210 AUDIT OF AN AUDIT: UNDERSTANDING THE INTERPRETATION AND REPORTING OF KEY PERFORMANCE VARIABLES OF THE IRISH NATIONAL AUDIT OF STROKE

Background

The Irish National Audit of Stroke (INAS) coordinates the collection and analysis of key performance variables which can be interpreted as proxies of care quality in stroke. Time metrics such as “Time-to-CT” and “Time-to-Thrombolysis” reflect the organisation of in-hospital stroke care pathways, with shorter times reflecting better care coordination and quality. While the INAS data dictionary defines each variable, differing interpretations of a definition can impact on the exact data point collected. We wished to understand the interpretation and reporting of key performance variables at all clinical sites reporting to INAS.

Methods

An online survey in three parts was designed and distributed to 34 INAS audit co-ordinators along with the INAS dictionary definition of each data variable. Audit co-ordinators were asked to select the exact data point they collect for that variable from a dropdown list, with space also allotted for free-text entry of any challenges they may encounter for that variable.

Results

Responses were received from 11/34 audit co-ordinators, representing 10/24 hospitals. Variability was seen in the specific times selected for data points including hospital arrival time, team time, and brain imaging time. This variability was seen across sites and regions. Data points with less scope for interpretation such as thrombolysis or thrombolysis time showed less variability.

Conclusion

By understanding the scope of responses given to any data point definition and the challenges that may exist for audit co-ordinators, it is hoped to achieve a consensus approach to defining variables for a robust core data set. Future data definitions may be refined to assist in the collection of exact data points that are accurate, consistent and reproducible across hospital sites. In so doing, all key elements of a patient’s pathway can be captured accurately and compared with best practice guidelines with a view to optimising future care provision and service organisation.

119 ENHANCING THE QUALITY OF STROKE CARE IN IRELAND - DEVELOPMENT OF AN IRISH NATIONAL STROKE AUDIT

Background

Population ageing, stroke treatment advances, changing models of care, and between-hospital heterogeneity in stroke outcomes demonstrate the necessity of continual audit of stroke care to support quality improvement at local and national levels, and to enhance patient recovery and wellbeing. This project aims to identify the core minimum datasets for acute and non-acute stroke care, and Patient-Reported Outcome Measures (PROMs), for integration in to the newly-developed Irish National Audit of Stroke (INAS), in addition to identifying resourcing needs and implementation procedures.

Methods

In Phase 1, a minimum dataset for acute stroke care was identified based on a scoping review of international practice and available guidelines. Phase 2 (ongoing) involves identifying datasets for non-acute rehabilitative and follow-up care based on a scoping review of international practice, iterative cycles of qualitative stakeholder engagement, and systematic review of PROMs. In Phase 3, a review of resourcing and data collection procedures used in stroke audits internationally will be used to produce an implementation strategy for data collection, contextualised to the Irish healthcare system.

Results

Twenty-one eligible international stroke registries were identified from the scoping review. Within Phase 1, core clinical and thrombectomy items in the Irish registry were benchmarked against internationally-collected items to identify common items and to generate an inventory of items that other registries collect that Ireland does not. Based on consensus agreement on the most frequently-occurring international items, as reviewed by key stakeholders, a core minimum dataset for audit of acute stroke care was delivered.

Conclusion

These minimum datasets shall act as the “gold standard” for evaluating stroke care in Ireland, by not only incorporating structure, process, and care quality outcome indicators, but also PROMs. The resultant datasets may inform policy and quality improvement initiatives, and shape health service delivery across the trajectory of stroke care, from hyper-acute care, to rehabilitation, and return to the community.

36 A YEAR WITHOUT THE FLU: MODELLING THE EFFECTS ON CARDIOVASCULAR MORTALITY FROM INFLUENZA IN IRELAND

Background

Cardiovascular diseases (CVDs) are consistently ranked among the leading causes of death among older adults in Ireland. COVID-19 and influenza infection are associated with cardiovascular complications. However, percentage of deaths caused by CVD among adults aged 75 and over in Ireland decreased from 32.9% to 31.0% from 2019 to 2020. Government-imposed social distancing measures resulted in abolition of influenza activity (IA). We analysed population data from the 2010/11–2019/20 influenza seasons to estimate the impact of reduced IA on CVD mortality rates during the COVID-19 pandemic season.

Methods

Quarterly mortality data for acute myocardial infarction (AMI) and cerebrovascular disease from first quarter (Q1) 2010 to fourth quarter (Q4) 2020 was obtained from the Central Statistics Office. Weekly data on influenza-like illness (ILI) rates and positive percentages (PP) (i.e. proportion of influenza-positive sentinel respiratory specimens) from week 40 2010 to week 20 2020 was obtained from the Health Protection Surveillance Centre. Excess mortality rate during influenza season was calculated as the percentage difference between Q4/Q1 and preceding third quarter (Q3) mortality rates. We adopted the Goldstein index (ILI rate × PP) as an indicator of IA. Time series analyses, Pearson correlation coefficients (r) and linear regression models were used to evaluate the relationships between IA and excess AMI and cerebrovascular disease mortality rates.

Results

Statistically significant positive associations were observed between IA and excess AMI (r = 0.557, p = 0.011) and cerebrovascular disease (r = 0.858, p < 0.001) mortality rates. Linear regression models predicted 0.072% (95% confidence interval 0.019%, 0.125%) and 0.095% (0.067%, 0.123%) increases in excess AMI and cerebrovascular disease mortality rates respectively per unit increase in IA levels.

Conclusion

Elimination of IA may have contributed towards limiting the effects of COVID-19 on CVD mortality rates, and consequently total excess mortality, among older adults in Ireland.

505 INTERLEUKIN-6, C-REACTIVE PROTEIN, FIBRINOGEN, AND RISK OF RECURRENCE AFTER ISCHEMIC STROKE: SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Recent randomised trials showed benefit for anti-inflammatory therapies in coronary disease but excluded stroke. The prognostic value of blood inflammatory markers after stroke is uncertain and guidelines do not recommend their routine measurement for risk stratification.

Methods

We performed a systematic review and meta-analysis of studies investigating the association of C-reactive protein (CRP), interleukin-6 (IL-6) and fibrinogen and risk of recurrent stroke or major vascular events (MVEs). We searched EMBASE and Ovid Medline until 10/1/19. Random-effects meta-analysis was performed for studies reporting comparable effect measures.

Results

Of 2,515 reports identified, 39 met eligibility criteria (IL-6, n = 10; CRP, n = 33; fibrinogen, n = 16). An association with recurrent stroke was reported in 12/26 studies (CRP), 2/11 (fibrinogen) and 3/6 (IL-6). On random-effects meta-analysis of comparable studies, CRP was associated with an increased risk of recurrent stroke [pooled hazard ratio (HR) per 1 standard-deviation (SD) increase in loge-CRP (1.14, 95% CI 1.06-1.22, p &lt; 0.01)] and MVEs (pooled HR 1.21, CI 1.10-1.34, p &lt; 0.01). Fibrinogen was also associated with recurrent stroke (HR 1.26, CI 1.07-1.47, p &lt; 0.01) and MVEs (HR 1.31, 95% CI 1.15-1.49, p &lt; 0.01). Trends were identified for IL-6 for recurrent stroke (HR per 1-SD increase 1.17, CI 0.97-1.41, p = 0.10) and MVEs (HR 1.22, CI 0.96-1.55, p = 0.10).

Conclusion

Despite evidence suggesting an association between inflammatory markers and post-stroke vascular recurrence, substantial methodological heterogeneity was apparent between studies. Individual-patient pooled analysis and standardisation of methods are needed to determine the prognostic role of blood inflammatory markers and to improve patient selection for randomised trials of inflammatory therapies.

Inflammatory cytokines, high-sensitivity C-reactive protein, and risk of one-year vascular events, death, and poor functional outcome after stroke and transient ischemic attack

Background

Inflammation driven by pro-inflammatory cytokines is a new therapeutic target in coronary disease. Few data exist on the association of key upstream cytokines and post-stroke recurrence. In a prospective cohort study, we investigated the association between pivotal cytokines, high-sensitivity C-reactive protein (hsCRP) and one-year outcomes.

Methods

BIO-STROKETIA is a multi-center prospective cohort study of non-severe ischemic stroke (modified Rankin score ≤ 3) and transient ischemic attack. Controls were patients with transient symptoms attending transient ischemic attack clinics with non-ischemic final diagnosis. Exclusion criteria were severe stroke, infection, and other pro-inflammatory disease; hsCRP and cytokines (interleukin (IL) 6, IL-1β, IL-8, IL-10, IL-12, interferon-γ (IFN-γ), tumor-necrosis factor-α (TNF-α)) were measured. The primary outcome was one-year recurrent stroke/coronary events (fatal and non-fatal).

Results

In this study, 680 patients (439 stroke, 241 transient ischemic attack) and 68 controls were included. IL-6, IL-1β, IL-8, IFN-γ, TNF-α, and hsCRP were higher in stroke/transient ischemic attack cases (p ≤ 0.01 for all). On multivariable Cox regression, IL-6, IL-8, and hsCRP independently predicted one-year recurrent vascular events (adjusted hazard ratios (aHR) per-quartile increase IL-6 1.31, confidence interval (CI) 1.02–1.68, p = 0.03; IL-8 1.47, CI 1.15–1.89, p = 0.002; hsCRP 1.28, CI 1.01–1.62, p = 0.04). IL-6 (aHR 1.98, CI 1.26–3.14, p = 0.003) and hsCRP (aHR 1.81, CI 1.20–2.74, p = 0.005) independently predicted one-year fatality. IL-6 and hsCRP (adjusted odds ratio per-unit increase 1.02, CI 1.01–1.04) predicted poor functional outcome, with a trend for IL-1β (p = 0.054).

Conclusion

Baseline inflammatory cytokines independently predicted late recurrence, supporting a rationale for randomized trials of anti-inflammatory agents for prevention after stroke and suggesting that targeted therapy to high-risk patients with high baseline inflammation may be beneficial.

Opportunistic screening for atrial fibrillation in a rural area

INTRODUCTION

Opportunistic screening is an effective means of identifying subjects with Atrial Fibrillation (AF). Previous studies of opportunistic screening have been performed areas with high population density and before the development of novel oral anticoagulant drugs. We performed a study to determine feasibility of AF screening in a predominantly rural, low population density area.

METHODS

Over 6 months, subjects 65 years and older were screened by local General Practitioners using radial pulse palpation confirmed by 12 lead Electrocardiogram. Data were recorded electronically and those with newly identified AF were followed up to examine management post diagnosis.

RESULTS

In total, 7262 subjects were screened and an irregular pulse was found in 916 (12.6%) of whom 735 (10.1%) had known AF and 55 (0.76%) had newly detected AF. Of these 55 patients with newly documented AF, 28 (50.9%) were women, 38 (69.1%) had hypertension and eight (14.5%) had a smoking history. Mean body mass index in subjects with newly documented AF was 28.9 kg/m(2)(SD 5.6) There was no significant difference in gender mix (P =  0.4), smoking history (P  =  0.8) or alcohol history (P  =  0.8) with the overall population. Fifty-one (92.7%) subjects had a CHA2DS2VaSC score  ≥ 2 of whom 33 (64.7%) were eventually anticoagulated and nine (17.6%) commenced on Aspirin. The rate of newly identified patients in AF was lower than in previous reported key studies because of a higher rate of subjects with known AF.

CONCLUSION

Opportunistic AF screening in a rural environment identified a substantial number of new cases, although less than in previous screening studies.

The 13th Stationary/83rd (Dublin) General Hospital, Boulogne, 1914-1919

Casualties from the Western Front during the First World War were often evacuated to base hospitals on the northern coast of France for more advanced and specialist care. These temporary base hospitals frequently had more than 1,000 beds and were typically staffed by older, more senior doctors than were present nearer the front line. The 13th Stationary Hospital opened in October 1914 on the Boulogne docks and became the main specialist unit for the treatment of eye, face and jaw injuries. In May 1917 it was renamed the 83rd (Dublin) Hospital when the staff was augmented by volunteer staff from Irish hospitals. The hospital subsequently housed an innovative 'physical medicine' or rehabilitation unit. The hospital remained open for the duration of the War, moving to Langenfeld in the Ruhr following the Armistice.

Evolution of Carotid Surgical Practice in the last Decade

Stroke units provide immediate care and appropriate intervention in the evolving stroke. The aims of this study were to review the practice of carotid endarterectomy (CEA) before and after the establishment of a Stroke Unit in St. James's Hospital. Prior to the introduction of the Stroke Unit, 263 CEA's were performed over a five-year period. 139/263 (53%) of these were for symptomatic disease. 229 were performed in the five years since. 179/229 (78%) of these were for symptomatic disease. The 30-day stroke and death rates were < 2% before the introduction of the Stroke Unit, and have remained unchanged. Since the introduction of the Stroke Unit, there has been a slight decrease in the overall number of CEA's performed with a 25% increase in the proportion of endarterectomies performed for symptomatic disease. Despite the reduction in surgery for asymptomatic disease the overall 30-day stroke and death rate remains excellent at 2/229 (2%).

Ischaemic stroke or TIA in older subjects associated with impaired dynamic blood pressure control in the absence of severe large artery stenosis

BACKGROUND

older subjects may require higher baseline blood pressures to maintain cerebral perfusion. We investigated whether episodic hypotension is associated with tissue infarction in subjects with syncopal symptoms at stroke onset.

METHODS

over 30 months, all acute strokes/TIAs were prospectively screened for symptoms of syncope or presyncope at stroke onset. Subjects with severe large vessel stenosis were excluded, while cases were referred for syncope unit investigation. All underwent 1.5 T MRI acutely, and suspected borderzone infarctions (BZI) were confirmed through Matlab-derived perfusion software. Case-control comparison was derived from stroke controls with no prior syncope history.

RESULTS

thirty-eight of 772 stroke patients described presyncope or syncope at stroke onset and had patent large vessels (4.9% of all strokes). Median age was 72 years (IQR 21.4). Twenty-two patients (58%) were prescribed antihypertensive agents at symptom onset. Twenty-six (68.4%) reported focal neurology <24 h in duration. 63.2% (n = 24) of cases reported prior syncope history, compared with 33% (N = 103) of controls, P < 0.001. Cases exhibited greater orthostatic BP drop than controls, P < 0.05 Twenty-four patients were diagnosed with vasovagal syncope through head-up tilt symptom reproduction, 9 with orthostatic hypotension, 4 with cardiac syncope and 1 with carotid sinus syndrome. Nineteen (50%) patients had an acute infarct on MRI, 14 of these were in the arterial borderzone (73.6%). The BZI group were significantly older than the non-BZI group, 79.2 yrs versus 63.3 yrs, P = 0.002.

CONCLUSION

subjects reporting hypotensive symptoms at stroke onset have a higher prevalence of borderzone infarction, despite being normotensive or hypertensive at baseline.

In-hospital stroke: characteristics and outcomes

In-hospital stroke (IS) made up 6.5% of strokes recorded in the Irish National Stroke Register in 2012. International research has demonstrated poorer outcomes post IS compared to out of hospital stroke (OS). We aimed to profile all IS and OS over a 22 month period and compare the two groups by gathering data from the HIPE portal stroke register. The study site is a primary stroke centre. IS represented 11% (50/458) of total strokes with over half (27/50, 54%) admitted initially with medical complaints. IS patients had a significantly longer length of stay (79.2 +/- 87.4 days vs. 21.9 +/- 45.9 days, p < 0.01) and higher mortality (13/50 vs. 39/408, p < 0.01). Patients in the IS group were also less likely to receive stroke unit care (1/50 vs. 136/408, p < 0.01). This study demonstrates the significant morbidity and mortality associated with IS and highlights the need for efforts to be made to optimize identification and management of acute stroke in this cohort.

Increased platelet activation in early symptomatic vs. asymptomatic carotid stenosis and relationship with microembolic status: results from the Platelets and Carotid Stenosis Study

BACKGROUND

Cerebral microembolic signals (MES) may predict increased stroke risk in carotid stenosis. However, the relationship between platelet counts or platelet activation status and MES in symptomatic vs. asymptomatic carotid stenosis has not been comprehensively assessed.

SETTING

University teaching hospitals.

METHODS

This prospective, pilot observational study assessed platelet counts and platelet activation status, and the relationship between platelet activation and MES in asymptomatic vs. early (≤ 4 weeks after TIA/stroke) and late phase (≥ 3 months) symptomatic moderate or severe (≥ 50%) carotid stenosis patients. Full blood count measurements were performed, and whole blood flow cytometry was used to quantify platelet surface activation marker expression (CD62P and CD63) and circulating leucocyte-platelet complexes. Bilateral simultaneous transcranial Doppler ultrasound monitoring of the middle cerebral arteries was performed for 1 h to classify patients as MES positive or MES negative.

RESULTS

Data from 31 asymptomatic patients were compared with 46 symptomatic patients in the early phase, and 35 of these patients were followed up to the late phase after symptom onset. The median platelet count (211 vs. 200 × 10(9)  L(-1) ; P = 0.03) and the median percentage of lymphocyte-platelet complexes was higher in early symptomatic than asymptomatic patients (2.8 vs. 2.4%; P = 0.001). The percentage of lymphocyte-platelet complexes was higher in early symptomatic than in asymptomatic patients with ≥ 70% carotid stenosis (P = 0.0005) and symptomatic patients recruited within 7 days of symptom onset (P = 0.028). Complete TCD data were available in 25 asymptomatic, 31 early phase symptomatic and 27 late phase symptomatic patients. Twelve per cent of asymptomatic vs. 32% of early phase symptomatic (P = 0.02) and 19% of late phase symptomatic patients (P = 0.2) were MES positive. Early symptomatic MES-negative patients had a higher percentage of lymphocyte-platelet complexes than asymptomatic MES-negative patients (2.8 vs. 2.3%; P = 0.0085).

DISCUSSION

Recently, symptomatic carotid stenosis patients have had higher platelet counts (potentially reflecting increased platelet production, mobilization or reduced clearance) and platelet activation status than asymptomatic patients. MES were more frequently detected in early symptomatic than asymptomatic patients, but the differences between late symptomatic and asymptomatic groups were not significant. Increased lymphocyte-platelet complex formation in recently symptomatic vs. asymptomatic MES-negative patients indicates enhanced platelet activation in this early symptomatic subgroup. Platelet biomarkers, in combination with TCD, have the potential to aid risk-stratification in asymptomatic and symptomatic carotid stenosis patients.

Factors that influence awareness and treatment of atrial fibrillation in older adults

AIM

The aims of this study were to investigate the prevalence of atrial fibrillation (AF), treatment rates of AF and the factors underlying awareness and treatment, in a large nationally representative study.

METHODS

A population sample of people aged 50+, living in the Republic of Ireland, were recruited as part of The Irish longitudinal study on ageing. Ten-minute electrocardiogram recordings were obtained (n = 4890), and analysed to detect AF. Self-reported arrhythmias, subjective and objective health measures (cardiovascular diseases, CHA2DS2-VASc variables and blood pressure) and medications were also recorded. Logistic regressions were used to determine associations with outcomes of presence of AF, lack of awareness and untreated AF.

RESULTS

Overall prevalence of AF was 3% (95% CI: 2.4-3.7%), with a marked age gradient and sex difference [4.8% (men) vs. 1.4% (women); P < 0.0001]. In total, 67.8% were at high risk of stroke (CHA2DS2-VASc ≥ 2), of whom 59.3% were inadequately treated. A high proportion of 38.1% were unaware of having AF. CHA2DS2-VASc nor HAS-BLED score influenced awareness or treatment. Lack of awareness was associated with lower education (P = 0.01), lower cognition (P = 0.04), rural location (OR = 3.67; P = 0.02) and number of general practitioner visits (P = 0.01), whereas untreated AF was influenced by frailty status (P = 0.04).

CONCLUSION

With projected doubling of numbers of persons over 80 in the next 30 years in the British Isles, detection and management of AF is pressing. Two-thirds of adults at high risk of stroke were inadequately treated. More regular screening for AF, application of criteria for stroke and bleeding risk and awareness of factors influencing diagnosis and treatment is recommended.

Medical complications and outcomes at an onsite rehabilitation unit for older people

BACKGROUND

The rehabilitation of older patients in Ireland after an acute medical event occurs at dedicated onsite hospital units or at offsite centres. Information on medical complications and outcomes is inadequate.

AIMS

Enumeration of medical complications of patients admitted to a dedicated onsite rehabilitation unit for older people, and the extent of co-morbidity in the population with the effects that this had on the evolution of medical complications.

METHODS

A retrospective analysis of patients admitted to a 58-bed onsite unit over a 1-year period was performed. Information collating co-morbidities, medical complications and functional outcomes was recorded.

RESULTS

Medical complications occurred in almost 95% of patients, where full data were available. Over one-third required intravenous therapy.

CONCLUSION

Twenty-four hour medical cover is required for older patients managed at onsite rehabilitation units. Further studies on offsite medical rehabilitation facilities for older patients are required.

Discharge of patients to long-term care from a large acute hospital over a 12-year period

BACKGROUND

Several factors may be important in determining the discharge of patients to long-term care from the acute hospital.

AIMS

We aimed to look at factors associated with discharge to long-term care from St. James's Hospital, Dublin between 1997 and 2008.

METHODS

Data obtained from a long-term care database within the geriatric service were analysed. This service is responsible for assessing and listing all patients for long-term care within the hospital.

RESULTS

3,107 patients were listed and 2,520 discharged to long-term care during the period. Mean age was 81.7±7.3 years and 64.1% were female. The number listed increased since 1997, but there was no change in age or gender. Median time to discharge was 52 days, but varied by year and was longer for public versus private facilities (mean difference=18 days, P=0.006). Mortality of those awaiting long-term care was 17.0%, but varied significantly by year and ranged form 9.3-29.0%. Mortality was higher in males, in those of older age and during the winter months.

CONCLUSIONS

Variation in the time to discharge appears to be associated with changes in the provision of publicly funded private nursing home beds.

The under use of thromboprophylaxis in older medical in-patients: a regional audit

BACKGROUND

The risk of venous thromboembolism (VTE) among medical in-patients increases with age. Thromboprophylaxis using low-molecular-weight heparin can reduce the incidence by 50%, but anecdotally is under-used in medical patients, particularly the elderly.

AIM

To examine prescribing practice for thromboprophylaxis in elderly in-patients in the Yorkshire region.

DESIGN

Regional audit of medical records and drug charts.

METHODS

A simultaneous audit was done of all medical in-patients >75 years on 30 wards in 10 hospitals. Guidelines published by the Scottish Intercollegiate Guidelines Network (SIGN) on the use of thromboprophylaxis were used as the standard. Data were collected on contraindications and/or indications for thromboprophylaxis and the type of prophylaxis used.

RESULTS

Of 601 patients studied (mean age 84.6 years), 117 (19.5%) had indications for thromboprophylaxis with no contraindications. Of these 117, 34 (29%) were receiving prophylaxis as per guidelines. There was more than one indication for thromboprophylaxis in 17% of those left untreated. The mean age of those receiving therapy was similar to those not receiving it (84.0 vs. 84.5 years, p = 0.66, t-test). Elderly in-patients on medical wards were more likely to receive appropriate treatment than those on geriatric wards (43% vs. 23%, p = 0.03, chi(2) test).

DISCUSSION

Thromboprophylaxis is under-used in older medical in-patients, despite their increased risk of VTE, particularly on geriatric wards. Greater consideration by doctors attending to older medical patients is needed if VTE is to be prevented.

Intravenous Thrombolysis for Acute Ischaemic Stroke: Preliminary Experience with Recombinant Tissue Plasminogen Activator in the UK

OBJECTIVE

To present the preliminary experience of implementing intravenous thrombolytic therapy for acute ischaemic stroke in three UK stroke centres.

BACKGROUND

Recombinant tissue plasminogen activator for ischaemic stroke received approval from UK regulatory authorities in April 2003. Since 1997, a small number of UK centres had used thrombolytic therapy in highly selected stroke patients. We present the early experience of that treatment in Glasgow and Newcastle.

DESIGN

Patients were selected and treated in accordance with the American Heart Association guidelines. Additionally, radiologic criteria employed in the European-Australasian Acute Stroke Studies were applied. National Institutes of Health Stroke Scale (NIHSS) scores were measured on admission, and Modified Rankin Scale (MRS) scores were assessed at 3 months for all patients with stroke treated prior to initiation of the Safe Implementation of Thrombolysis in Stroke monitoring program for implementation of thrombolysis in stroke in April 2001. Intracranial and systemic haemorrhagic complications were recorded.

RESULTS

120 patients received thrombolytic treatment (approximately 1% of all admissions with presumed stroke). Mean age was 69 years (range 22-93) and initial median NIHSS score was 17 (range 3-31). In the two centres for which temporal data were available, the mean delay between symptom onset and treatment was 139 min (range 20-185). Sixteen episodes of cerebral haemorrhage or haemorrhagic transformation of any degree occurred, of which 5 (4%) were symptomatic. One patient deteriorated and died before repeat CT imaging could be performed. One non-fatal episode of systemic bleeding occurred. One patient was lost to follow-up. At 3 months, 31% of recipients had achieved good (MRS 0-1) outcome, 22% moderate (MRS 2-3) outcome and 21% (MRS 4-5) poor outcome. Twenty-one per cent died within 3 months of stroke. Observed frequency of bleeding complications and protocol violations (6%) was similar to those reported elsewhere.

CONCLUSION

A small proportion of stroke patients received thrombolytic treatment. Patients treated were more severely affected than in other published European and North American series. Outcomes and complications were consistent with experience elsewhere.

White matter disease and sleep-disordered breathing after acute stroke

OBJECTIVE

To assess sleep-disordered breathing (SDB) in patients with acute stroke and its relationship to prestroke cerebrovascular disease, particularly leukoariosis.

METHODS

The authors studied SDB and CT evidence of prestroke cerebrovascular disease, nonacute brain infarction, and white matter disease (WMD) in 78 previously independent patients with acute stroke. Subjects underwent respiratory sleep studies to determine the Apnea-Hypopnea Index (AHI) and Desaturation Index (DI) 7 to 14 days following stroke. CT scans were evaluated for severity of acute prestroke cerebrovascular disease and WMD severity.

RESULTS

Prestroke cerebrovascular disease was present in 49 (63%) patients and was associated with worse SDB (mean AHI 35 vs 23, p < 0.01; mean DI 28 vs 18, p < 0.05), particularly in men (mean AHI 43 vs 27, p < 0.01). WMD severity correlated with AHI (r = 0.26, p < 0.05) and age (r = 0.56, p < 0.01). WMD severity in frontal and basal ganglia areas showed the strongest association. On multivariate analysis, WMD severity correlated independently with AHI (R(2) = 0.07, p < 0.05).

CONCLUSIONS

The presence of prestroke cerebrovascular disease and severity of WMD are associated with worse SDB. These findings suggest that either white matter is particularly vulnerable to the hypoxia and blood pressure variability associated with SDB or that WMD is a major factor exacerbating SDB following stroke.

Sleep-disordered breathing following acute stroke

BACKGROUND

The reported prevalence of sleep apnoea following stroke varies between 44% and 72%, but its course and relations are unclear.

AIM

To determine the prevalence and course of sleep-disordered breathing in acute stroke in-patients, and its relation to age, stroke subtype, pre-stroke handicap and post-stroke outcome.

DESIGN

Prospective uncontrolled observational study.

METHODS

Paired respiratory sleep studies were performed at week 2 and week 6-9 following stroke. Pre- and post-stroke handicap (modified Rankin Score) and week 2 and week 6-9 disability (Barthel Score) and impairment (Scandinavian Neurological Stroke Score) were assessed. Pre-stroke sleepiness was determined by Epworth Score.

RESULTS

There were 68 patients in the week 2 study, and 50 in the week 6-8 study. Mean week 2 Apnoea Hypopnoea Index (AHI) was 30; 64 patients (94%) had an AHI > or =10. Mean AHI was higher in subjects with lacunar vs. cortical strokes (44 vs. 28, p<0.05), in subjects aged > or =65 years (32 vs. 21, p<0.05) and in those with greater pre-stroke handicap (modified Rankin Score 2 vs. <2) (41 vs. 27, p<0.05). In 50 paired studies, mean AHI fell from 31 to 24 (p<0.01) and the proportion with AHI > or =10 fell from 96% to 72%. Pre-stroke sleepiness was associated with post-stroke neurological impairment (r=-0.325, p<0.05) and disability (r=-0.377, p<0.05).

DISCUSSION

Sleep-disordered breathing improves in the first 6-9 weeks following stroke, but remains highly prevalent. Worse sleep-disordered breathing was observed following lacunar stroke, and in older subjects or those with pre-stroke handicap.

Clinical decision making in nursing: theoretical perspectives and their relevance to practice

AIM OF PAPER

This paper is a response to Thompson's paper 'A conceptual treadmill: the need for a middle ground in clinical decision making theory' published in the Journal of Advanced Nursing in 1999.

SUMMARY OF CONTENT

This author agrees with his main recommendations, which are to seek a middle ground in the current polarized debate over clinical decision making in nursing, and to draw upon Hammond's Cognitive Continuum theory to do so. The theoretical background is sketched out, and the implications of these recommendations are analysed against this. It is argued that nurses now need to move the academic debate forward in such a way as to make serious impact on developing and improving practice. Cognitive continuum theory, in the way in which it focuses on practice, holds considerable potential to assist this move.

CONCLUSION

Drawing on cognitive continuum theory necessarily leads to consequences which are not addressed in Thompson's paper: namely a need to consider the quality of nursing decisions, and a willingness to consider approaches to decision making which have been neglected or criticised by nurses. These consequences are explored here, and the implications of adopting this approach for nurses are outlined.

Cardiac rhythm disturbances in the obstructive sleep apnea syndrome: effects of nasal continuous positive airway pressure therapy

STUDY OBJECTIVES

A high incidence of nocturnal cardiac rhythm disturbances among patients with obstructive sleep apnea (OSA) syndrome has been described in some reports, but not in others. We wished to examine the prevalence of significant cardiac rhythm disturbance in patients with established moderate to severe OSA syndrome and, in particular, to assess the impact of nasal continuous positive airway pressure (nCPAP) therapy.

DESIGN AND SETTING

A prospective study of consecutive eligible patients in a dedicated sleep disorders unit of a university teaching hospital.

MEASUREMENTS AND RESULTS

Holter monitoring was performed for 18 h in 45 patients with previously diagnosed OSA syndrome (mean [SD] apnea/hypopnea frequency [AHI] of 50 [23]/h) and repeated within 2 to 3 days after institution of nCPAP therapy. Investigators were blinded to the patients' treatments during data analysis. Thirty-five patients were found to have some cardiac rhythm disturbance, but only 8 had pathologically significant disturbances (ventricular tachycardia or fibrillation, complex ventricular ectopy, new-onset supraventricular tachycardia other than sinus tachycardia, pauses of > 2 s, and second- or third-degree heart block). Significant rhythm disturbances occurred only during the nighttime, and there was a significant correlation between OSA severity and the severity of rhythm disturbance (p = 0.04, r = 0.301). No significant correlation was found between OSA severity and any other anthropometric parameter measured. nCPAP therapy resulted in abolition of rhythm disturbance in seven of these eight patients; the eighth patient was found to have coexisting severe aortic valve disease requiring valve replacement.

CONCLUSION

The data indicate that OSA syndrome predisposes to clinically significant cardiac rhythm disturbances that can be successfully controlled by nCPAP therapy.

Paradoxical vocal cord motion causing stridor after thyroidectomy

Two women developed stridor immediately after thyroidectomy as a result of paradoxical vocal cord motion. In both cases the cord function showed a normal pattern during vocalisation but paradoxical movement was seen at laryngoscopy during tidal breathing. The abnormality improved in both patients over time with speech therapy. Whilst the syndrome of paradoxical vocal cord motion is classically thought to have a largely psychological aetiology, subtle interference with laryngeal innervation at surgery is more likely to have been the cause in these cases.