=0.022).

Conclusion

In conclusion, the expression of miRNA 146a is significantly downregulated in ischemic stroke patients. Further studies are needed to assess its diagnostic utility and therapeutic potentials.

Quality of life after stroke: impact of clinical and sociodemographic factors

OBJECTIVES

The aim of the study was to analyze the impact of ischemic stroke on health-related quality of life (QoL) and associate this event with individuals' clinical and sociodemographic characteristics.

METHODS

We investigated the clinical and demographic aspects of stroke patients. The Modified Rankin Scale, National Institutes of Health Stroke Scale (NIHSS) and the Stroke Specific Quality of Life Scale (SS-QoL) were used for correlation analysis.

RESULTS

Among 131 patients with ischemic stroke, 53.4% of patients presented with moderate to severe disability on the Rankin Scale. According to the SS-QoL, several QoL domains were compromised. QoL was significantly negatively correlated with the values of the Rankin and NIHSS scales, indicating lower QoL among people with worse functional status and greater clinical severity of stroke (p<0.001). The use of orthosis and total anterior circulation infarct subtype of stroke led to a more marked reduction in QoL.

CONCLUSION

The present study described an inversely proportional relationship between the severity of stroke, disability and QoL. The use of orthosis also had a negative impact on QoL. Early identification of these factors could promote better interventions for individuals with ischemic stroke, minimizing disabilities and improving QoL.

Comorbidity and intercurrent diseases in geriatric stroke rehabilitation: a multicentre observational study in skilled nursing facilities

Background

Older patients often have multiple comorbidities and are susceptible to develop intercurrent diseases during rehabilitation. This study investigates intercurrent diseases and associated factors in patients undergoing geriatric stroke rehabilitation, focussing on pre-existing comorbid conditions, overall comorbidity and baseline functional status.

Materials and methods

This multicentre prospective cohort study included 15 skilled nursing facilities. Data were collected at baseline and at discharge. The primary outcome measures were presence and number of intercurrent diseases. Furthermore, their impact on change in rehabilitation goals or length of stay was examined. Comorbidity was assessed with the Charlson index, and functional status with the Barthel index (BI).

Results

Of the 175 included patients, 51% developed an intercurrent disease. A lower baseline BI, a higher Charlson index, presence of diabetes mellitus (DM) and kidney disease were related to the occurrence of an intercurrent disease (p < 0.05). Moreover, a lower BI, a higher Charlson index, and particularly the presence of DM were independently associated. If both comorbidity and a lower baseline functional status were present, the odds ratio (95% CI) of developing intercurrent diseases was 6.70 [2.33-19.2], compared to 1.73 [0.52-5.72] (comorbidity only) and 1.62 [0.53-4.94] (only BI ≤ 14).

Conclusions

On admission, functional impairments and comorbidity, particularly diabetes, independently contribute to developing intercurrent diseases during geriatric stroke rehabilitation. Therefore, routine evaluation of comorbidity integrated with functional status at the start of rehabilitation is essential to identify patients at risk. Finally, particular attention should be paid to patients with DM to prevent intercurrent diseases and support optimal functional recovery .