Association of Urinary Incontinence with Cognition,Transfers and Discharge Destination in Acute Stroke Inpatient Rehabilitation

Background

Acute-stroke prognostic indicators remain controversial including relationship of urinary incontinence with outcomes in cognition, transfers, and discharge destination.

Management of Demented Patients with Urinary Incontinence: A Case Study

Objective: To assess whether a demented patient with urinary incontinence (UI) could learn to use an adapted version of timed voiding (i.e., instead of being led by a caregiver, the patient learns to perform timed voiding by herself). Indeed, UI affects a large number of patients with dementia and creates a substantial burden to the caregiver. UI is the most common complaint at the time of institutionalization and it is often the cause of premature institutionalization. Timed voiding is a promising intervention, but one whose effectiveness remains to be demonstrated. Additionally, timed voiding has the disadvantage of being constraining for caregivers, requiring them to be present to stimulate the patient to urinate at each of the scheduled occasions. Method: The present intervention required the patient to learn (1) to associate an auditory signal from a timer to the action of urination, (2) to reprogram the timer, using the spaced retrieval technique. An ABAB paradigm was used to assess the effectiveness of this program to eliminate urinary accidents. Results: The results of the intervention showed that the use of the timer was effective in helping the patient to reduce her urinary leaks from 1.5 diurnal accidents per week to zero during four months. Conclusion: UI in patients with dementia seems treatable. Such intervention could contribute to delay institutionalization of patients with dementia through maintaining their autonomy and reducing the burden of caregivers.     

Mortality and Predictors of Death Poststroke: Data from a Multicenter Prospective Cohort of Lebanese Stroke Patients

Background: Despite efforts to reduce stroke mortality rates, the disease remains a leading cause of death in Lebanon highlighting the importance of understanding risk factors and subsequent mortality. We examined mortality rates during the first year after acute stroke and the major short-term (1-month) and long-term (1-year) mortality predictors. Methods: Data were collected prospectively on hospitalized stroke patients from 8 hospitals in Beirut during a 1-year period. Patients were followed up for 1-year or until death. Mortality rates were assessed at 1-month and at 1-year poststroke and predictors of death were evaluated using Cox proportional hazard model. Results: A total of 191 stroke patients were included. Survival data were completed for over 97% of patients. Cumulative mortality rates were 14.1% at 1-month and 22% at 1-year. Predictors of short-term and long-term mortality in univariate analysis were low socioeconomic status, intensive care unit admission, decreased level of consciousness, stroke severity, and presence of complications. Marital status also predicted short-term mortality, while age greater than 64 years, atrial fibrillation, coronary heart disease, hypertension, Bamford and TOAST classifications and surgery need were also long-term mortality predictors. In multivariate analysis, stroke severity and presence of complications were predictors of death at 1-month and at 1-year. Low socioeconomic status, dependency in daily living activities, and the presence of comorbidities were additional predictors of 1-year mortality. Conclusions: Approximately 1 over 5 of patients did not survive 1-year after stroke. There is a need for public awareness campaigns to improve stroke knowledge, warning, and prevention which may reduce this high stroke mortality rate in Lebanon.     

The inter- and intraobserver reliabilities of a new classification system for ischaemic stroke: the South London Stroke Register

Objectives: This study aims to determine the inter- and intraobserver reliabilities of an aetiological classification devised as part of a community-based stroke register. Methods: Patients with first-ever acute ischaemic stroke were clinically assessed and received investigation according to a set protocol. Results of the clinical assessment and investigations were used to determine an aetiological stroke subtype for each patient by observer 1. Aetiological subtypes consisted of extracranial large artery atherosclerosis (LAAec), intracranial large artery atherosclerosis (LAAic), high-risk cardioembolism (CH), medium-risk cardioembolism (CM), small vessel occlusion (SVO), other aetiology (OTH), no aetiology identified (NA) and multiple probable or multiple possible aetiology (MPA). The same data were distributed to a further four observers along with the criteria for the classification system. Two of the observers were retested on the same patients after of period of 8 weeks. Inter- and intraobserver agreement was determined using the kappa statistic, which gives the chance-adjusted percentage agreement. Results: Forty-five consecutive patients were included. The overall kappa statistic for ischaemic stroke was 0.91 indicating excellent agreement. Kappa statistics were highest for the more frequent subtypes of SVO (0.97) and CH (0.97). Substantially high kappa statistics were also obtained for the less-frequent categories of LAAec (0.91), CM (0.84), NA (0.89) and MPA (0.87). A low kappa statistic was obtained for the category OTH (0.16), which had a low frequency of reporting, indicating poor agreement. The kappa statistic for probable categories was higher than the kappa statistic for all stroke subtypes at 0.96. Intraobserver agreement between first and second assignments of subtype diagnoses for both observers reached excellent agreement with kappa statistics of 0.83 and 0.85. Conclusion: The aetiological classification system, designed for use in the investigation of the epidemiology, stroke subtype and their relation to the natural history of stroke in a multiethnic inner city population, allows high inter- and intrarater agreements of subtype diagnosis.     

Cohort profile: The South London Stroke Register – a population-based register measuring the incidence and outcomes of stroke

PurposeThe South London Stroke Register (SLSR) is a population-based cohort study, which was established in 1995 to study the causes, incidence, and outcomes of stroke. The SLSR aims to estimate incidence, and acute and long term needs in a multi-ethnic inner-city population, with follow-up durations for some participants exceeding 20 years.ParticipantsThe SLSR aims to recruit residents of a defined area within Lambeth and Southwark who experience a first stroke. More than 7700 people have been registered since inception, and >2750 people continue to be followed up. At the 2011 census, the source population was 357,308.Findings to dateThe SLSR was instrumental in highlighting the inequalities in risk and outcomes in the UK, and demonstrating the dramatic improvements in care quality and outcomes in recent decades. Data from the SLSR informed the UK National Audit Office in its 2005 report criticising the poor state of stroke care in England. For people living in the SLSR area the likelihood of being treated in a stroke unit increased from 19% in 1995–7 to 75% in 2007–9. The SLSR has investigated health inequalities in stroke incidence and outcome. SLSR analyses have demonstrated that lower socioeconomic status was associated with poorer outcome, and that Black people and younger people have not experienced the same improvements in stroke incidence as other groups.Future plansAs part of an NIHR Programme Grant for Applied Research, from April 2022 the SLSR has expanded to recruit ICD-11 defined stroke (including those with <24 h symptoms where there are neuroimaging findings), and have expanded the follow up interviews to collect more detailed information on quality of life, cognition, and care needs. Additional data items will be added over the Programme based on feedback from patients and other stakeholders.     

Incidence and case fatality rates of stroke subtypes in a multiethnic population: the South London Stroke Register.

OBJECTIVE: To identify sociodemographic differences in the incidence of the subtypes of first ever stroke in a multiethnic population. METHODS: A prospective community stroke register (1995-8) was developed using multiple notification sources and pathological and clinical classifications of stroke. Standardisation of rates was to European and World populations and adjusted for age, sex and socioeconomic status in multivariate analyses. A multiethnic population of 234 533 in south London, of whom 21% are black was studied. RESULTS: A total of 1254 cases were registered. The average age of stroke was 71.7 years with black patients being 11.3 years younger than white patients (p<0.0001). The incidence rate/1000 population was 1.33 (crude) (95% CI 1.26 to 1.41), 1.28 (European adjusted) (95% CI 1.2 to 1.35) with a 2.18 (95% CI 1.86 to 2.56) (p<0.0001) age and sex adjusted incidence rate ratio in the black population. Radiological diagnosis was confirmatory in 1107 (88.3%) with 862 (68.7%) infarction, 168 (13.4%) primary intracerebral haemorrhage, and 77 (6.2%) subarachnoid haemorrhage. Of the cerebral infarction cases 189 (21.9%) were total anterior circulatory, 250 (29%) partial anterior, 141 (16.4%) posterior (POCI) and 282 (32.7%) lacunar infarcts. The black group had a significantly higher incidence of all subtypes of stroke except for POCI and unclassified strokes. The incidence rate ratio (IRR) for men compared with women was 1.34 (95% confidence interval (95% CI) 1.19 to 1.50; p<0.001). The IRR for manual versus non-manual occupations in those aged 35-64 years was 1.64 (95%CI 1.22 to 2.23; p<0.0001). There was a borderline significant increase in adjusted survival at 6 months in the black group 95% (CI 0.61 to 1.03, p=0.078) with a hazard ratio of 0.79 after adjustment and stratification. CONCLUSIONS: Although the black population is at increased risk of stroke and most subtypes of stroke, this is not translated into significant differences in survival. Hence black/white differences in mortality are mainly driven by incidence of stroke. There are striking demographic inequalities in the risk of stroke in this multiethnic inner city population that need to be tackled through interagency working. Although the reasons for the increased risk in the black population are unclear, demographic factors such as socioeconomic status do seem to play a significant independent part.     

Altered Taste and Stroke: A Case Report and Literature Review

Abstract

Patients with altered taste perception following stroke are at risk for malnutrition and associated complications that may impede recovery and adversely affect quality of life. Such deficits often induce and exacerbate depressive symptomatology, which can further hamper recovery. It is important for clinicians and rehabilitation specialists to monitor stroke patients for altered taste perception so that this issue can be addressed. The authors present the case of a patient who experienced an isolated ischemic infarct affecting a primary cortical taste area. This case is unusual in that the isolated injury allowed the patient to remain relatively intact cognitively and functionally, and thus able to accurately describe her taste-related deficits. The case is further used to describe the relevant neurological taste pathways and review potential taste-related therapies.     

Sacral Nerve Root Stimulation for the Treatment of Urge Incontinence and Detrusor Dysfunction Utilizing a Cephalocaudal Intraspinal Method of Lead Insertion: A Case Report

Sacral nerve root stimulation (SNRS) is known to be effective in the treatment of pelvic motor dysfunction( 1 - 4 ). Bladder and urethral motor disorders commonly treated include urinary urge incontinence, voiding/detrusor dysfunction, and urgency/frequency syndromes. To date, neurostimulation specific to bladder and urethral dysfunction has applied a unilateral, trans‐sacral approach. (Interstim, Medtronic, Minneapolis, MN) Despite some success, this method has been associated with technical failures in maintaining electrode position( 5 , 6 ). As an alternative, this case report describes the selective epidural application of a cephalocaudal (“retrograde”) lead insertion method in a patient with severe detrusor dysfunction and urinary urge incontinence( 7 ).     

Association between Heart Failure and Clinical Prognosis in Patients with Acute Ischemic Stroke: A Retrospective Cohort Study

Background and PurposeIschemic stroke is a common cause of death worldwide. In clinical practice it is observed that many individuals who have experienced an ischemic stroke also suffer from simultaneous comorbidities such as heart failure, which could be directly associated with a worse clinical prognosis. Therefore, this study analyzed outcomes in terms of the severity of the event, inhospital mortality, duration of hospital stay, and inhospital recurrence of the episode, in order to determine the implications resulting from the presentation of both pathologies.MethodsThis was a retrospective-cohort, hospital-based study.ResultsThe study included 110 subjects with heart failure (exposed) and 109 subjects without heart failure (nonexposed). The incidence of inhospital mortality was 27.27% in exposed patients and 9.17% in nonexposed patients (p<0.001), and the presence of heart failure increased the risk of death by 92% (p=0.027). According to scores on the National Institutes of Health Stroke Scale, the median severity was worse in exposed than nonexposed patients (16.1 vs. 9.2, p =0.001). The median hospital stay was 9 days in subjects with heart failure and 7 days in nonexposed patients (p=0.011). The rate of inhospital stroke did not differ significantly between exposed and nonexposed patients (1.82% vs. 0.92%, p=0.566).ConclusionsIndividuals with heart failure who suffer from an acute ischemic stroke show worse clinical outcomes in terms of mortality, event severity, and duration of hospital stay.     

Positional Vertigo After Isolated Cerebellar Nodulus Stroke: A Report of 3 Cases

We report 3 cases (69-year-old man, 71-year-old man, and 82-year-old woman) of isolated cerebellar nodulus stroke patients, who presented with positional vertigo alone that lasted only for 2-4 days. Brain magnetic resonance imaging helped diagnosing these cases. Although rare, clinicians should be aware of isolated cerebellar nodulus stroke, when facing with patients with paroxysmal vertigo of acute onset.     

Real-World Outcomes of Acute Ischemic Stroke Treatment with Intravenous Thrombolysis: A Systematic Review and Meta-Analysis

Background

Evidence from outside the typical clinical research setting, such as the real-world setting, complements evidence coming from randomized controlled trials. The purpose of this study was to evaluate all available evidence from the real-world observational trials about long-term outcomes of treatment with intravenous (IV) recombinant tissue-type plasminogen activator (rt-PA) compared with not treated with IV rt-PA (non-rt-PA) in patients with acute ischemic stroke.