Practice patterns, role and impact of advanced practice nurses in stroke care: A mixed-methods systematic review

AIM(S)

To undertake a systematic review of the practice patterns and roles of advanced practice nurses (APNs) in inpatient and outpatient stroke-care services; and to evaluate the impact of APN-led inpatient and outpatient stroke-care services on clinical and patient-reported outcomes.

DESIGN

A mixed-methods systematic review.

METHODS

A systematic search was conducted across six electronic databases for primary studies. Data were synthesised using a convergent integrated approach. DATA SOURCES (INCLUDE SEARCH DATES) *FOR REVIEWS ONLY: A systematic search was conducted across PubMed, CINAHL, Cochrane Library, Embase, PsycInfo and ProQuest Dissertations & Theses Global, for primary studies published between the inception of the databases and 3 November 2022.

RESULTS

Findings based on the 18 included primary studies indicate that the APNs' roles have been implemented across the continuum of stroke care, including pre-intervention care, inpatient care and post-discharge care. Practicing at an advanced level, the APNs engaged in clinical, operational and educational undertakings across services and disciplines. Positive clinical and patient-reported outcomes have been attributed to their practice.

CONCLUSION

The review highlights the critical role of APNs in improving stroke care, especially in the pre-intervention phase. Their clinical expertise, patient-centered approach and collaboration can transform stroke care. Integrating APNs into stroke care teams is essential for better management and outcomes in light of the increasing stroke burden.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Healthcare institutions should integrate APNs to enhance pre-intervention stroke care, improve diagnostic accuracy and expedite treatment. APNs can prioritise patient-centric care, including assessments, coordination and education. Medication reconciliation, timely rehabilitation referrals and lifestyle modifications for secondary stroke prevention are crucial. Implementing advanced practice nursing frameworks ensures successful APN integration, leading to improved stroke care and better patient outcomes in response to the growing stroke burden.

IMPACT (ADDRESSING)

What problem did the study address? Poor clarity of the role of advanced practice nurses among patients, physicians, healthcare professionals, health policymakers and nurses. What were the main findings? Advanced practice nurses practise across the continuum of stroke care, mainly in pre-intervention care which takes place before initiating treatment, inpatient care and post-discharge care. The implementation of the advanced practice nurse role in stroke care has contributed positively to clinical and patient-reported outcomes. Where and on whom will the research have an impact? Insights from the review are envisioned to inform healthcare policymakers and leaders in the implementation and evaluation of the APN role in stroke care.

REPORTING METHOD

Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution. TRIAL AND PROTOCOL REGISTRATION: https://figshare.com/ndownloader/files/41606781; Registered on Open Science Framework osf.io/dav8j.

Reporting standard for describing first responder systems, smartphone alerting systems, and AED networks

Standardized reporting of data is crucial for out-of-hospital cardiac arrest (OHCA) research. While the implementation of first responder systems dispatching volunteers to OHCA is encouraged, there is currently no uniform reporting standard for describing these systems. A steering committee established a literature search to identify experts in smartphone alerting systems. These international experts were invited to a conference held in Hinterzarten, Germany, with 40 researchers from 13 countries in attendance. Prior to the conference, participants submitted proposals for parameters to be included in the reporting standard. The conference comprised five workshops covering different aspects of smartphone alerting systems. Proposed parameters were discussed, clarified, and consensus was achieved using the Nominal Group Technique. Participants voted in a modified Delphi approach on including each category as a core or supplementary element in the reporting standard. Results were presented, and a writing group developed definitions for all categories and items, which were sent to participants for revision and final voting using LimeSurvey web-based software. The resulting reporting standard consists of 68 core items and 21 supplementary items grouped into five topics (first responder system, first responder network, technology/algorithm/strategies, reporting data, and automated external defibrillators (AED)). This proposed reporting standard generated by an expert opinion group fills the gap in describing first responder systems. Its adoption in future research will facilitate comparison of systems and research outcomes, enhancing the transfer of scientific findings to clinical practice.

ACT-FAST: a quality improvement project to increase the percentage of acute stroke patients receiving intravenous thrombolysis within 60 minutes of arrival at the emergency department

INTRODUCTION

Stroke is a leading cause of death and disability, with the administration of recombinant transcriptase-plasminogen activator (rtPA) improving outcomes in a time-dependent manner. Only 52.3% of eligible stroke patients at our institution received rtPA within 60 minutes of arrival. We aimed to improve the percentage of acute stroke patients receiving rtPA within 60 minutes of arrival at the emergency department (ED).

METHODS

This study presents results from the first year of a clinical practice improvement project that implemented quality improvement interventions. The primary outcome measure was percentage of acute ischaemic stroke patients receiving rtPA within 60 minutes of arrival at the ED. Secondary outcome measures included components of total door-to-needle (DTN) time and factors for delay to thrombolysis. Interventions were establishment of standardised acute stroke activation guidelines, screening question at ED registration, prehospital notification of stroke activation, public education, scripting for thrombolysis consent and easy access to equipment.

RESULTS

The percentage of patients thrombolysed within 60 minutes increased to 60.6% (p = 0.27), and DTN time decreased from 59 minutes to 54.5 minutes (p = 0.15). This was attributable to reduced door-to-physician time, door-to-imaging time and decision time, although the results were not significant. There was no significant increase in symptomatic intracranial haemorrhage or mortality secondary to stroke. Length of stay was significantly reduced by 1.5 days (p < 0.048).

CONCLUSION

The interventions resulted in an increasing but non-significant trend of acute stroke patients receiving thrombolysis within 60 minutes. Outcomes will be monitored for a longer duration to demonstrate trends and sustainability.

Elevated plasma and synovial fluid interleukin-8 and interleukin-18 may be associated with the pathogenesis of knee osteoarthritis

PURPOSE

Osteoarthritis (OA) of the knee is a multifactorial degenerative disease typically defined as the 'wear and tear' of articular joint cartilage. However, recent studies suggest that OA is a disease arising from chronic low-grade inflammation. We conducted a study to investigate the relationship between chronic inflammatory mediators present in both the systemic peripheral blood system and localised inflammation in synovial fluid (SF) of OA and non-OA knees; and subsequently made direct comparative analyses to understand the mechanisms that may underpin the processes involved in OA.

METHODS

20-Plex proteins were quantified using Human Magnetic Luminex® assay (R&D Systems, USA) from plasma and SF of OA (n = 14) and non-OA (n = 14) patients. Ingenuity Pathway Analysis (IPA) software was used to predict the relationship and possible interaction of molecules pertaining to OA.

RESULTS

There were significant differences in plasma level for matrix metalloproteinase (MMP)-3, interleukin (IL)-27, IL-8, IL-4, tumour necrosis factor-alpha, MMP-1, IL-15, IL-21, IL-10, and IL-1 beta between the groups, as well as significant differences in SF level for IL-15, IL-8, vascular endothelial growth factor (VEGF), MMP-1, and IL-18. Our predictive OA model demonstrated that toll-like receptor (TLR) 2, macrophage migration inhibitory factor (MIF), TLR4 and IL-1 were the main regulators of IL-1B, IL-4, IL-8, IL-10, IL-15, IL-21, IL-27, MMP-1 and MMP-3 in the plasma system; whilst IL-1B, TLR4, IL-1, and basigin (BSG) were the regulators of IL-4, IL-8, IL-10, IL-15, IL-18, IL-21, IL-27, MMP-1, and MMP-3 in the SF system.

CONCLUSION

The elevated plasma IL-8 and SF IL-18 may be associated with the pathogenesis of OA via the activation of MMP-3.

Knowledge on Bone Banking among Participants in an Orthopaedic Conference: A Preliminary Survey

Despite increasing use of bone graft in Malaysia, there was still lack of data to quantify knowledge level on bone banking among orthopaedic community who are involved in transplantation related work. Therefore, a survey on awareness in tissue banking specifically bone banking, usage and choice of bone grafts was conducted. From 80 respondents, 82.5% were aware about tissue banking however only 12.5% knew of the existence of tissue banks in Malaysia. Femoral head was the bone allograft most often used as a substitute to autograft. Only 34.8% respondents preferred irradiated bone grafts whilst 46.9% preferred nonirradiated, indicating the need to educate the importance of radiation for sterilising tissues. Exhibition was the most preferred medium for awareness programme to disseminate information about bone banking in the orthopaedic community. The professional awareness is necessary to increase the knowledge on the use of bone graft, hence to increase bone transplantation for musculoskeletal surgeries in the country.

Predicting Pneumonia in Acute Ischaemic Stroke: Comparison of Five Prediction Scoring Models

INTRODUCTION

Although pneumonia is a major complication after acute ischaemic stroke (AIS), pneumonia prediction scores have not been extensively validated. This study aimed to compare the discrimination performance of 5 pneumonia prediction scores in AIS patients.

MATERIALS AND METHODS

We retrospectively reviewed all consecutive adult AIS patients whom presented to our emergency department within 4.5 hours of symptom-onset between January 2012 and February 2015. Diagnosis had to be made by a neurologist and infarcts confirmed by neuroimaging. We excluded patients with pneumonia on presentation. Pneumonia predictors were based on the 5 prediction scoring models: Kwon's score, Chumbler's score, Acute Ischaemic Stroke-Associated Pneumonia Score (AIS-APS), A²DS² score and ISAN score. The definition of stroke-associated pneumonia was based on the criteria by the Pneumonia in Stroke Consensus Group. Analysis using area under receiver operating characteristics curve (AUROC) was performed.

RESULTS

Forty (5.5%) out of 731 patients analysed had stroke-associated pneumonia (SAP). A²DS² score had the highest discrimination capacity (AUROC 0.88; 95% CI, 0.84 to 0.92), followed by AIS-APS (AUROC 0.87; 95% CI, 0.83 to 0.91), Kwon's score (AUROC 0.86; 95% CI, 0.82 to 0.92), Prestroke Independence, Sex, Age and National Institutes of Health Stroke Scale (ISAN) score (AUROC 0.85; 95% CI, 0.80 to 0.90) and Chumbler's score (AUROC 0.79; 95% CI, 0.74 to 0.84). However, there was no statistical difference of discrimination capacity among A²DS² score, AIS-APS and Kwon's score.

CONCLUSION

A²DS² , AIS-APS and Kwon's scores performed comparably in discriminating SAP in AIS patients.

Abstract TP334: The Cultural Appropriateness of the National Institute of Health Stroke Scale (NIHSS) in Singapore: a Survey on Healthcare Workers’ Opinions

Introduction: The National Institute of Health Stroke Scale (NIHSS) is the most utilized scale for neurological deficits of stroke, assessing various components including dysphasia and dysarthria. However, some non-Western countries have found certain components in the NIHSS to be inappropriate due to cultural differences, but no studies have been conducted in Singapore. We sought the opinions of healthcare workers in Singapore who are involved in stroke care on the cultural appropriateness of the NIHSS.

Hypothesis: The NIHSS contains components which are considered culturally inappropriate by healthcare workers in Singapore.

Methods: We surveyed 79 healthcare workers who care for stroke patients (24 doctors, 40 nurses, 15 speech therapists), on cultural appropriateness of the dysphasia and dysarthria components of the NIHSS in Singapore, using a standardized questionnaire.

Results: The majority of respondents (84%) found ≥1 objects tested for dysphasia culturally inappropriate, with 33% substituting with another picture, 29% skipping the object and 32% using a physical object. Most (86%) opined that ≥1 dysphasia objects should be changed, specifically the hammock (67%) and cactus (51%). The dysphasia phrases and kitchen scene were reported as culturally inappropriate by 49% and 29% of the respondents respectively. For the dysarthria component, 58% found ≥1 word culturally inappropriate and 75% reported adjusting the acceptability of responses by patient demographics.

Conclusions: The dysphasia objects, dysphasia phrases and dysarthria phrases of the NIHSS are culturally inappropriate in Singapore. There are inconsistencies in handling these issues and responses are commonly being adjusted to patient’s demographics. Thus we aim to modify the standard NIHSS based on response to this survey and to develop a NIHSS version that is culturally suitable in Singapore.

A Qualitative Study into Stroke Caregivers' Educational Needs — Perspectives of Caregivers and Healthcare Professionals

Background:

Healthcare professionals (HCPs) often provide information based on what they thought caregivers would need and like to know, rather than on the latter's perceived or actual needs. The current descriptive study was undertaken to find out more about HCP's and caregivers' perceptions of educational needs while the stroke survivor is still being cared for in an acute hospital.

Methods:

Ten caregivers, five nurses, and two neurologists were interviewed about their perceptions of educational needs during the stroke survivors' stay in acute care. All interviews were audiotaped, transcribed verbatim, and then analysed to identify main patterns of responses. The Framework Approach, which involves the steps of familiarisation, identifying a thematic framework, indexing, charting, mapping, and interpretation was used to inform the analysis.

Results:

Caregivers and HCPs agreed on the need for information on disease progression, prevention of recurrence, practical and emotional care. However, HCPs felt caregivers should also know about medication, which was not mentioned by any of the caregivers. Caregivers preferred “hands-on experience” and “hearing” from HCP to print materials. While some caregivers felt that their active involvement in caregiving training was not required if a foreign domestic worker (FDW) was to be hired, HCPs interviewed felt strongly that next-of-kin should, nonetheless, be trained as well.

Conclusion:

The expressed needs on stroke education did not differ greatly between caregivers and HCPs. Perhaps unique to the Singapore context, is the availability of FDWs to take on the care-giving role. HCPs should be aware of differences in expectations in the level of involvement of family members in the presence of a FDW.

Fibrous Dysplasia Masquerading as Extramedullary Relapse After Bone Marrow Transplantation for Chronic Myeloid Leukemia

A 19-year old girl suffered from relapse of chronic myeloid leukemia (CML) after bone marrow transplantation. The disease was controlled by interferon and imatinib mesylate, but was complicated by autoimmune hyperthyroidism. She presented with unilateral proptosis with no extraocular muscle or visual defect at 26 months follow-up. Systemic investigations showed no recurrence of leukemia or thyrotoxicosis. Magnetic resonance imaging revealed an extensive retro-orbital base of skull lesion. A trans-oral biopsy showed fibrous dysplasia and continuous observation was advised. The unusual sequence of events and the differential diagnoses for unilateral proptosis in post bone marrow transplantation (BMT) cases are discussed.

Bilateral femoral neuropathy associated with disseminated intravascular coagulopathy: a case report

We report a case of 20-year-old man who presented with bilateral femoral nerve palsy following resuscitation for traumatic massive blood loss and its consequence. A high suspicious index for this complication may lead to its early recognition. Its related pathoanatomy is discussed based on the described evidences in the literature. Nonoperative treatment remains as a recommended option for coagulopathy-related neuropathy.

Melioidotic osteomyelitis treated with antibiotic-calcium hydroxyapatite composite: case report with four-year follow-up

Melioidosis is caused by an infection by Burkholderia pseudomallei. Osteomyelitis is a recognised manifestation of melioidosis but Burkholderia pseudomallei is a relatively rare aetiological agent in musculoskeletal infections. We report a 32-year-old diabetic man with septicaemia due to melioidotic infection of the spleen, liver and distal femur. The osteomyelitis relapsed despite being treated with the standard radical debridement and insertion of gentamycinimpregnated polymethylmetacrylate (PMMA) beads, followed by an optimal antibiotic therapy. The PMMA-gentamycin beads were then removed. The bone defect was debrided and packed with calcium hydroxyapatite blocks filled with ceftazidime powder. The osteomyelitis was successfully treated and the patient remained free of infection four years postoperatively. Computed tomography demonstrated successful incorporation of the calcium hydroxyapatite into host bone.

Preliminary results of radiation dose escalation for locally advanced nasopharyngeal carcinoma

PURPOSE

To study the safety and efficacy of dose escalation in tumor for locally advanced nasopharyngeal carcinoma (NPC).

METHODS AND MATERIALS

From September 2000 to June 2004, 50 patients with T3-T4 NPC were treated with intensity-modulated radiotherapy (IMRT). Fourteen patients had Stage III and 36 patients had Stage IVA-IVB disease. The prescribed dose was 76 Gy to gross tumor volume (GTV), 70 Gy to planning target volume (PTV), and 72 Gy to enlarged neck nodes (GTVn). All doses were given in 35 fractions over 7 weeks. Thirty-four patients also had concurrent cisplatin and induction or adjuvant PF (cisplatin and 5-fluorouracil).

RESULTS

The average mean dose achieved in GTV, GTVn, and PTV were 79.5 Gy, 75.3 Gy, and 74.6 Gy, respectively. The median follow-up was 25 months, with 4 recurrences: 2 locoregional and 2 distant failures. All patients with recurrence had IMRT alone without chemotherapy. The 2-year locoregional control rate, distant metastases-free and disease-free survivals were 95.7%, 94.2%, and 93.1%, respectively. One treatment-related death caused by adjuvant chemotherapy occurred. The 2-year overall survival was 92.1%.

CONCLUSIONS

Dose escalation to 76 Gy in tumor is feasible with T3-T4 NPC and can be combined with chemotherapy. Initial results showed good local control and survival.

The incidence of deep venous thrombosis following arthroscopic knee surgery

A prospective cohort study was undertaken at two centers to look for the incidence of deep vein thrombosis (DVT) following knee arthroscopic surgery. Eighty-four patients who had 90 arthroscopic procedures were reviewed. The relevant risk factors: past or family history of DVT, smoking, oral contraceptives, body weight, haemoglobin level, platelet count, tourniquet time and type of anaesthesia were documented. All patients were subjected to preoperative and post-operative duplex ultrasound. Only one patient (1.2 %) was noted to have DVT involving the peroneal vein. We concluded that the incidence of DVT after knee arthroscopy was very low in this study population.

Tarsal tunnel syndrome caused by ganglion

We report a case of delayed diagnosis of tarsal tunnel syndrome caused by a ganglion arising from the talo-calcaneal joint. Unusually the symptoms were mainly due to the lateral planter nerve compression with a positive Tinel's sign. A surgical decompression was successful in relieving the dysaesthesia in spite of a 7 years history.

Lace-like enhancement pattern of osteosarcoma of rib and liver metastasis in CT scans

The rib is an uncommon site of osteosarcoma. With the use of adjuvant chemotherapy and aggressive surgical resection of the metastatic pulmonary lesions, extrapulmonary metastases are becoming more clinically evident. Primary rib osteosarcoma with extrapulmonary metastasis is exceedingly rare. A case is reported, showing that the pattern of metastasis of rib osteosarcoma is similar to that of primary bone osteosarcoma. The liver metastasis occurred after resection of the metastatic pulmonary lesions. A CT scan of the primary rib lesion and liver metastasis both showed a lace-like enhancement pattern, its histological appearance corresponding with neoplastic osteoid. With the increasing use of CT abdomen for localization of extrapulmonary metastases, lace-like enhancement may be seen more readily in the future.

Development of follicular dendritic cell sarcoma in hyaline-vascular Castleman's disease of the nasopharynx: tracing its evolution by sequential biopsies

AIMS

Hyaline-vascular Castleman's disease (HVCD) and follicular dendritic cell (FDC) sarcoma occurring in the nasopharynx are both extremely rare. We report the first case of transformation of the former into the latter as documented by sequential biopsies. The steps involved in the transformation were described in detail and the possible role of p53 studied.

METHODS AND RESULTS

The patient presented at the age of 23 years with nasopharyngeal HVCD. Hyaline- vascular Castleman's disease with FDC overgrowth was diagnosed in a recurrence 8 years later, and a frank FDC sarcoma developed at the same site 11 years after initial presentation. The patient remained disease-free 3 years after excision and adjuvant chemotherapy. The FDC sarcoma comprised swirling fascicles of spindly cells with indistinct cell borders. The tumour cells expressed the FDC markers CD21, CD35 and CNA.42 and in-situ hybridization for Epstein-Barr virus-encoded RNAs was negative. Over-expression of p53 protein was observed in the FDC sarcoma and an increased number of weakly p53-positive spindly cells could also be demonstrated in the HVCD specimen. This finding suggested a possible role of p53 in the evolution from HVCD to FDC sarcoma. Critical analysis of the literature shows that, among the 13 reported cases of FDC sarcoma associated with Castleman's disease, possible progression from the latter to the former is documented in only two cases.

CONCLUSIONS

The sequential changes observed in the current case provide further evidence to strengthen the role of HVCD as a possible precursor of FDC sarcoma. There is a possible role of p53 in the transformation process but confirmation by future studies is needed.

Aggressive subcutaneous panniculitis-like T-cell lymphoma: complete remission with fludarabine, mitoxantrone and dexamethasone

Subcutaneous panniculitis-like T-cell lymphoma (SCPTCL) is a rare cutaneous T-cell lymphoma. The optimal treatment of this disease is undefined. A 36-year-old woman presented with swinging pyrexia, weight loss and disseminated SCPTCL involving her limbs and trunk. Typical histological features of panniculitic infiltration with rimming of fat cells and sparing of the dermis and epidermis were seen. Immunophenotyping confirmed a CD8+ cytotoxic T-cell phenotype. The patient was successfully treated with a combination of fludarabine, mitoxantrone and dexamethasone (FND), and has remained in remission 15 months after cessation of treatment. FND may be an effective regimen for aggressive SCPTCL.

The K318A mutant of bacteriophage T7 DNA primase-helicase protein is deficient in helicase but not primase activity and inhibits primase-helicase protein wild-type activities by heterooligomer formation

Lysine 318 in the conserved sequence SXXXGXGKS of bacteriophage T7 gene 4A' protein was mutated to an alanine to understand the effect of this substitution on the helicase and primase activities. The dTTPase activity of 4A'/K318A mutant protein was much lower than that of 4A', and both Km and kcat values were affected. The Km of the mutant protein was 3-5-fold higher, and the kcat was about 100-fold lower, than that of 4A'. The mutation did not affect the ability of 4A'/K318A to assemble into hexamers or bind DNA in the presence of MgdTTP. Interestingly, the mutant protein does not bind DNA in the presence of MgdTMP-PCP. The reduced dTTPase activity, however, decreased the helicase activity of the mutant protein to an undetectable level, whereas its primase activity was only 1.5-2.5-fold lower. When 4A'/K318A mutant protein was mixed with 4A', heterooligomers were formed and the helicase and the DNA-dependent dTTPase activities of 4A' were inhibited, but the DNA-independent activity actually increased. The extent of decrease in activities upon heterooligomer formation depended both on the length of time 4A' and 4A'/K318A proteins were incubated and on the concentration of the mutant protein. In addition, the decrease in the dTTPase activity was observed only when the two proteins were incubated in the absence of MgdTTP and DNA, conditions under which both proteins form unstable hexamers. Even though 4A'/K318A does not bind a 30-mer DNA in the presence of MgdTMP-PCP, heterooligomers were capable of binding DNA with the same stoichiometry as 4A'. Protein-DNA cross-linking experiments with (dT)30 and poly(5-BrdU) showed that DNA interacts with five and perhaps all six subunits of 4A'. Therefore, unless heterooligomer restores the ability of the mutant protein to bind DNA in the presence of MgdTMP-PCP, these results suggest that the DNA can bind 4A' by interacting with a few subunits. However, a fully active hexamer is required for both the helicase and the single-stranded M13 DNA-dependent dTTPase activities.