FACTORS ASSOCIATED WITH MET AND UNMET REHABILITATION NEEDS AFTER STROKE: A MULTICENTRE COHORT STUDY IN DENMARK AND NORWAY

ObjectivesTo examine patient-reported needs for care and rehabilitation in a cohort following different subacute pathways of rehabilitation, and to explore factors underpinning met and unmet needs.DesignObservational multicentre cohort study.Patients and methodsA total of 318 Norwegian and 155 Danish patients with first-ever stroke were included. Participants answered questions from the Norwegian Stroke Registry about perceived met, unmet or lack of need for help and training during the first 3 months post stroke. The term “training” in this context was used for all rehabilitative therapy offered by physiotherapists, occupational or speech therapists. The term “help” was used for care and support in daily activities provided by nurses or health assistants.ResultsNeed for training: 15% reported unmet need, 52% reported met need, and 33% reported no need. Need for help: 10% reported unmet need, 58% reported met, and 31% reported no need. Participants from both Norway and Denmark had similar patterns of unmet/met need for help or training. Unmet need for training was associated with lower functioning, (odds ratio (OR) = 0.32, p < 0.05) and more anxiety (OR = 0.36, p < 0.05). Patients reporting unmet needs for help more often lived alone (OR = 0.40, p < 0.05) and were more often depressed (OR = 0.31, p < 0.05).ConclusionSimilar levels of met and unmet needs for training and help at 3 months after stroke were reported despite differences in the organization of the rehabilitation services. Functioning and psychological factors were associated with unmet rehabilitation needs.LAY ABSTRACTThe aim of this study was to examine patient-reported needs for care and rehabilitation among selected patients with stroke in Norway and Denmark. A total of 318 Norwegian and 155 Danish patients with first-ever stroke were included. Participants answered the following 2 questions from the Norwegian Stroke Registry: Have you received enough help after the stroke? Have you received as much training as you wanted after the stroke? The term “training” in this context was used for all rehabilitative therapy offered by physio-, occupational or speech therapists. The term «help» was used for care and support in daily activities provided by nurses or health assistants. Levels of anxiety and depression were investigated. With regard to training needs, 15% of all participants reported unmet needs, 52% reported that their needs had been met, and 33% reported that they had no need for training. Regarding the need for help, 10%, 58% and 31% reported unmet needs, that needs had been met, and that they had no need for care, respectively. Participants in the 2 countries had similar patterns of unmet/met needs for help or training. Unmet need for training was associated with low function and anxiety. Patients reporting an unmet need for help more often lived alone and were more often depressed. There was no difference in met or unmet needs between Norwegian and Danish participants.Different rehabilitative follow-up after stroke did not affect levels of met and unmet rehabilitation needs. Health services should pay special attention to patients at risk, including those who are anxious or depressed, live alone or have functional deficits after stroke.Key words: stroke, rehabilitation, unmet needs, rehabilitation pathways

Stroke is a major cause of death, with an increasing number of patients affected worldwide (1). Stroke survivors often have varying degrees of physical, psychosocial and cognitive disabilities, which may substantially affect their functional ability in daily and working life (2). Treatment offered by specialized stroke units (3), inpatient multidisciplinary rehabilitation teams (4) and community-based rehabilitation services adapted to patients’ home environment (5) are key elements to successful rehabilitation. At all intervention levels, the identification of patients’ individual needs is crucial for the optimization of rehabilitation outcomes. The definition of a need is, however, not unambiguous (6). A pragmatic approach is to adopt the most commonly used definition of healthcare needs and define rehabilitation needs as the needs that can be fulfilled by rehabilitation interventions and services (7). From the patient’s perspective, a need represents the perception of a situation in which help or support is desired. If adequate help is not offered, the provision of services does not fit the needs, gaps occur and needs become unmet (8).A perceived need for therapy, comprehensive care, pscyhological support or information are examples of commonly reported unmet needs post-stroke (9).Unmet rehabilitation needs may persist for years after stroke (10). According to a UK study, they are more often reported by people with disabilities, those belonging to ethnic minorities, and those living in the most deprived areas (10). According to a recent systematic review of 19 studies, mostly cross-sectional in design, 74% of stroke survivors experienced at least one unmet need. The studies revealed heterogeneous levels of unmet needs, ranging between 5% and 40% for care and between 2% and 36% for therapy (9). In most studies, unmet needs were assessed by using different multi-item questionnaires, such as the Longer-term Unmet Need after Stroke (11) and the Greater Manchester Stroke Assessment Tool (12), or by the self-report of long-term needs after stroke (10).In a Swedish registry study evaluating perceived unmet or partly met rehabilitation needs with a single question, 21.5% of patients reported unmet needs one year after stroke. Important underpinning factors were older age, dependency on others, pain and depressive/ affective symptoms (13).Rehabilitation practices are formulated and enacted in a cultural and historical context aligned to the development of healthcare services (14). Specialized stroke rehabilitation is integrated in the public healthcare systems in Nordic countries (15), but, whereas the Norwegian study region mainly emphasizes inpatient rehabilitation, the Danish region has developed an additional and more specialized, community-based rehabilitation programme (16). Although some studies have reported different rehabilitation pathways in the early subacute phase of stroke (17), no previous studies have, to our knowledge, compared unmet needs post stroke in participants with different subacute rehabilitation pathways.The primary aim of this study was to examine patient-reported needs for healthcare and rehabilitation services in a cohort with different rehabilitation pathways recruited from 2 Nordic country-regions. Secondary aims were to assess to what extent these needs were met or unmet 3 months post stroke and to explore factors associated with met and unmet needs.     

Transplantation of Autologous Keratinocyte Suspension in Fibrin Matrix to Chronic Venous Leg Ulcers: Improved Long-Term Healing after Removal of the Fibrin Carrier

BACKGROUND The transplantation of keratinocytes suspended in fibrin carrier represents a candidate regimen for chronic ulcer treatment in an outpatient setting. We evaluated the integration and survival of autologous individualized keratinocytes applied within fibrin matrix onto chronic venous leg ulcers in vivo. Parallel in vitro culture was used to validate keratinocyte survival and apoptosis in fibrin compared to collagen matrix carrier.
METHODS Seven patients with chronic venous leg ulcers were transplanted with autologous keratinocytes suspended in fibrin sealant after isolation and expansion from full-skin biopsy. The fibrin carrier was removed in three patients after 7 days, whereas four patients served as control with fibrin remaining. In parallel in vitro cultures, primary keratinocyte movement in fibrin as well as viability in three-dimensional (3D) fibrin versus collagen lattices was examined.
RESULTS Complete ulcer healing was observed in four of seven ulcers after a mean duration of 14.5 weeks. If the fibrin layer was removed, complete wound healing occurred in three of three patients, compared to one of four in the control group. In vitro, keratinocytes formed a monolayer underneath but remained isolated and nonmobile within the fibrin matrix, suggesting reepithelialization along the lower fibrin interphase. Keratinocyte culture in 3D fibrin at clinically used concentration (90 mg/mL) caused high levels of apoptosis, similar to 3D collagen, which was prevented by diluting fibrin concentration to 3 mg/mL.
CONCLUSIONS Transplantation of autologous keratinocytes suspended in fibrin is efficient in the treatment of chronic venous leg ulcers. Due to an antimigratory and survival-compromising effect, the presently used fibrin carrier should be removed after a few days of transplantation.     

Construct validity of the Capacity Profile in preschool children with cerebral palsy

The Capacity Profile (CAP) classifies additional care needs, subdivided into five domains of body functions (physical health, motor, sensory, mental, and voice/speech) of children with stable conditions. Construct validity of the CAP was established in 72 children (56 males, 16 females) with cerebral palsy (CP); median age 2 years 7 months, range 2 years 6 months to 3 years; 34 unilateral and 37 bilateral spastic-type CP, one dyskinetic-type CP. Gross Motor Function Classification System (GMFCS) classification was 24 in level I, eight in level II, 18 in level III, 14 in level IV, and eight in level V. All CAP domains were significantly associated ( p <0.001) with the Functional Skills (rho=−0.42 to −0.85) and Caregiver Assistance scales (rho=−0.42 to −0.82) of the Dutch Paediatric Evaluation of Disability Inventory. The CAP-motor domain and GMFCS were strongly correlated (rho=0.91, p <0.001). Stepwise regression analysis demonstrated that the CAP domains contributed 74% to mobility (CAP-motor 66%, mental 6%, voice 2%); 75% to self-care (CAP-voice 61%, mental 12%, physical 2%); and 70% to social functionality (CAP-mental 68%, voice 2%). CAP demonstrated good construct validity in young children with CP. The independent contribution of CAP domains to daily function underscores the importance of comprehensive assessment with regard to all domains of body functions in heterogeneous conditions like CP.     

Effects of sympathetic nerve stimulation on membrane potential in the circular muscle layer of mouse distal colon

Little is known about the effects of sympathetic nerve stimulation on the membrane potential of colonic smooth muscle. In the distal colon of the mouse, intracellular microelectrodes were used to record the effects of lumbar colonic (LCN) and intermesenteric nerve (IMN) stimulation on circular muscle membrane potential in vitro. A two-compartment organ bath was used to selectively perfuse the colon and inferior mesenteric ganglion (IMG). In the presence of nifedipine (1-2 microM) (to the colonic compartment only), spontaneous depolarizations (myoelectric complexes, MCs) were recorded about every 4 min. MCs consisted of a prolonged burst of rapid oscillations in membrane potential (approximately 2 Hz) that were superimposed on a slow depolarization (mean amplitude 12 mV). Single electrical stimuli (600 microseconds duration) delivered to the LCN or IMN did not elicit a detectable change in the membrane potential. However, trains of stimuli (e.g., 60 pulses at 10-20 Hz) to the LCN or IMN during the intervals between MCs evoked a depolarization (with superimposed action potentials in the absence of nifedipine). Trains of stimuli delivered during the plateau phase of the MC reduced or abolished the rapid oscillations, without a further membrane depolarization. The MC period was unaffected by stimulation of the IMN or LCN. Responses were abolished by the selective perfusion of guanethidine (1 microM) to the colon, or by severing the LCN. Hexamethonium (500 microM) (to the colon) abolished MCs, induced sustained depolarization and attenuated the amplitude of the sympathetic depolarizations by 74%. In hexamethonium, sympathetic responses remained attenuated when the membrane of the circular muscle was repolarised by sodium nitroprusside (1 microM). Immunohistochemical studies of the colon revealed intense immunoreactivity for tyrosine hydroxylase in the myenteric plexus but not in the circular muscle layer. It is suggested that responses to sympathetic nerve stimulation in the circular muscle layer of the mouse colon are secondary to actions on the enteric nervous system.     

Bridging a Temporary High Risk of Sudden Arrhythmic Death. Experience with the Wearable Cardioverter Defibrillator (WCD)

The implantable cardioverter defibrillator (ICD) is able to reduce sudden arrhythmic death in patients who are considered to be at high risk. However, the arrhythmic risk may be increased only temporarily as long as the proarrhythmic conditions persist, left ventricular ejection fraction remains low, or heart failure prevails. The wearable cardioverter defibrillator (WCD) represents an alternative approach to prevent sudden arrhythmic death until either ICD implantation is clearly indicated or the arrhythmic risk is considered significantly lower or even absent. The WCD is also indicated for interrupted protection by an already implanted ICD, temporary inability to implant an ICD, and lastly refusal of an indicated ICD by the patient. The WCD is not an alternative to the ICD, but a device that may contribute to better selection of patients for ICD therapy. The WCD has the characteristics of an ICD, but does not need to be implanted, and it has similarities with an external defibrillator, but does not require a bystander to apply lifesaving shocks when necessary. The WCD was introduced into clinical practice about 8 years ago, and indications for its use are currently expanding. This article describes the technological aspects of the WCD, discusses current indications for its use, and reviews the clinical studies with the WCD. Additionally, data are reported on the clinical experience with the WCD based on 354 patients from Germany hospitalized between 2000 and 2008 who wore the WCD for a mean of 3 months. (PACE 2010; 33:353–367)     

Predicting Recurrence of Vasovagal Syncope: A Simple Risk Score for the Clinical Routine

Background: Predictors for recurrence of syncope are lacking in patients with vasovagal syncope. The aim of this study was to identify risk factors for recurrence of syncope and develop a simple prognostic risk score of clinical value.
Methods: Two hundred seventy-six patients with a history of vasovagal syncope were prospectively followed for 2 years. Diagnosis of vasovagal syncope was based on clinical history and negative standard work-up. Inclusion in the study was independent from the result of the head-up tilt test, which was performed in all cases. Risk factors for syncope recurrence were evaluated by the Cox proportional hazards regression model and implemented in a risk score, which was validated with the log-rank test and an internal cross-validation.
Results: The Cox-regression analysis identified the number of previous syncopal events, history of bronchial asthma, and female gender as predictors for syncope recurrence (all P < 0.05). In contrast, head-up tilt test response had no predictive value (P = 0.881). Developing a risk score, study patients were identified as having high (recurrence rate during 2 years of follow-up: 37.2%), intermediate (24.8%), and low (6.5%) risk for syncope recurrence (receiver operating characteristic [ROC] of score 0.83, P < 0.01; Log-rank test for event-free survival, P < 0.005).
Conclusions: In patients with vasovagal syncope, risk of recurrence can be stratified and is predictable based on a simple risk score.     

THE PRESENCE OF CYTOKINES IN LANGERHANS' CELL HISTIOCYTOSIS

Langerhans' cell histiocytosis (LCH) is characterized by an accumulation and/or proliferation of cells with a Langerhans' cell (LC) phenotype. The aetiology and pathogenesis of LCH are unknown; it is suggested that LCH is caused by an immunological dysregulation. Production of cytokines is a central feature of immunological regulation. LCH lesions and normal LCs were studied for the presence of cytokines known to influence the functioning of LCs: IL-1α, IL-1β, IL-4, GM-CSF, IFN-γ, TGF-α, TGF-β, bFGF, and TNF-α. Cytokines were abundantly present within LCH lesions; LCH cells stained for IL-1α, IL-1β, IL-4, GM-CSF, TGF-α, TGF-β, TNF-α, and IFN-γ. Macrophages, lymphocytes, eosinophil granulocytes, and, surprisingly, multinucleated giant cells were also sources of cytokines. These results suggest that cytokines play a prominent role in the pathogenesis of LCH and may explain phenomena that often occur in LCH, such as osteolysis and fibrosis and the recruitment of typical inflammatory infiltrates. The results also suggest that a ‘down-regulatory’ signal is lacking in LCH, resulting in an accumulation and/or proliferation of abnormal LCs.