Integrated care pathways in stroke management

BACKGROUND: an organized, goal-defined and time-specified plan of management as envisaged by the integrated care pathway approach can achieve quality outcomes at lower cost. Integrated care pathways may have applications to stroke management because diagnosis is well defined, complex interdisciplinary inputs are required and there is good evidence on best practice. METHOD: we reviewed medical, nursing, rehabilitation and health services databases to identify studies on integrated care pathways in stroke management. Criteria for inclusion were: use of a care pathway or similar methods in acute or rehabilitation settings, randomized studies or non-randomized comparisons with concurrent or historical controls and some form of outcome assessment. RESULTS: we identified six non-randomized studies of acute stroke. One used concurrent controls; the rest used historical controls. Only one study investigated stroke rehabilitation and this used a quasi-randomized controlled design. Five studies in the acute setting demonstrated reduced hospital stay. A reduction in costs of care was reported in all five studies that examined costs. Two studies reported improved uptake of medical interventions. No difference in length of hospital stay, costs or functional status was seen in the rehabilitation study. CONCLUSIONS: integrated care pathway methodology may facilitate quality and cost improvements in stroke care, but evidence is weak and uncertainty exists. Further evidence is needed before implementation in practice.     

Clock drawing task, mini-mental state examination and cognitive-functional independence measure: relation to functional outcome of stroke patients

The use of reliable and valid brief cognitive screening instrument for selecting the appropriate candidates for stroke rehabilitation is crucial. Clinicians often face the question which test should be preferred, that will best correlate with functional outcome. The objective of this study was to compare the clock drawing task with other cognitive tests used for the evaluation of discharge functional outcome in elderly stroke patients. We conducted a retrospective chart study including 151 consecutive patients, admitted for inpatient comprehensive rehabilitation following acute stroke. The clock drawing task (CDT), mini-mental state examination (MMSE) and the cognitive-functional independence measure (cognFIM) were used to assess the cognitive status. Functional status outcome was evaluated by the functional independence measure (FIM), using absolute and relative parameters of efficacy and efficiency. Correlation coefficients (Pearson correlation) between the three cognitive tests resulted in r-values ranging from 0.51 to 0.59 (P<0.001). All three tests correlated significantly with motor outcomes. MMSE did not confer additive value to CDT. It is concluded that CDT is similar to mini-mental and both are somewhat better than cognFIM with respect to the evaluation of functional status outcome following stroke. The correlations between the tests as well as the simplicity of administration favor the use of either CDT or MMSE in the initial assessment of elderly stroke patients.     

Stroke beyond the first hours: the role of monitoring

It is now recognized that a specialized multidisciplinary team, focusing on the care of stroke patients, leads to lower mortality and better outcomes. The positive effect of stroke units in regard to the outcome of stroke patients seems to be related to the careful monitoring of clinical parameters and clinical emergencies. The monitoring of physiological parameters in the acute phase of stroke can be considered an important management tool that can improve significantly the quality of care provided. It allows timely detection and correction of complications and consequently has a beneficial effect on outcome.     

Stroke beyond the First Hours: The Role of Monitoring

It is now recognized that a specialized multidisciplinary team, focusing on the care of stroke patients, leads to lower mortality and better outcomes. The positive effect of stroke units in regard to the outcome of stroke patients seems to be related to the careful monitoring of clinical parameters and clinical emergencies. The monitoring of physiological parameters in the acute phase of stroke can be considered an important management tool that can improve significantly the quality of care provided. It allows timely detection and correction of complications and consequently has a beneficial effect on outcome.     

Outcome parameters for trials in atrial fibrillation: recommendations from a consensus conference organized by the German Atrial Fibrillation Competence NETwork and the European Heart Rhythm Association.

Atrial fibrillation (AF), the most common atrial arrhythmia, has a complex aetiology and causes relevant morbidity and mortality due to different mechanisms, including but not limited to stroke, heart failure, and tachy- or bradyarrhythmia. Current therapeutic options (rate control, rhythm control, antithrombotic therapy, 'upstream therapy') only prevent a part of this burden of disease. New treatment modalities are therefore currently under evaluation in clinical trials. Given the multifold clinical consequences of AF, controlled trials in AF patients should assess the effect of therapy in each of the main outcome domains. This paper describes an expert consensus of required outcome parameters in seven relevant outcome domains, namely death, stroke, symptoms and quality of life, rhythm, left ventricular function, cost, and emerging outcome parameters. In addition to these 'requirements' for outcome assessment in AF trials, further outcome parameters are described in each outcome domain. In addition to a careful selection of a relevant primary outcome parameter, coverage of outcomes in all major domains of AF-related morbidity and mortality is desirable for any clinical trial in AF.     

Accuracy of Clinical Judgment of the Chin-Down Posture for Dysphagia During the Clinical/Bedside Assessment as Corroborated by Videofluoroscopy in Adults with Acute Stroke

Speech-language pathologists tend to rely on the noninstrumental swallowing evaluation in making recommendations about a patient’s diet and management plan. The present study was designed to examine the sensitivity and specificity of the accuracy of using the chin-down posture during the clinical/bedside swallowing assessment. In 15 patients with acute stroke and clinically suspected oropharyngeal dysphagia, the correlation between clinical and videofluoroscopic findings was examined. Results identified that there is a difference in outcome prediction using the chin-down posture during the clinical/bedside assessment of swallowing compared to assessment by videofluoroscopy. Results are discussed relative to statistical and clinical perspectives, including site of lesion and factors to be considered in the design of an overall treatment plan for a patient with disordered swallowing.     

急性卒中后谵妄

谵妄是急性卒中的一种常见并发症,通常提示患者转归不良、病死率较高、住院时间较长以及痴呆风险增高.因此,急性卒中后谵妄的早期发现和干预具有重要意义.文章从卒中后谵妄的发病机制、危险因素、诊断评估、治疗和转归等方面进行了综述.     

Diabetes hyperglycemia and recovery from stroke

Strokeis a major cause of death and severe disability in older people. Despite the burden of disease, there is still no safe, simple and proven medical therapy for the treatment of acute stroke. Advances in acute stroke treatment have been either consistently disappointing (neuroprotective therapy) or fraught with controversy regarding risk/benefit (thrombolysis), and attention is once again being directed towards physiological variables that may influence outcome. Both insulin-dependent and non-insulin-dependent diabetes mellitus are major risk factors for stroke. Diabetes mellitus has also been shown to be associated with increased mortality and reduced functional outcome after stroke. Hyperglycemia is a frequent finding following stroke and may reflect the metabolic stress of the acute event, so-called stress hyperglycemia, and/or underlying impaired glucose metabolism. Several large clinical studies have now demonstrated a positive association between a raised blood glucose and poor outcome from stroke; greater mortality and reduced functional recovery. What is not clear is to what extent hyperglycemia is a 'normal' physiological response to stroke or whether hyperglycemia per se increases cerebral damage in the acute phase. There are many potential mechanisms by which hyperglycemia can exert a harmful effect upon cerebral tissue and it is probable that an important relationship exists, not only between glucose and stroke outcome, but also between insulin and neuroprotection. It remains to be determined whether lowering and maintaining 'normal' glucose levels in the immediate aftermath of stroke, combined with the administration of insulin as an acute treatment, can modify this outcome.     

Awareness of Dysphagia by Patients Following Stroke Predicts Swallowing Performance

Patients awareness of their disability after stroke represents an important aspect of functional recovery. Our study aimed to assess whether patient awareness of the clinical indicators of dysphagia, used routinely in clinical assessment, related to an appreciation of a swallowing problem and how this awareness influenced swallowing performance and outcome in dysphagic stroke patients. Seventy patients were studied 72 h post hemispheric stroke. Patients were screened for dysphagia by clinical assessment, followed by a timed water swallow test to examine swallowing performance. Patient awareness of dysphagia and its significance were determined by detailed question-based assessment. Medical records were examined at three months. Dysphagia was identified in 27 patients, 16 of whom had poor awareness of their dysphagic symptoms. Dysphagic patients with poor awareness drank water more quickly (5 ml/s vs. <1 ml/s, p = 0.03) and took larger volumes per swallow (10 ml vs. 6 ml, p = 0.04) than patients with good awareness. By comparison, neither patients with good awareness or poor awareness perceived they had a swallowing problem. Patients with poor awareness experienced numerically more complications at three months. Stroke patients with good awareness of the clinical indicators of dysphagia modify the way they drink by taking smaller volumes per swallow and drink more slowly than those with poor awareness. Dysphagic stroke patients, regardless of good or poor awareness of the clinical indicators of dysphagia, rarely perceive they have a swallowing problem. These findings may have implications for longer-term outcome, patient compliance, and treatment of dysphagia after stroke. This work was presented in abstract form at the Dysphagia Research Society meeting, Burlington, Vermont, 1999     

Outcome parameters for trials in atrial fibrillation: executive summary.

Atrial fibrillation (AF), the most common atrial arrhythmia, has a complex aetiology and causes relevant morbidity and mortality due to different mechanisms, including but not limited to stroke, heart failure, and tachy- or bradyarrhythmia. Current therapeutic options (rate control, rhythm control, antithrombotic therapy, 'upstream therapy') only prevent a part of this burden of disease. Several new treatment modalities are therefore under evaluation in controlled trials. Given the multifold clinical consequences of AF, trials in AF patients should assess the effect of therapy in each of the main outcome domains. This paper describes an expert consensus of required outcome parameters in seven relevant outcome domains, namely death, stroke, symptoms and quality of life, rhythm, left ventricular function, cost, and emerging outcome parameters. In addition to these 'requirements' for outcome assessment in AF trials, further, more detailed outcome parameters are described. In addition to a careful selection of a relevant primary outcome parameter, coverage of outcomes in all major domains of AF-related morbidity and mortality is desirable for any clinical trial in AF.     

Systematic review and meta-analysis of the efficacy of melatonin in experimental stroke

Melatonin is a candidate neuroprotective drug for ischaemic stroke. Any decision to proceed to clinical trial for such drugs should be based on an unbiased assessment of all available data. Such an assessment should include not only the efficacy of a drug but also the in vivo characteristics and limits--in terms of time window, dose, species and model of ischaemia used--to that efficacy. Here we use a systematic approach to establish the limits to and characteristics of the neuroprotective efficacy of melatonin in experimental stroke. We have used systematic review and meta-analysis to assess the evidence for a protective effect of melatonin in animal models of focal cerebral ischaemia. Fourteen studies were identified describing procedures involving 432 animals. The point estimate for the effect of melatonin was a 42.8% (95% CI 39.3-46.3%) improvement in outcome. Efficacy was greater when ketamine anaesthesia was used, and melatonin was equally effective in permanent or temporary ischaemia. Study quality was generally poor by clinical trial standards, and no evidence was found regarding the efficacy of melatonin in focal cerebral ischaemia in aged, hypertensive or diabetic animals, in species other than rats, or at time windows beyond 2 hr. These findings demonstrate a marked efficacy of melatonin in animal models of focal cerebral ischaemia, identify priority areas for future animal research, and suggest melatonin as a candidate neuroprotective drug for human stroke.     

How demographic and clinical characteristics contribute to the recovery of post-stroke dysphagia?

According to the analysis to find out how demographic and clinical characteristics influent the dysphagia outcome after stroke, furthermore, giving some insights to clinical treatment.One hundred eighty post-stroke dysphagia (PSD) patients were enrolled in this retrospective study at the stroke rehabilitation department. The outcome measurements are beside water swallow test at discharge and length of stay at hospital. Twenty-five demographic and clinical variables were collected for this study. Logistic regression and multilinear regression were utilized to estimate models to identify the risk and protect predictors of PSD outcome.Mouth-opening degree, drooling severity scale (DSS) level, mini-mental state exam (MMSE) level, Barthel index and Berg balance scale were significant different between recovered and unrecovered group. Type of stroke, MMSE degree, DSS and hemoglobin level shown significant predictive value for PSD outcome in logistic regression. In addition, obstructive sleep apnea (OSA) and DSS degree were important risk factors for PSD outcome. Gender, body mass index, drinking, hypertension, recurrent stroke, water swallow test level on admission, Berg balance scale, DSS and days between onset to admission shown significant predictive value for length of stay of PSD patients.PSD outcome was influenced by type of stroke, MMSE degree, DSS and hemoglobin level significantly and obstructive sleep apnea act as an important risk role for PSD recovery.     

The impact of cerebrovascular disease

Stroke may be affected by pathologic conditions such as atherosclerosis, vascular injury, coagulopathy, and increased platelet aggregability. Knowledge of the pathophysiology of stroke is critical in order to effectively prevent or treat this disabling state. Cerebrovascular disease is the third leading cause of death in the USA. It is also associated with significant morbidity, leading to extremely high health care costs and lost productivity. Total estimated costs of stroke are estimated to be more than $45 billion annually. This is an especially important issue for patients with diabetes, who are at higher risk for stroke and have a worse clinical outcome than non-diabetic patients. This review describes the impact of vascular disease, particularly cerebrovascular disease, and describes the pathophysiology of the disease. Interventions that result in reduction of stroke will likely result in decreased health care costs and improved clinical outcomes.     

Measuring treatment response in Alzheimer's disease clinical trials

Alzheimer's disease (AD) is a progressive disorder that negatively impacts cognitive, behavioral, and functional abilities. Because of the complex nature of this disease, it is crucial to design assessment procedures that accurately track disease progression across a wide variety of symptom domains. One important use of such techniques is to assess the effectiveness of therapeutic compounds in AD clinical trials. A number of outcome measures that assess cognitive, behavioral, functional, or global ability have been developed for this purpose. This paper describes the assessment measures that are most commonly used in AD trials. The inherent strengths and limitations of each evaluative technique are summarized, as well as how these outcome measures are useful to the practicing clinician.     

缺血性卒中后步行能力评估工具

步行评估工具在评估卒中患者步行功能、判断预后和提供康复治疗依据方面具有重要作用.了解步行功能评估工具的种类、使用方法以及临床意义,有助于缺血性卒中患者步行功能的评定和康复策略的制定.文章就常用的卒中后患者步行功能评估工具进行了综述.     

Valvular Heart Disease: Assessment of Valve Morphology and Quantification Using MR

For clinical evaluation and decision-making in patients with valvular heart disease, the diagnostic armamentarium expands steadily. This evolution makes it difficult to choose the most appropriate approach for a specific valvular lesion. It may also reflect our uncertainty of what are the findings that best predict clinical outcome of patients, e.g. after surgery. Accordingly, for each type of valvular lesion, some pathopysiological considerations are stated in order to derive the most important measures that would allow optimal guidance of patients. Based on these considerations the value of an MR study is discussed for each valvular lesion. Newest advances in MR technology allow for highly accurate measurements of regurgitant volumes and hence, MR may be the method of choice for a quantitative evaluation of regurgitant valves. For assessment of stenosis severity, measurement of transvalvular pressure gradient is an appropriate measure and MR may not confer benefits over echocardiography, provided the ultrasound window is adequate (and stroke volume is in the normal range). With respect to surgical treatment, valvular morphology is of pivotal importance, particularly for the mitral valve, and echocardiography still appears to be the first line method. Little data relate lesion severity and/or morphology to clinical outcome. Conversely, the extent of cardiac adaptation to pressure- and/or volume-overload, i.e. ventricular remodeling, is a strong predictor of outcome, and is therefore most important for final judgement of the patient. For assessment of left and right ventricular remodeling, echocardiography typically provides all the necessary information. However, in special cases with discrepant findings, with inadequate ultrasound window, or in the preoperative work-up, MR may provide important information regarding cardiac adaptation to valvular lesion.     

Evaluation of Guideline Adherence for Cardiac Catheterization in Patients With Presumed Obstructive Coronary Artery Disease in Germany (ENLIGHT-KHK) – A Multicentre,Prospective, Observational Study

IntroductionThe diagnosis or exclusion of obstructive stable coronary artery disease (SCAD) in clinical practice is challenging and therefore clinical guidelines provide recommendations on the use of non-invasive and invasive testing. For Germany, data obtained from the OECD and health insurances indicate a potential non-adherence to guideline-recommended diagnostic pathways. However, there is a lack of prospective and reliable evidence for appropriate use of invasive coronary angiography (CA) in Germany.ObjectiveTo provide evidence on the nature and extent of guideline non-adherence in patients undergoing CA with presumed obstructive SCAD in Germany and, to evaluate the clinical and economic consequences of potential deviations in guideline adherence.MethodsENLIGHT-KHK is a multicentre, prospective observational study recruiting 1500 patients being admitted for CA with presumed obstructive SCAD and exclusion of acute myocardial infarction (DRKS00015638). The primary outcome measure is the adherence to clinical guidelines in the decision-making process for use of CA. Therefore, the patients' diagnostic pathways and adherence to German and European guidelines will be assessed using clinical data, health-claims data, and a patient questionnaire. The primary safety outcome is a composite of myocardial infarction, stroke and all-cause death. Secondary outcome measures are periprocedural complications and costs. Using a decision-analytic model, the clinical and economic impact of observed guideline adherence in clinical practice will be assessed. Potential barriers and facilitators of guideline-adherent decision-making will be evaluated via semi-structured interviews.ConclusionsENLIGHT-KHK will give insights into the appropriateness of invasive CA in Germany and enable the development of concepts to improve guideline-adherence in the German health-care setting.     

Prediction of long-term functional outcome in patients with acute ischemic non-embolic stroke

In a prospective observational study, we assessed the relative value of conventional stroke risk factors and emerging markers in the prediction of functional outcome of patients surviving the acute phase of an ischemic non-embolic stroke. All available eligible patients consecutively admitted due to a first-ever acute ischemic non-embolic stroke during a 2-year period were evaluated. In a total of 105 patients (54 males, 51 diabetic) a series of clinical, biochemical and imaging characteristics were recorded, including demographic data, blood pressure, serum glucose, insulin, lipids, inflammatory markers, intima-media thickness of the carotid arteries (IMT), brain damage location and size of the infarct volume. Barthel Activities of Daily Living Index (BI) scale was used to assess the severity of neurological deficit on admission and the functional outcome 6 months after discharge. Brain infarct volume, stroke location in the anterior circulation, age, diabetes mellitus, IMT and plasma interleukin-1beta levels proved to be significant determinants of long-term functional outcome, assessed by BI disability score. ROC curve analyses indicated that the infarct volume is superior to other predictors in the diagnosis of patients with unfavorable functional outcome (BI<95) at 6 months post-discharge (area under the curve, AUC=0.80, 95% confidence interval 0.64-0.95; p=0.003). Significant differences in the mean infarct volume were noted among age tertiles, with the diabetic patients in the 3rd tertile of age experiencing the worst outcome (LSD test, p=0.019). Taken together, the assessment of infarct volume seems to have a significant predictive value regarding long-term functional outcome, especially in the elderly diabetic patients.     

Towards a vaccine for chronic obstructive pulmonary disease

This review discusses chronic obstructive pulmonary disease as an outcome of two pathogenic pathways: the first resulting from inhalation of toxins and the second a consequence of bacterial colonisation of damaged airways. Earlier assessment of the role played by bacteria in acute exacerbations was compromised by a deficiency of quality data and the use of parameters more relevant to invasive infection. Data are reviewed to support a hypothesis that states intrabronchial inflammation reflects an excessive and inappropriate host response (largely mediated by Th17 cells derived from gut-associated lymphoid tissues) to colonising bacteria acting as an 'antigen sump' (in essence, a hypersensitivity reaction). It is proposed that both viral and bacterial infections exacerbate inflammation through a common pathway that involves colonising bacteria. An oral vaccine containing inactivated non-typeable Haemophilus influenzae augments a protective loop that involves the aspiration of bronchus content into the gut and reduces the severity of acute exacerbations including the need for hospital admission by reducing the 'load' of bacteria comprising this final common path. The positive clinical results from trials using oral NTHi support both the concept that bacterial colonisation of damaged airways is a potent second pathogenic pathway and that oral immunotherapy provides a significant therapeutic advance in limiting damage in chronic obstructive pulmonary disease.     

缺血性小卒中转归不良的相关因素

目的：探讨缺血性小卒中患者转归不良的危险因素。方法前瞻性纳入缺血性小卒中患者,在发病后90 d时应用改良Rankin量表评估临床转归,0~2分定义为转归良好。对转归良好组与转归不良组人口统计学资料、血管危险因素、临床资料、影像学资料、卒中病因学分型、实验室化验结果、治疗方法等进行比较,采用多变量logistic回归分析确定缺血性小卒中患者早期转归不良的独立危险因素。结果共纳入516例缺血性小卒中患者。发病后90 d时90例（17.44％）转归不良,426例（82.56％）转归良好。多变量logistic回归分析显示,年龄[优势比（odds ratio, OR）1.045,95％可信区间（confidence interval, CI）1.017~1.074;P=0.002]、心脏病（OR 2.021,95％CI 1.063~3.841;P=0.032）、基线美国国立卫生研究院卒中量表（ National Institutes of Health Stroke Scale, NIHSS）评分（OR 1.662,95％CI 1.177~2.347;P=0.004）、肢体运动障碍（OR 2.430,95％CI 1.010~5.850;P=0.048）、共济运动障碍（ OR 2.929,95％CI 1.188~7.221;P=0.020）、早期神经功能恶化（OR 50.994,95％CI 17.659~147.258;P<0.001）、梗死灶直径（OR 1.279,95％CI 1.075~1.521;P=0.005）、非责任血管狭窄（ OR 2.518,95％CI 1.145~5.536;P=0.022）、大动脉粥样硬化性卒中（ OR 2.010,95％CI 1.009~4.003;P=0.047）是缺血性小卒中转归不良的独立危险因素。结论缺血性小卒中早期转归不良与年龄、心脏病史、基线NIHSS评分、肢体运动障碍、共济运动障碍、早期神经功能恶化、梗死灶直径、非责任血管狭窄、大动脉粥样硬化性卒中密切相关,需早期完善相关检查,明确病因分型,指导临床进行正确治疗。