Differences in stroke care practices between regional and metropolitan hospitals

BACKGROUND: A recent audit of stroke care in major Australian metropolitan teaching hospitals showed considerable variation in care practices and uptake of evidence-based therapies. We could find no published data on stroke care practices in regional Australia. AIM: To compare acute stroke care practices at four regional hospitals with a metropolitan teaching hospital with a stroke unit. METHODS: The hospital medical records of 30 consecutive patients at each hospital (total 150 patients), with a discharge diagnosis of stroke, were retrospectively audited to identify differences in stroke care practices, including the use of investigations, acute interventions, and secondary prevention strategies, between the regional and metropolitan, and between smaller (less than 150 stroke admissions annually) and larger (more than 250 admissions annually) hospitals. RESULTS: Patients treated at regional or smaller hospitals were less likely to have a computed tomography head scan within 24 h of admission, carotid duplex, echocardiography, estimations of lipids and glucose, a swallow assessment, involvement of allied health professionals or be prescribed prophylaxis against deep vein thrombosis, compared to patients treated at metropolitan or larger hospitals. CONCLUSIONS: Significant differences in stroke care practices exist between regional/smaller and metropolitan/larger hospitals. Strategies designed to minimize variation in care practices, such as evidence-based care pathways, should be explored.     

Controlled trial of multidisciplinary care teams for acutely ill medical inpatients: enhanced multidisciplinary care

Background: Acute hospital general medicine services care for ageing complex patients, using the skills of a range of health‐care providers. Evidence suggests that comprehensive early assessment and discharge planning may improve efficiency and outcomes of care in older medical patients. Aim: To enhance assessment, communication, care and discharge planning by restructuring consistent, patient‐centred multidisciplinary teams in a general medicine service. Methods: Prospective controlled trial enrolling 1538 consecutive medical inpatients. Intervention units with additional allied health staff formed consistent multidisciplinary teams aligned with inpatient admitting units rather than wards; implemented improved communication processes for early information collection and sharing between disciplines; and specified shared explicit discharge goals. Control units continued traditional, referral‐based multidisciplinary models with existing staffing levels. Results: Access to allied health services was significantly enhanced. There was a trend to reduced index length of stay in the intervention units (7.3 days vs 7.8 days in control units, P = 0.18), with no change in 6‐month readmissions. In‐hospital mortality was reduced from 6.4 to 3.9% (P = 0.03); less patients experienced functional decline in hospital (P = 0.04) and patients’ ratings of health status improved (P = 0.02). Additional staffing costs were balanced by potential bed‐day savings. Conclusion: This model of enhanced multidisciplinary inpatient care has provided sustainable efficiency gains for the hospital and improved patient outcomes.     

Rural Organization of Australian Stroke Teams: Emergency Department project

Background: Many junior doctors have poor stroke assessment skills. Although major efforts have gone in to changing the attitudes of clinicians to stroke through the development of guidelines and implementation strategies, the most important step may be to make sure that medical schools include appropriate teaching of this important topic in their curricula. The Rural Organization of Australian Stroke Teams Emergency Department (ROASTED) project sought to determine the effectiveness of a practical intervention to improve the assessment and education of stroke knowledge among our junior emergency department doctors. Methods: We used a prospective before and after study of two separate cohorts (intervention vs no intervention) to assess the stroke knowledge of our junior emergency department doctors and to test the effectiveness of an educational intervention. The project took place at five sites in rural Victoria in November 2006. Both cohorts undertook the same two validated quizzes 1 month apart. At the intervention sites two 1‐h tutorials were conducted between the quizzes and participants were encouraged to use a web‐based educational tool. Results: Pre‐project stroke knowledge was shown to be poor at all of the participating sites. At the sites where no intervention took place no improvement in knowledge was shown (z = 0.83, P = 0.41, two‐sided Mann–Whitney U‐test). The median score for quiz 1 was 8.1 (41%, interquartile range (IQR) 6.5–9.4) and for quiz 2, 7.2 (36%, IQR 5.1–9.3). At the intervention sites, participants significantly improved their stroke knowledge between quiz 1 and quiz 2 (z= 4.75, P < 0.001). The median score for quiz 1 in this cohort was 8.3 (42%, IQR 6.5–10.0) and for quiz 2, 12.8 (64%, IQR 12.0–14.8). Conclusion: This project showed that junior doctors have an inadequate knowledge of stroke and that among our junior emergency department doctors there is a need for the ROASTED intervention and other innovative educational measures.     

Inpatient continuous cardiac monitoring in hyper‐acute stroke: a comparison between telemetry by cardiology and stroke unit

This retrospective study assessed the pattern of telemetry usage and rates of atrial fibrillation (AF) detection in the 6 months pre‐ and post‐implementation of stroke unit monitored telemetry; 122/154 (79%) of patients had telemetry prior to implementation of stroke unit based telemetry and 164/194 (85%) in the 5 months post (P = 0.31). The use of stroke unit based telemetry was associated with a small increase of telemetry usage and significant increase in telemetry hours per patient. AF detection was similar during the two study periods.     

Establishment of a stroke unit in a district hospital: review of experience

Background: The experience and outcomes of co‐locating acute stroke and stroke rehabilitation care in a district hospital were reviewed. Method: Information for patients admitted to Blacktown and Mt Druitt Hospitals before and after setting up an acute stroke unit (SU) (12 months data for each period), including mortality and length of stay (LOS) at the hospital were obtained from various sources, including the diagnosis‐related group and subacute and non‐acute casemix databases. Results: There was a significant reduction of mortality (18 vs 10%; P = 0.01) and reduced total LOS (46 vs 39 days; P = 0.01) with similar functional outcomes in the post‐SU period. Fifty per cent of patients were unable to access the acute SU. Patients admitted into the SU had lower mortality (5 vs 14%; P = 0.01) and were also discharged from hospital earlier (35 vs 54 days; P = 0.01) than patients admitted into general wards during the post‐SU period. Thirty‐four per cent of patients received rehabilitation within the rehabilitation facility in the post‐SU period compared with 19% in the pre‐SU period. Conclusion: The Blacktown experience showed the feasibility of establishing a co‐located SU within rehabilitation facility with good outcomes as illustrated by the significant reduction in the stroke mortality, a reduction in the total LOS and an increase in the number of patients receiving rehabilitation post‐stroke.     

Stroke management: updated recommendations for treatment along the care continuum

The Australian Clinical Guidelines for Stroke Management 2010 represents an update of the Clinical Guidelines for Stroke Rehabilitation and Recovery (2005) and the Clinical Guidelines for Acute Stroke Management (2007). For the first time, they cover the whole spectrum of stroke, from public awareness and prehospital response to stroke unit and stroke management strategies, acute treatment, secondary prevention, rehabilitation and community care. The guidelines also include recommendations on transient ischaemic attack. The most significant changes to previous guideline recommendations include the extension of the stroke thrombolysis window from 3 to 4.5 h and the change from positive to negative recommendations for the use of thigh-length antithrombotic stockings for deep venous thrombosis prevention and the routine use of prolonged positioning for contracture management.     

Does an integrated care pathway improve processes of care in stroke rehabilitation? A randomized controlled trial

OBJECTIVE: to evaluate whether integrated care pathways improve the processes of care in stroke rehabilitation. DESIGN: comparison of processes of care data collected in a randomized controlled trial. PARTICIPANTS: acute stroke patients undergoing rehabilitation randomized to receive integrated care pathways management (n=76) or conventional multidisciplinary care (n=76). MEASUREMENTS: proportion of patients meeting recommended standards for processes of care using a validated stroke audit tool. RESULTS: integrated care pathways methodology was associated with higher frequency of stroke specific assessments, notably testing for inattention (84% versus 60%; P=0.015) and nutritional assessment (74% versus 22%, P<0.001). Documentation of provision of certain information to patients/carers (89% versus 70%; P=0.024) and early discharge notification to general practitioners (80% versus 45%; P<0.001) were also more common in this group. There were no significant differences in the processes of interdisciplinary co-ordination and patient management between the integrated care pathways group and the control group. CONCLUSION: integrated care pathways may improve assessment and communication, even in specialist stroke settings.     

Changing attitudes to the management of ischaemic stroke between 1997 and 2004: a survey of New Zealand physicians

Aim: In 1997, a survey of New Zealand physicians’ opinions on the management of stroke was carried out. Since then, there have been a number of advances in stroke therapy. We have repeated the 1997 survey to assess changes in physicians’ opinions on stroke management. Methods: A questionnaire was sent to 293 physicians responsible for patients admitted with acute stroke to hospitals throughout New Zealand. It included questions on the management of acute stroke and secondary prevention and was based on the 1997 questionnaire. Results: Responses were received from 211 physicians of whom 174 (82%) managed patients with an acute stroke. The number of respondents who thought that stroke units were efficacious has increased (57% in 1997 to 89%, P < 0.001). The use of aspirin acutely (P < 0.001) and intravenous tissue plasminogen activator (P = 0.006) has also increased. In 2004, antihypertensive therapy for secondary stroke prevention would be commenced if the blood pressure was 150/90 by 98% of respondents and 140/90 by 70% of respondents. In 2004, a statin would be commenced if the total cholesterol level was 4.0 mmol/L by 56% of respondents and 5.0 mmol/L by 91% of respondents. Conclusions: This survey has shown important changes in the management of ischaemic stroke over the past 7 years.     

Laryngeal penetration and aspiration in individuals with stable COPD

Background and objective: Swallowing is closely coordinated with breathing but in COPD altered synchronization may predispose patients to a breach of the upper airway protective mechanisms. However, aspiration during swallow has never been shown in COPD. We examined penetration of liquid material into the airway of patients with COPD and correlated it with breathing‐swallow patterns. Methods: A case–control study was performed. Patients with COPD (n = 16) were matched with normal control subjects (n = 15). Sub‐mandibular videofluoroscopy was carried out during swallow of graduated volumes of barium to detect penetration (contrast enters the airway and may contact vocal folds) and aspiration (contrast passes glottis). Respiration was monitored simultaneously to gauge synchronization. Hospitalization and mortality were assessed after 36 months. Results: Penetration/aspiration scores were higher in patients with COPD (3.3 ± 0.7 vs 1.6 ± 0.4 in healthy controls, P = 0.03; mean ± SE). Penetration with aspiration was observed in 4/16 patients with COPD versus 1/15 controls (P = 0.07). Penetration with or without aspiration was found in 6/16 patients (P = 0.04). Inspiration‐swallow‐expiration patterns were favoured in individuals with COPD (P = 0.02). Penetration/aspiration was associated with higher respiratory rates (P = 0.01), reduced hyoid elevation (P = 0.04), post‐swallow larynx penetration (P = 0.05) and oxygen desaturation (P = 0.01). There was a trend for the penetration/aspiration group to have an adverse outcome. Conclusions: Upper airway protective mechanisms may be flawed in COPD, possibly through reduced coordination of breathing with swallowing. This abnormality may contribute to COPD morbidity in a subgroup of patients.     

The effect of PCSK9 inhibitors on brain stroke prevention: A systematic review and meta-analysis

Background and aimsAlthough proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been shown to improve cardiovascular outcomes, their effects on brain stroke risk are unclear. The present meta-analysis aimed to evaluate the effects of PCSK9 inhibitors on brain stroke prevention.Methods and resultsWe searched PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov for research published until December 30, 2020, to find randomized controlled trials (RCTs) of PCSK9 inhibitors for brain stroke prevention. Relative risk (RR) and 95% confidence intervals (CIs) were used to represent the outcomes. Seven RCTs with 57,440 participants, including 29,850 patients treated with PCSK9 inhibitors and 27,590 control participants, were included. PCSK9 inhibitors were associated with significant reductions in total brain stroke risk (RR, 0.77; 95% CI, 0.67–0.88; P < 0.001) and ischemic brain stroke risk (RR, 0.76; 95% CI, 0.66, 0.89; P < 0.001) in comparison with the control group. There was no significant difference in cardiovascular mortality (RR, 0.95; 95% CI, 0.84–1.07; P = 0.382) and the risk of hemorrhagic brain stroke (RR, 1.00; 95% CI, 0.66–1.51; P = 0.999) between patients treated with PCSK9 inhibitors and controls. PCSK9 inhibitors did not significantly increase the incidence of neurocognitive adverse events (RR, 1.02; 95% CI, 0.81–1.29; P = 0.85). Moreover, subgroup analysis showed no difference in cognitive function disorder risks among different PCSK9 inhibitors and treatment times.ConclusionsPCSK9 inhibitors significantly reduced the risk of total brain stroke and ischemic brain stroke without increasing the risk of brain hemorrhage and neurocognitive impairment.     

Osteoprotegerin concentrations and prognosis in acute ischaemic stroke

Abstract. Jensen JK, Ueland T, Atar D, Gullestad L, Mickley H, Aukrust P, Januzzi JL (Odense University Hospital, Denmark; Rikshospitalet, Oslo, Norway; Massachusetts General Hospital, USA). Osteoprotegerin concentrations and prognosis in acute ischaemic stroke. J Intern Med 2010; 267 : 410–417. Aim. Concentrations of osteoprotegerin (OPG) have been associated with the presence of vascular and cardiovascular diseases, but the knowledge of this marker in the setting of ischaemic stroke is limited. Methods and results. In 244 patients with acute ischaemic stroke (age: 69 ± 13 years), samples of OPG were obtained serially from presentation to day 5. Patients with overt ischaemic heart disease and atrial fibrillation were excluded. The patients were followed for 47 months, with all‐cause mortality as the sole end‐point. Multivariable predictors of OPG values at presentation included haemoglobin (T = ?2.82; P = 0.005), creatinine (T = 4.56; P < 0.001), age (T = 9.66; P < 0.001), active smoking (T = 2.25; P = 0.025) and pulse rate (T = 3.23; P = 0.001). At follow‐up 72 patients (29%) had died. Patients with OPG ≤2945 pg mL^?1 at baseline had a significantly improved survival rate on univariate analysis (P < 0.0001); other time‐points did not add further prognostic information. In multivariate analysis, after adjustment for age, stroke severity, C‐reactive protein levels, troponin T levels, heart and renal failure concentrations of OPG independently predicted long‐term mortality after stroke (adjusted hazard ratio, 2.3; 95% CI: 1.1 to 4.9; P = 0.024). Conclusion. Osteoprotegerin concentrations measured at admission of acute ischaemic stroke are associated with long‐term mortality.     

Post‐stroke hypertension control and receipt of health care services among veterans

Many ischemic stroke patients do not achieve goal blood pressure (BP < 140/90 mm Hg). To identify barriers to post‐stroke hypertension management, we examined healthcare utilization and BP control in the year after index ischemic stroke admission. This retrospective cohort study included patients admitted for acute ischemic stroke to a VA hospital in fiscal year 2011 and who were discharged with a BP ≥ 140/90 mm Hg. One‐year post‐discharge, BP trajectories, utilization of primary care, specialty and ancillary services were studied. Among 265 patients, 246 (92.8%) were seen by primary care (PC) during the 1‐year post‐discharge; a median time to the first PC visit was 32 days (interquartile range: 53). Among N = 245 patients with post‐discharge BP data, 103 (42.0%) achieved a mean BP < 140/90 mm Hg in the year post‐discharge. Provider follow‐ups were: neurology (51.7%), cardiology (14.0%), nephrology (7.2%), endocrinology (3.8%), and geriatrics (2.6%) and ancillary services (BP monitor [30.6%], pharmacy [20.0%], nutrition [8.3%], and telehealth [8%]). Non‐adherence to medications was documented in 21.9% of patients and was observed more commonly among patients with uncontrolled compared with controlled BP (28.7% vs 15.5%; P = .02). The recurrent stroke rate did not differ among patients with uncontrolled (4.2%) compared with controlled BP (3.8%; P = .89). Few patients achieved goal BP in the year post‐stroke. Visits to primary care were not timely. Underuse of specialty as well as ancillary services and provider perception of medication non‐adherence were common. Future intervention studies seeking to improve post‐stroke hypertension management should address these observed gaps in care.     

Intraplaque haemorrhage at carotid artery surgery - a predictor of cardiovascular mortality

Abstract. Objective . To ascertain whether carotid intraplaque haemorrhage (IH) in patients undergoing carotid artery surgery is a predictor of increased cardiac mortality over a 5.5 year follow-up. Design and subjects . Carotid artery plaques were obtained at surgery from 47 consecutive patients (41 men. six women), median age 67 (range 48–81) years, with symptoms of carotid transient ischaemic attacks (TIAs) or carotid territory minor stroke. As determined at preoperative angiography, the degree of stenosis was 50–99%. Specimens were classified histologically as manifesting severe atherosclerosis, fibrous plaque, IH, or residual IH debris. Setting . Medical Angiology and Vascular Surgery Units, Malmö General Hospital. Intervention . Carotid endarterectomy. Main outcome measure . Correlation between mortality and IH. Results . At follow-up after 5.5 years, mortality was 28% (13/47) overall, 92% (12/13) in the IH subgroup [of stroke (n = 1) or myocardial infarction (n = 11)], but only 3% (1/34), of pancreatic cancer, in the non-IH subgroup (P = 0.0001). Mortality was also significantly higher in the severe atherosclerosis than in the fibrous plaque subgroup, 39% (12/31) vs. 6% (1/16) (P = 0.044), but not significantly increased in any other subgroup (fibrous plaque, residual IH, TIA, minor stroke, or acetylsalicylic acid or anticoagulant treatment). No correlation existed between IH or death and haemoglobin value or platelet count. Conclusions . Evidence of recent IH seen at carotid artery surgery may be a marker of cardiovascular mortality. As IH was also found in a post-mortem control subgroup, the difference may be due to abnormality in blood components (e.g., coagulation factors) or impaired vessel-wall healing capacity (e.g. endothelial dysfunction).     

Community Physicians' Cooperation with a Program of In-Home Comprehensive Geriatric Assessment

OBJECTIVES: To study the cooperation of primary care physicians with a community-based prevention and health promotion program for older persons, to study physician factors related to cooperation, and to determine any relationship between physician cooperation and patient adherence to program recommendations and patient satisfaction with health care. DESIGN AND SETTING: A survey administered in subjects' homes and physicians' offices in Santa Monica, California. PARTICIPANTS: Patients (n = 81) were intervention group subjects in a 3-year, randomized, controlled trial of in-home comprehensive geriatric assessment paired with prevention and health promotion. Physicians (n = 50) were selected if they had been contacted at least once by a study nurse practitioner about one of these patients. MEASUREMENTS: Physician cooperation was rated by study nurse practitioners. Physicians were interviewed to identify factors associated with cooperation. Patients' satisfaction with health care and adherence were measured prospectively throughout the 3-year program. MAIN RESULTS: Physicians exhibiting better cooperation had fewer years in practice (P = .03) and were more likely to discuss the program with their patients (P = .005), see benefit for their patients from the program (P = .02), and rate program information as useful (P = .002). Higher physician cooperation did not predict higher patient satisfaction (P = .23) but did predict higher patient adherence to program recommendations (P = .02). CONCLUSIONS: Physicians rated as cooperative were more likely to have a positive appraisal of the program, and their patients had higher adherence to program recommendations. These findings suggest that strategies for increasing primary care physician cooperation might improve effectiveness of similar community-based prevention and health promotion programs.     

Comparison of fatigue levels in patients with stroke and patients with end-stage heart failure: application of the fatigue assessment scale

OBJECTIVES: To examine the assessment of fatigue using the Fatigue Assessment Scale (FAS) in patients with stroke and to compare the levels of fatigue reported by patients with stroke, patients with chronic heart failure (CHF), and healthy controls. DESIGN: Cross‐sectional analysis. SETTING: Stroke rehabilitation unit, heart failure outpatient clinic, general Dutch population. PARTICIPANTS: Three different samples were included: 80 patients with stroke, 137 patients with CHF, and 160 healthy controls. MEASUREMENTS: Fatigue was measured according to the FAS at baseline and at 2‐month follow‐up. Depressive symptoms were assessed at baseline using the Beck Depression Inventory (BDI). RESULTS: The internal consistency (α) of the FAS was 0.77 at baseline and at 2‐month follow‐up. Test–retest reliability was 0.81 for a 2‐month interval. Factor analysis of the combined pool of FAS and BDI items revealed two distinct factors that measure fatigue and depression as two separate constructs. Patients with stroke (15.3±7.6) and patients with CHF (16.5±7.9) reported similar levels of fatigue (P=.44). The level of fatigue in patients with stroke and patients with CHF was considerably higher than in healthy controls (9.2±5.6; P<.001). Using the healthy controls as a reference group, multivariable logistic regression revealed that patients with stroke were at six times greater risk (odds ratio (OR)=6.18, 95% confidence interval (CI)=3.31–11.55; P<.001) and patients with CHF were at eight times greater risk (OR=8.03; 95% CI=4.63–13.94; P<.001) for having fatigue symptoms. CONCLUSION: The FAS is an adequate measure of fatigue in patients with stroke. Levels of fatigue in patients with stroke are similar to levels in patients with CHF, emphasizing its clinical significance in stroke.     

Low positive predictive value of the ABCD2 score in emergency department transient ischaemic attack diagnoses: the South Western Sydney transient ischaemic attack study

Background: The ABCD² stroke risk score is recommended in national guidelines for stratifying care in transient ischaemic attack (TIA) patients, based on its prediction of early stroke risk. We had become concerned about the score accuracy and its clinical value in modern TIA cohorts. Methods: We identified emergency department‐diagnosed TIA at two hospitals over 3 years (2004–2006). Cases were followed for stroke occurrence and ABCD² scores were determined from expert record review. Sensitivity, specificity and positive predictive values (PPV) of moderate–high ABCD² scores were determined. Results: There were 827 indexed TIA diagnoses and record review was possible in 95.4%. Admitted patients had lower 30‐day stroke risk (n= 0) than discharged patients (n= 7; 3.1%) (P < 0.0001). There was no significant difference in proportion of strokes between those with a low or moderate–high ABCD² score at 30 (1.2 vs 0.8%), 90 (2.0 vs 1.9%) and 365 days (2.4 vs 2.4%) respectively. At 30 days the sensitivity, specificity and PPV of a moderate–high score were 57% (95% confidence interval (CI) 25.0–84.2), 32.2% (95% CI 29.1–35.6) and 0.75% (95% CI 0.29–1.91) respectively. Conclusions: Early stroke risk was low after an emergency diagnosis of TIA and significantly lower in admitted patients. Moderate–high ABCD² scores did not predict early stroke risk. We suggest local validation of ABCD² before its clinical use and a review of its place in national guidelines.     

Risk factor profile in Chinese‐Australian stroke patients living in Sydney

Aim: To examine and compare stroke risk factors and their management in stroke patients of Chinese descent versus English‐speaking background (ESB)‐Australian patients. Methods: Cohort study. Fifty‐one Chinese‐Australians and 119 ESB‐Australians who were admitted to hospitals within Sydney metropolitan area with a recent acute ischaemic or haemorrhagic stroke were recruited. Results: Chinese‐Australian patients tended to have a favourable smoking (0% current smokers vs 15%, P = 0.036) and drinking (5% current medium/heavy drinkers vs 17%, P = 0.005) pattern compared with the Australian patients. The prevalence of diabetes mellitus was higher in Chinese‐Australians (31% vs 10%, P = 0.003). The management of hypertension and atrial fibrillation (AF) in Chinese‐Australians was suboptimal (19% untreated hypertension vs 8%, P = 0.102; 78% AF not on Warfarin vs 51%, P = 0.264). Conclusion: The findings of this study suggest that targeting specific stroke prevention strategies may be useful for Chinese‐Australians. Larger‐scale studies need to be conducted to confirm these findings.     

Predictors of prolonged vancomycin-resistant enterococci colonization in acute stroke patients admitted to an intensive care unit: A retrospective cohort study

To investigate the factors affecting the duration of vancomycin-resistant enterococci (VRE) colonization in stroke patients.A total of 52 stroke patients with VRE colonization were enrolled. We divided the groups into several factors and confirmed whether each factor affected VRE colonization. Independent t test, bivariate correlation analysis, and Cox proportional hazards model were used to confirm statistical significance.Among 52 patients, 28 were ischemic stroke and 24 were hemorrhagic stroke. The mean duration of the VRE colonization was 39.08 ± 44.22 days. The mean duration of VRE colonization of the ischemic stroke patients was 25.57 ± 30.23 days and the hemorrhagic stroke patients was 54.83 ± 52.75 days. The mean intensive care unit (ICU) care period was 15.23 ± 21.98 days. Independent sample t test showed the hemorrhagic stroke (P < .05), use of antibiotics (P < .01), oral feeding (P < .01) were associated with duration of VRE colonization. Bivariate correlation analysis showed duration of ICU care (P < .001) was associated with duration of VRE colonization. Cox proportional hazard model showed oral feeding (P = .001), use of antibiotics (P = .003), and duration of ICU care (P = .001) as independent factors of duration of VRE colonization.Careful attention should be given to oral feeding, duration of ICU care, and use of antibiotics in stroke patients, especially hemorrhagic stroke patients, for intensive rehabilitation at the appropriate time.     

Improving care for patients with dysphagia

BACKGROUND: Early diagnosis and effective management of dysphagia reduce the incidence of pneumonia and improve quality of care and outcome. Dysphagic stroke patients rarely perceive that they have a swallowing problem, and thus carers have to take responsibility for following the safe swallow recommendations made by the Speech and Language Therapist (SLT). Published work and observations in our own Trust indicated that patients with dysphagia may be fed in a manner which places them at significant risk of aspiration, despite SLT advice for safe swallowing. OBJECTIVE: To determine compliance with swallowing recommendations in patients with dysphagia and to investigate the effectiveness of changes in practice in improving compliance. DESIGN: Sequential observational study before and after targeted intervention. SETTING: An acute general and teaching hospital in an inner city area. SUBJECTS: All patients with dysphagia on the caseload of the speech and language therapy department at the time of the study. METHODS: Observations were made on compliance with the recommendations of SLTs regarding consistency of fluids, dietary modifications, amount to be given at a single meal/drink, swallowing strategies, general safe swallow recommendations and whether supervision was required. A dysphagia link nurse programme was established, together with modification of an in-house training scheme, use of pre-thickened drinks and modification of swallowing advice sheets. The same observations were repeated after this intervention. RESULTS: Thirty-one patients were observed before and 54 after the intervention. There was improvement in compliance with the recommendations on consistency of fluids (48-64%, P<0.05), amount given (35-69%, P<0.05), adherence to safe swallow guidelines (51-90%, P<0.01) and use of supervision (35-67%, P<0.01). There were no significant differences in compliance with dietary modifications or swallowing strategies. Improvement in compliance was demonstrated in medical and geriatric wards and the stroke unit, but not in the surgical wards. Compliance with 'nil by mouth' instructions was 100% throughout. CONCLUSIONS: Relatively simple and low-cost measures, including an educational programme tailored to the needs of individual disciplines, proved effective in improving the compliance with advice on swallowing in patients with dysphagia. It is suggested that this approach may produce widespread benefit to patients across the NHS.     

Hypertension is an independent predictor of mean platelet volume in patients with acute ischaemic stroke

Introduction: Mean platelet volume (MPV) was shown to be significantly increased in patients with acute ischaemic stroke, especially in non‐lacunar strokes. Moreover, some studies concluded that increased MPV is related to poor functional outcome after ischaemic stroke, although this association is still controversial. However, the determinants of MPV in patients with acute ischaemic stroke have never been investigated. Subjects and methods: We recorded the main demographic, clinical and laboratory data of consecutive patients with acute (admitted within 24 h after stroke onset) ischaemic stroke admitted in our Neurology Service between January 2003 and December 2008. MPV was generated at admission by the Sysmex XE‐2100 automated cell counter (Sysmex Corporation, Kobe, Japan) from ethylenediaminetetraacetic acid blood samples stored at room temperature until measurement. The association of these parameters with MPV was investigated in univariate and multivariate analysis. Results: A total of 636 patients was included in our study. The median MPV was 10.4 ± 0.82 fL. In univariate analysis, glucose (β= 0.03, P= 0.05), serum creatinine (β= 0.002, P= 0.02), haemoglobin (β= 0.009, P < 0.001), platelet count (β=?0.002, P < 0.001) and history of arterial hypertension (β= 0.21, P= 0.005) were found to be significantly associated with MPV. In multivariate robust regression analysis, only hypertension and platelet count remained as independent determinants of MPV. Conclusions: In patients with acute ischaemic stroke, platelet count and history of hypertension are the only determinants of MPV.