Post-stroke pathway analysis and link with one year sequelae in a French cohort of stroke patients: the PAPASePA protocol study

Background

Stroke is a health problem with serious consequences, both in terms of mortality, and after-effects affecting patient quality of life. Stroke requires both urgent and chronic management involving the entire health care system. Although large variability in the management of stroke patients have been noticed, knowledge of the diversity and the scalability of post-stroke pathways, whether it is the care pathway or the life pathway, is currently not sufficient. Moreover the link between post-stroke pathways and patients sequelae have not been yet clearly defined. All this information would be useful to better target the needs to improve stroke patient management.

The purposes are to identify the post-stroke life pathways components associated with sequelae (activity limitations – main purpose, cognitive disorders, anxio-depressive disorders, fatigue, participation restrictions) at 3 months and 1 year post-stroke, to define a typology of life pathways of patients during the post-stroke year and to analyze the social and geographical inequalities in the management of stroke.

Methods

Design: a prospective multicenter comparative cohort study with a follow up to 1 year after the acute episode.

Participant centers: 13 hospitals in the Aquitaine region (France).

Study population: patients diagnosed with a confirmed ischemic or hemorrhagic stroke included in the Aquitaine Observatory of Stroke (ObA2) cohort and voluntary to participate.

Data sources are existing databases (ObA2 database and the French National Health Data System - SNDS) to collect information about care pathways, patient characteristics and stroke characteristics and Ad hoc surveys to collect information about life pathways and post-stroke sequelae. The endpoints of the study are post-stroke activity limitations evaluated by the modified Rankin score, other post-stroke sequelae (Cognitive disorders, anxio-depressive disorders, fatigue, restriction of participation) assessed by standardized and validated scales and Clusters of patients responding to pathways with common or similar characteristics.;

Discussion

By integrating a longitudinal dimension and relying on a large cohort, the project will make it possible to identify the sources of disturbances and the factors favorable to the outcome of the life pathways, important for the planning of the offer and the management of the public policies concerning stroke pathways.

Trial registration

ClinicalTrials.gov ID: NCT03865173, March 6th, 2019.

[Analysis of the discrimination of the final marks after the first computerized national ranking exam in Medicine in June 2016 in France]

INTRODUCTION

The first computerised national ranking exam (cNRE) in Medicine was introduced in June 2016 for 8214 students. It was made of 18 progressive clinical cases (PCCs) with multiple choice questions (MCQs), 120 independent MCQs and 2 scientific articles to criticize. A lack of mark discrimination grounded the cNRE reform. We aimed to assess the discrimination of the final marks after this first cNRE.

METHODS

A national Excel^® file gathering overall statistics and marks were transmitted to the medical faculties after the cNRE. The mean points deviation between two papers and the percentage of points ranking 75% of students allowed us to analyse marks' discrimination.

RESULTS

The national distribution sigmoid curve of the marks is superimposable with previous NRE in 2015. In PCCs, 72% of students were ranked in 1090 points out of 7560 (14%). In independents MCQs, 73% of students were ranked in 434 points out of 2160 (20%). In critical analysis of articles, 75% of students were ranked in 225 points out of 1080 (21%). The above percentages of students are on the plateau of each discrimination curve for PCCs, independent MCQs and critical analysis of scientific articles.

CONCLUSION

The cNRE reduced equally-ranked students compared to 2015, with a mean deviation between two papers of 0.28 in 2016 vs 0.04 in 2015. Despite the new format introduced by the cNRE, 75% of students are still ranked in a low proportion of points that is equivalent to previous NRE in 2015 (between 15 et 20% of points).

[Educational assessment of the first computerized national ranking exam in France in 2016: Opportunities for improvement]

In June 2016, 8124 medical students in their sixth year of graduation passed the first computerized national ranking exam (CNRE) in France after which they will have to choose what medical specialty they will be practicing all their life. We conducted the first educational assessment of this CNRE according to two criteria: the relevance of the questions and the cognitive domain mainly required to answer these questions. We propose two improvements for the future CNRE: promote student reasoning in the multiple choices questions, reduce to 10 the number of multiple choice questions in the progressive clinical cases and increase by 9 their total number (from 18 to 27), and use a majority of mini-clinical cases for isolated multiple choice questions in order to focus students on reasoning instead of simple knowledge restitution.

Five-year follow-up of persons with brain injury entering the French vocational and social rehabilitation programme UEROS: Return-to-work, life satisfaction, psychosocial and community integration

BACKGROUND

Social and vocational reintegration of persons with brain injury is an important element in their rehabilitation.

AIMS

To evaluate the 5-year outcome of persons with brain injury included in 2008 in the Aquitaine Unit for Evaluation, Training and Social and Vocational Counselling programme (UEROS).

METHOD

57 persons with brain injury were recruited from those who completed the 2008 UEROS programme. Five years later, an interview was done to assess family and vocational status, autonomy and life satisfaction. These results were compared with those from persons completing the 1997-1999 programme.

RESULTS

The typical person entered the 2008 UEROS programme 6 years after a severe brain injury (42%) and was male, single and 35 years. At the 5-year follow-up, more persons lived with a partner (+23%) and lived in their own home (+21%). 47% were working vs 11% on entering the programme. Approximately half were satisfied or very satisfied with their quality of life. Having a job in 2013 was associated with a high education level, less cognitive sequelae, having a job in 2008 and no health condition.

CONCLUSIONS

The UEROS programme is effective with regard to return-to-work and improvement of autonomy in persons with brain injury, irrespective of length of time from injury.

No beneficial effect of bracing after anterior cruciate ligament reconstruction in a cohort of 969 athletes followed in rehabilitation

OBJECTIVE

Compare the clinical outcomes of different knee braces in the early phase of rehabilitation after anterior cruciate ligament reconstruction (ACLR) in athletes.

MATERIALS AND METHODS

We conducted a retrospective database study of athletes during early rehabilitation in a tertiary referral hospital between 1 February 2008 and 30 October 2010 after ACLR using bone patellar tendon bone (BPTB) or hamstring autograft. Differences in mid-patellar knee circumference, pain, and range of motion were assessed at admission. All patients followed the same rehabilitation protocol. Patients who had complications preventing them from following the assigned rehabilitation program were analyzed separately. Patients who completed their rehabilitation program were also assessed for thigh muscle atrophy, extension deficit≥2°, quality of walking, PPLP1 and subjective IKDC scores. The type and frequency of complications and their frequency was documented. The above-mentioned parameters were analyzed in 3 different groups: rigid brace in full extension, articulated brace (0°-90° for first 3 weeks then 0-120°) or no brace.

RESULTS

The analysis included 969 patients. Rehabilitation started at 4.5±2.9 days after surgery and ended at 32.4±3.0 days postoperative. At the beginning, flexion was lower in patients with a rigid brace (P<0.01). There was no difference in the frequency or severity of complications between the three study groups, nor was there a significant difference in the clinical outcomes listed above.

CONCLUSION

Postoperative bracing after ACLR has not beneficial effect on clinical outcomes and the complication rate. Patients who wore the rigid brace had limited flexion early on.

Post-acute referral of stroke victims in a French urban area: Results of a specific program

OBJECTIVE

The main objective of this study was to describe the distribution of referrals offered to patients assessed in the "Post-Acute Stroke program" of Bordeaux University Hospital (France). This program was developed in 2008 to organize the dispensation of care in rehabilitation units specialized in neurological diseases.

MATERIAL AND METHODS

This was a single-centre observational study. Between July 2008 and December 2012, data on the number of stroke patients hospitalized at the Bordeaux University Hospital and their post-acute referral were collected from the local hospital discharge database. Some of these patients were assessed by Physical Rehabilitation and Medicine physicians participating in the program. Proposed and actual referrals, time from admission to assessment and functional status were also collected.

RESULTS

Among 4189 stroke patients, 1465 (35%) survivors were assessed, of whom 932 (22.2%) were discharged to inpatient rehabilitation facilities. There were no patients discharged to this type of unit without an assessment. Among the 1465 patients who were assessed, 57.2% were referred to specialized rehabilitation units, 6.3% were discharged to non-specialized rehabilitation units and 26% returned home directly. The median total length of stay in acute units varied from 10 to 15days depending on referral orientation.

CONCLUSION

Patients that were assessed were more likely to be transferred to specialized rehabilitation units than to non-specialized rehabilitation units. The Post-Acute Stroke program has the particularity of combining private and public specialized rehabilitation units in a common collaborative referral system while retaining the control and flexibility of personalised referral for each patient in the light of local care availability.

Assessment of quality of life in stroke patients with hemiplegia

Stroke is a major public health issue. Even though most hemiplegic stroke patients may obtain a good functional outcome, many remain dissatisfied with their lives. Indeed, quality of life and subjective well-being should be taken into account in any assessment of stroke survival.

OBJECTIVE

To assess long-term quality of life in stroke patients (compared with healthy controls) and the corresponding determinants and predictive factors.

METHOD

The patient population consisted of 80 of the 217 first-stroke survivors treated between January and June 2005 in the Clinical Neurosciences Department at Bordeaux University Hospital. After a mean follow-up period of 2 years, 24 patients were interviewed in their homes and data from the 56 others were obtained in a telephone interview. Demographic information, clinical status on admission and functional status (as assessed by Barthel Index) and depression (on the ADRS) at the time of the study visit were recorded. Quality of life was assessed by using the Sickness Impact Profile (SIP-65) and Bränholm and Fugl-Meyer's Satisfaction with Life Scale (LiSat 11). The patients' data were compared with those from 149 healthy controls.

RESULTS

Life satisfaction and quality of life were significantly impaired in stroke patients, compared with controls. All life domains were impaired. The worst scores were observed for independence and health-related items in the LiSat 11 and the physical and communication items in the SIP-65. Quality of life was strongly correlated with functional independence, the persistence of hemiplegia and depressive mood, which is in agreement with literature findings. Neither gender nor the initial Rankin score had a significant impact on these parameters.

DISCUSSION-CONCLUSION

Quality of life at 2 years is significantly impaired in stroke survivors and seems more difficult to predict than functional independence. However, in addition to these objective results, our interviews suggest that receiving adequate social support might be as important to patients as recovering independence.

A randomized controlled trial on early physiotherapy intervention versus usual care in acute care unit for elderly: potential benefits in light of dietary intakes

OBJECTIVE

To evaluate effects of early intensive physiotherapy during acute illness on post hospitalization activity daily living autonomy (ADL).

DESIGN

Prospective randomized controlled trial of intensive physiotherapy rehabilitation on day 1 to 2 after admission until clinical stability or usual care.

SETTING

acute care geriatric medicine ward.

PATIENTS

A total of 76 acutely ill patients, acutely bedridden or with reduced mobility but who were autonomous for mobility within the previous 3 months. Patients in palliative care or with limiting mobility pathology were excluded. Mean age was 85.4 (SD 6.6) years.

MEASUREMENTS

At admission, at clinical stability and one month later: anthropometry, energy and protein intakes, hand grip strength, ADL scores, and baseline inflammatory parameters. An exploratory principal axis analysis was performed on the baseline characteristics and general linear models were used to explore the course of ADL and nutritional variables.

RESULTS

A 4-factor solution was found explaining 71.7% of variance with a factor "nutrition", a factor "function" (18.8% of variance) for ADL, handgrip strength, bedridden state, energy and protein intakes, serum albumin and C-reactive protein concentrations; a factor "strength" and a fourth factor . During follow-up, dietary intakes, handgrip strength, and ADL scores improved but no changes occurred for anthropometric variables. Intervention was associated only with an increase in protein intake. Better improvement in ADL was found in intervention group when model was adjusted on "function" factor items.

CONCLUSION

Physical intervention programs should be proposed according to nutritional intakes with the aim of preventing illness induced disability.

Assessment of agonist-antagonist shoulder torque ratios in individuals with paraplegia: a new interpretative approach

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To evaluate isokinetic shoulder flexor-extensor (F/E) and abductor-adductor (Ab/Ad) torque ratios in individuals with paraplegia using a new interpretative approach. We proposed to study torque ratios according to joint angle sections (15 degrees angle subgroups) over a selected range of motion.

SETTING

Pathokinesiology Laboratory, Montreal, Canada.

METHOD

Sixteen individuals with complete motor paraplegia, without shoulder pain or impairment, were included in this study. After a preloading period of 1 s, maximum isokinetic concentric contractions of all muscle groups were completed at 30, 60 and 120 degrees s(-1) over the entire tested ranges of motion (70 to -35 degrees for the flexion-extension and 15 to 60 degrees for the abduction-adduction). After the continuous torque curves were rebuilt, the mean F/E and Ab/Ad torque ratios were calculated and analyzed every 15 degrees.

RESULTS

A significant modification of the F/E (F=66.3; P<0.001) and Ab/Ad (F=100.6; P<0.001) torque ratios was observed according to the 15 degrees angle subgroup evaluated. More precisely, a progressive decline of both the F/E and Ab/Ad ratios was noted as the shoulder flexion or abduction progressed. Angular velocity did not have any influence on torque ratio values.

CONCLUSION

Angle subgroup torque ratio analysis leads to a better estimation of the balance between the agonist and antagonist muscle groups than does traditional peak torque ratio analysis. In individuals with paraplegia, this precise estimation of torque ratios may lead to the development of specific shoulder strengthening programs to prevent muscle imbalance and its consequences.

Kinematic and electromyographic analysis of rising from a chair during a "Sit-to-Walk" task in elderly subjects: role of strength

BACKGROUND

With aging, the deterioration of the ability to rise from a chair constitutes a major source of disability and a factor contributing to the loss of autonomy. The aim of this study was to describe kinematic and electromyographic characteristics of rising from a chair during a Sit-to-Walk task and to investigate the relationships between lower limb muscle strength and Sit-to-Walk characteristics.

METHODS

Twenty-four healthy elderly subjects (mean age: 73.8 (6.4) years) were included. The task analyzed consisted in standing up and taking a step. Kinematic data were obtained using a 3D motion analysis software. Surface electromyography of eight lower limb muscles was recorded. Isokinetic strength of ankle plantar flexor and knee flexors and extensors was evaluated.

FINDINGS

The Sit-to-Walk was divided into four phases. For 19 subjects, this task can be considered as a continuum with an overlap of the phases. In comparison with the Sit-to-Stand description, the Sit-to-Walk transition phase, which combined trunk flexion and knee extension, appeared longer in order to increase the body forward transfer for gait initiation. In most cases, the tibialis anterior and peroneus longus muscles were first activated. The isokinetic strength of the knee extensors was negatively correlated with the amplitude of trunk flexion and the knee flexors/extensors torque ratio was correlated with the length of this phase.

INTERPRETATION

Characterization of Sit-to-Walk movement provides information about the ability to rise from a chair. In the elderly, a better knowledge of its determinants could lead to improve strategies for rehabilitation of this critical task.

Muscle phosphocreatine post-exercise recovery rate is related to functional evaluation in hospitalized and community-living older people

OBJECTIVE

to explore muscle mitochondria function with respect to age, functional status and nutrition in community-living and recovering hospitalized older subjects.

MEASUREMENTS

subjects were assessed for nutrition, hand-grip strength, 10-meter gait time, a modified timed get-up-and-go test and activities of daily living score (ADL). 31P magnetic resonance spectroscopy (31P MRS) was used to assess the initial rate of post-exercise phosphocreatine recovery (ViPCr) for mitochondrial function evaluation in 25 hospitalized older subjects (86.1 + 5.3 y) and in 25 community-living younger ones (74.5 + 6.2 y).

RESULTS

in multiple linear regression, longer time on the get-up-and-go test was independently associated with lower values of ViPCr (p = 0.008). For all subjects and in the 8 patients unable to perform this test, ViPCr was negatively correlated with the ADL score (respectively p < 0.001 and p = 0.025).

CONCLUSION

particularly in hospitalized and frail older subjects, muscle mitochondrial function was related to the global physical functional assessment.

Disability and quality of life in elderly people with diabetes

To implement preventive policies of disability in older diabetic people, the role of diabetes in the disablement process should be investigated. Diabetes mellitus is consistently associated with a higher prevalence of disability at all states, as well as with a progression in disability states and may be considered as a brake on recovery. This association is partially explained by existing complications, associated conditions (obesity, depression, arterial hypertension) treatment burden, and other social characteristics (lower income, lower educational level). Finally, in the disablement process, the role of altered muscle metabolism due to diabetes, aging, nutrition and sedentary lifestyle may represent a major target for interventions to improve functions and potentially activities in elderly people.