What happens to stroke patients after hospital discharge?

Of 231 stroke patients discharged from hospital, 34 patients (14.7%) had died when reviewed 6 months later. Of 195 survivors, 115 (58%) were independent and living in the community. The remaining 80 (42%) patients were dependent. The majority of dependent patients were in institutional care but 29 (36%) were residing in the community of whom a substantial number were not receiving physiotherapy, occupational therapy or day care. Patients who were dependent in nursing homes were less likely to have received physiotherapy (48% versus 70%) or occupational therapy (28% versus 60%) compared to disabled patients in hospital based extended nursing care. 45 patients (24%) had been re-admitted to hospital although only 48% of patients had been reviewed in hospital outpatients since discharge. 64% of patients were on anti-thrombotic treatment. This survey suggests that 6 months after hospital discharge, most stroke patients are still alive and living in the community. Many of the dependent survivors have ongoing unmet medical and rehabilitation needs.     

Do relatives of elderly patients block the discharge process?

There is a perception that relatives of older patients "block" their discharge from acute hospitals, thereby compounding the capacity crises of Ireland's A+E departments. This study prospectively analyses 1,240 consecutive referrals to the discharge co-ordinator of an acute general hospital over a two-year period. The number of bed-days consumed by all patients whose discharge was delayed was calculated, in addition to reasons for delay and whether or not patients' relatives were opposing discharge. There were 90 cases of delayed discharge resulting in 2,436 bed-days consumed over the study period. Reasons for delays principally centred on access to long-term care facilities and organisation of community supports. Patients' relatives opposed discharge in 9 of the 90 delayed cases. Concerns expressed by patients' relatives reflected the paucity of community supports available for older people and their carers. Older people's relatives are patient advocates and seek appropriate facilities for those whom they represent.     

Ectopic discharge in Aβ afferents as a source of neuropathic pain

Ectopic discharge in axotomized dorsal root ganglion neurons is a key driver of neuropathic pain. However, the bulk of this activity is generated and carried centrally in large diameter myelinated Aβ afferents, a cell type that normally signals touch and vibration sense. Evidence is considered suggesting that following axotomy, Aβ afferents undergo a change in their electrical characteristics and also in the neurotransmitter complement that they express. This dual phenotypic switching renders them capable of (1) directly driving postsynaptic pain signaling pathways in the spinal cord, and (2) triggering and maintaining central sensitization.     

Can pre-assessment of patients with LUTS result in early discharge from urology clinic?

Waiting times for appointments for urological out-patients in Ireland and the U.K. can be excessively long. Nurse-led Lower Urinary Tract symptom (LUTs) pre-assessment clinics have been introduced to streamline patient care pathways. We examined whether a nurse-led pre-assessment LUTS clinic could result in the rapid assessment and discharge of patients following their first out-patient visit. A pilot study was undertaken whereby patients referred with LUTS were sent for pre-assessment prior to their out-patients appointment. 214 consecutive patients underwent pre-assessment. Of these, 39 (18%) patients were discharged following their first out-patient visit and 27 (13%) patients were discharged after a second attendance. A further 35 (16%) patients continued to attend but underwent no further investigations or treatment, and possibly should have been discharged earlier. Overall 46% of pre-assessed patients could have been discharged early from the urology clinic. In conclusion a nurse-led pre-assessment LUTS clinic could result in the rapid assessment and discharge of patients following their first out-patient visit.     

Is spontaneous high-voltage rhythmic spike discharge in Long Evans rats an absence-like seizure activity?

A distinct high-voltage rhythmic spike (HVRS) discharge characterized by a barrage of negative spikes oscillating at 5-12 Hz was observed in chronically implanted Long Evans rats. Spontaneous HVRS discharges were exhibited in 90% of 40 Long Evans rats and occurred during sudden arrest of ongoing behavior (immobility) with occasional facial/whisker twitching. However, the function of HVRS discharges in Long Evans rats remains inconclusive to date and has been associated with alpha tremor/mu rhythm, attentive mu wave, and absence seizure. To elucidate the function of HVRS discharges in Long Evans rats, several experiments were performed. In a 6-h recording session (12:00-18:00), HVRS activities primarily occurred in several specific vigilance states, being particularly abundant in a short-lasting period before vigilance changes. Several characteristics, such as durations, oscillatory frequencies, and interspike intervals (ISIs) of HVRS discharges, were altered during wake-sleep states. Oscillatory frequencies were negatively correlated with durations of HVRS segments. In addition, ISIs of a HVRS episode exhibited a crescendo-decrescendo pattern. These variable ISIs could explain why a negative correlation was found between oscillatory frequencies and durations of HVRS episodes. Moreover, HVRS discharges were demonstrated to have widespread and near-synchronous distribution to bilateral cortical areas. In addition, innocuous electrical stimuli were unable to stop ongoing HVRS discharges. By contrast, noxious stimuli elicited behavioral arousal and immediately terminated most HVRS discharges. Cortical-evoked potentials in response to mild electrical stimulation under HVRS discharges were different from those under waking state but resemble those under slow-wave sleep with a smaller magnitude. Moreover, the temporal and spectral characteristics of spontaneous HVRS activities were analogous to those of seizure activities induced by penicillin and pentylenetetrazol. The incidence of spontaneous HVRS discharges was significantly decreased by ethosuximide administration. Based on these results, HVRS discharge might not be associated with a voluntary mu-rhythm behavior, instead it behaves as an absence-like seizure activity. These results were also collaborated using other genetic absence-seizure rats, such as WAG/Rij and GAERS rats. Possible mechanisms for the generation and termination of paroxysmal HVRS discharges are also discussed.     

A follow-up study of psychiatric consultations in the general hospital: What happens to patients after discharge?

BACKGROUND: An appropriate follow-up is considered essential in the consultation-liaison psychiatry setting, but it is often neglected. This study evaluated the effectiveness of the psychiatric consultation process in the general hospital, by investigating what occurred to patients 3-5 months after discharge. METHODS: We used a three-part questionnaire: (1) the results of the consultation process; (2) a telephone interview with patients, and (3) a telephone interview with the patients' primary care physician, to whom the patients were referred after discharge from hospital. We contacted all consecutive, unselected patients referred to psychiatric consultation from January to July 1999. Complete data were available for 119 patients from an initial group of 318. RESULTS: The consultation process was well accepted by patients and useful to general hospital physicians to complete the final diagnosis of the patient when discharged from hospital. In most cases (78.9%), the psychiatric letter was attached to the discharge letter. The second part of the questionnaire indicated that most patients were satisfied with the consultation process. They thought it helped focus their problems and 60% asserted that they felt better after following their psychiatrists' instructions or therapy. The primary care physicians agreed with the diagnostic results of the psychiatric consultation, mainly followed the psychiatrists' advice, and generally expressed positive comments about the consultation-liaison service. CONCLUSIONS: Compliance of hospital physicians, patients, and primary care physicians was good. Follow-up studies on outcome of psychiatric consultations are few and further analysis is strongly recommended.     

Neuronal discharge patterns in the Globus Pallidus pars interna in a patient with Parkinson’s disease and hemiballismus secondary to subthalamotomy

Alterations in the basal ganglia-thalamocortical “motor” circuit activity, have been proposed to explain many features associated with hypokinetic and hyperkinetic movement disorders. We describe the firing pattern of the globus pallidus pars interna in a Parkinson disease’s patient who developed Hemichorea-Ballismus subsequent to ipsilateral subthalamotomy, and compare findings to those from PD patients submitted to pallidotomy while in the OFF-medication state. Single units obtained from extracellular recordings were extracted and mean discharge frequency, interspike interval and coefficient of variation (defined as Tonicity Score) were computed. Discharge density histograms, analysis of distribution and spectral analysis were also performed. Mean firing frequency showed no significant difference between PD patients in the OFF state and the patient we report. However, a significant difference in tonicity was found for this patient characterized by a regular, non-bursting firing pattern. The findings indicate that in HB caused by lesions to STN in the parkinsonian state, GPi firing rates can be similar to and firing pattern more regular than those observed in GPi of PD patients OFF-medication with intact STN.