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Leys D, Chollet F, Bousser MG, Mas J. Rapport 22-11. Prise en charge en urgence dans les unités neurovasculaires des personnes ayant un accident vasculaire cérébral. BULLETIN DE L'ACADÉMIE NATIONALE DE MÉDECINE 2022. [DOI: 10.1016/j.banm.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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2
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Dziewas R, Michou E, Trapl-Grundschober M, Lal A, Arsava EM, Bath PM, Clavé P, Glahn J, Hamdy S, Pownall S, Schindler A, Walshe M, Wirth R, Wright D, Verin E. European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia. Eur Stroke J 2021; 6:LXXXIX-CXV. [PMID: 34746431 DOI: 10.1177/23969873211039721] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 07/27/2021] [Indexed: 12/30/2022] Open
Abstract
Post-stroke dysphagia (PSD) is present in more than 50% of acute stroke patients, increases the risk of complications, in particular aspiration pneumonia, malnutrition and dehydration, and is linked to poor outcome and mortality. The aim of this guideline is to assist all members of the multidisciplinary team in their management of patients with PSD. These guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. An interdisciplinary working group identified 20 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence and wrote evidence-based recommendations. Expert opinion was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found moderate quality of evidence to recommend dysphagia screening in all stroke patients to prevent post-stroke pneumonia and to early mortality and low quality of evidence to suggest dysphagia assessment in stroke patients having been identified at being at risk of PSD. We found low to moderate quality of evidence for a variety of treatment options to improve swallowing physiology and swallowing safety. These options include dietary interventions, behavioural swallowing treatment including acupuncture, nutritional interventions, oral health care, different pharmacological agents and different types of neurostimulation treatment. Some of the studied interventions also had an impact on other clinical endpoints such as feedings status or pneumonia. Overall, further randomized trials are needed to improve the quality of evidence for the treatment of PSD.
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Affiliation(s)
- Rainer Dziewas
- Department of Neurology, University Hospital Münster, Münster, Germany.,Department of Neurology and Neurorehabilitation, Klinikum Osnabrück, Osnabrück, Germany
| | - Emilia Michou
- Department of Speech Language Therapy, School of Health Rehabilitation Sciences, University of Patras, Greece.,Centre for Gastrointestinal Sciences, Faculty of Biology, Medicine and Health, University of Manchester and the Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | | | - Avtar Lal
- Guidelines Methodologist, European Stroke Organisation, Basel, Switzerland
| | - Ethem Murat Arsava
- Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Pere Clavé
- Centro de Investigación Biomédica en Red de Enfermedades, Hepáticas y Digestivas (CIBERehd), Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
| | - Jörg Glahn
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Hospital Ruhr-University Bochum, Germany
| | - Shaheen Hamdy
- Centre for Gastrointestinal Sciences, Faculty of Biology, Medicine and Health, University of Manchester and the Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Sue Pownall
- Department of Speech & Language Therapy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Antonio Schindler
- Department of Biomedical and Clinical Sciences, Phoniatric Unit, Sacco Hospital Milano, University of Milano, Milan, Italy
| | - Margaret Walshe
- Department of Clinical Speech and Language Studies, Trinity College, Dublin, Ireland
| | - Rainer Wirth
- Department of Geriatric Medicine, Marien Hospital Herne, University Hospital Ruhr-University Bochum, Germany
| | - David Wright
- School of Pharmacy, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Eric Verin
- Department of Physical and Rehabilitation Medicine, Rouen University Hospital, Rouen, France
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3
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Breuckmann F, Nabavi DG, Post F, Grau AJ, Giannitsis E, Hochadel M, Senges J, Busse O, Münzel T. [Comparison between chest pain units and stroke units : Essential components of the vascular emergency care system: comparison of structure, certification process, quality benchmarking and reimbursement]. Herz 2021; 46:141-150. [PMID: 32990815 PMCID: PMC7523490 DOI: 10.1007/s00059-020-04984-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 08/17/2020] [Accepted: 08/26/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Chest pain units (CPU) and stroke units (SU) have both become established as essential components of clinical emergency care. For both instances dedicated certification processes are installed. Up to summer 2020, 290 CPUs and 335 SUs have been successfully certified. OBJECTIVE The aim of this review is to compare the structures and the current certification situation of CPUs and SUs. Also, the younger CPU certification process is compared to the long established SU certification standard. MATERIAL UND METHODS The comparison includes the historical background, the certification process, quality benchmarking, possible additive structures, the current status of certification in Germany, the transfer of the concept to the European level as well as reimbursement issues. RESULTS Both certification concepts show clear analogies. Evidence for SUs is supported by a positive Cochrane analysis and for CPUs there are many studies from the German CPU registry. The main differences include a uniform CPU system versus a multistep SU system of certification. Furthermore, SU have obligatory elements of quality documentation but only facultative quality indicator assessment for CPUs. From an economic viewpoint operation and procedural key (OPS) numbers guarantee a better reflection of the use of resources in the complex treatment of stroke, which could not yet be established for CPUs. CONCLUSION The well-established CPU concept could additionally benefit from a superordinate quality control. Adequate quality benchmarking appears to be fundamental for gap analyses and for the establishment of a separate remuneration structure. In this respect the German Society for Cardiology as the certifying institution is required to establish an appropriate mechanism within the framework of regular updates of criteria.
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Affiliation(s)
- Frank Breuckmann
- Medizinische Klinik I, Herz-Jesu-Krankenhaus Dernbach, Südring 8, 56428, Dernbach, Deutschland.
| | - Darius G Nabavi
- Neurologie mit Stroke Unit, Vivantes Klinikum Neukölln, Berlin, Deutschland
| | - Felix Post
- Klinik für Kardiologie, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Deutschland
| | - Armin J Grau
- Klinik für Neurologie, Klinikum Ludwigshafen, Ludwigshafen am Rhein, Deutschland
| | - Evangelos Giannitsis
- Zentrum für Kardiologie, Angiologie, Pneumologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Matthias Hochadel
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen, Deutschland
| | - Jochen Senges
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen, Deutschland
| | - Otto Busse
- Deutsche Schlaganfall-Gesellschaft, Berlin, Deutschland
| | - Thomas Münzel
- Zentrum für Kardiologie, Kardiologie I, Universitätsmedizin Mainz, Mainz, Deutschland
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Yaria J, Gil A, Makanjuola A, Oguntoye R, Miranda JJ, Lazo-Porras M, Zhang P, Tao X, Ahlgren JÁ, Bernabe-Ortiz A, Moscoso-Porras M, Malaga G, Svyato I, Osundina M, Gianella C, Bello O, Lawal A, Temitope A, Adebayo O, Lakkhanaloet M, Brainin M, Johnson W, Thrift AG, Phromjai J, Mueller-Stierlin AS, Perone SA, Varghese C, Feigin V, Owolabi MO. Quality of stroke guidelines in low- and middle-income countries: a systematic review. Bull World Health Organ 2021; 99:640-652E. [PMID: 34475601 PMCID: PMC8381090 DOI: 10.2471/blt.21.285845] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To identify gaps in national stroke guidelines that could be bridged to enhance the quality of stroke care services in low- and middle-income countries. METHODS We systematically searched medical databases and websites of medical societies and contacted international organizations. Country-specific guidelines on care and control of stroke in any language published from 2010 to 2020 were eligible for inclusion. We reviewed each included guideline for coverage of four key components of stroke services (surveillance, prevention, acute care and rehabilitation). We also assessed compliance with the eight Institute of Medicine standards for clinical practice guidelines, the ease of implementation of guidelines and plans for dissemination to target audiences. FINDINGS We reviewed 108 eligible guidelines from 47 countries, including four low-income, 24 middle-income and 19 high-income countries. Globally, fewer of the guidelines covered primary stroke prevention compared with other components of care, with none recommending surveillance. Guidelines on stroke in low- and middle-income countries fell short of the required standards for guideline development; breadth of target audience; coverage of the four components of stroke services; and adaptation to socioeconomic context. Fewer low- and middle-income country guidelines demonstrated transparency than those from high-income countries. Less than a quarter of guidelines encompassed detailed implementation plans and socioeconomic considerations. CONCLUSION Guidelines on stroke in low- and middle-income countries need to be developed in conjunction with a wider category of health-care providers and stakeholders, with a full spectrum of translatable, context-appropriate interventions.
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Affiliation(s)
- Joseph Yaria
- Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Artyom Gil
- Division of Country Health Programme, WHO European Office for the Prevention and Control of Noncommunicable Diseases, Moscow, Russia
| | | | - Richard Oguntoye
- Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - J Jaime Miranda
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Maria Lazo-Porras
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Puhong Zhang
- The George Institute for Global Health, Beijing, China
| | - Xuanchen Tao
- The George Institute for Global Health, Beijing, China
| | | | - Antonio Bernabe-Ortiz
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - German Malaga
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Irina Svyato
- Moscow School of Management SKOLKOVO, Moscow, Russia
| | - Morenike Osundina
- Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Camila Gianella
- Department of Psychology, Pontificia Universidad Católica del Perú, Lima, Peru
| | - Olamide Bello
- Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Abisola Lawal
- Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Ajagbe Temitope
- Department of Medicine, University College Hospital, Ibadan, Nigeria
| | | | | | - Michael Brainin
- Department of Neurosciences and Preventive Medicine, Danube University, Krems, Austria
| | - Walter Johnson
- Department of Neurosurgery, Loma Linda University, California, United States of America
| | - Amanda G Thrift
- School of Clinical Sciences, Monash University, Melbourne, Australia
| | | | | | | | - Cherian Varghese
- Noncommunicable Disease Department, World Health Organization, Geneva, Switzerland
| | - Valery Feigin
- National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand
| | - Mayowa O Owolabi
- Department of Medicine, University College Hospital, 200001 Ibadan, Oyo State, Nigeria.Correspondence to Mayowa O Owolabi ()
| | - on behalf of the Stroke Experts Collaboration Group
- Department of Medicine, University College Hospital, Ibadan, Nigeria
- Division of Country Health Programme, WHO European Office for the Prevention and Control of Noncommunicable Diseases, Moscow, Russia
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- The George Institute for Global Health, Beijing, China
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
- Moscow School of Management SKOLKOVO, Moscow, Russia
- Department of Psychology, Pontificia Universidad Católica del Perú, Lima, Peru
- Thung Chang Hospital, Thung Chang District, Nan, Thailand
- Department of Neurosciences and Preventive Medicine, Danube University, Krems, Austria
- Department of Neurosurgery, Loma Linda University, California, United States of America
- School of Clinical Sciences, Monash University, Melbourne, Australia
- Health System Research Institute, Nonthaburi, Thailand
- Institute for Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
- Noncommunicable Disease Department, World Health Organization, Geneva, Switzerland
- National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand
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Strecker C, Günther F, Harloff A. Who Should Rather Undergo Transesophageal Echocardiography to Determine Stroke Etiology: Young or Elderly Stroke Patients? Front Neurol 2021; 11:588151. [PMID: 33391153 PMCID: PMC7775476 DOI: 10.3389/fneur.2020.588151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/30/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: The indication of transesophageal echocardiography (TEE) in acute stroke is unclear. Thus, we systematically studied the impact of TEE on determining stroke etiology and secondary prevention in patients of different age-groups with cryptogenic stroke. Methods: Four hundred and eighty five consecutive patients with acute retinal or cerebral ischemia were prospectively included and underwent routine stroke workup including TEE. Stroke etiology was identified according to the TOAST classification and patients were divided in those with determined and cryptogenic stroke etiology without TEE results. Then, the frequency of high- and potential-risk sources in TEE was evaluated in <55, 55–74, and ≥75 year-old patients with cryptogenic stroke etiology. Results: Without TEE, stroke etiology was cryptogenic in 329(67.8%) patients and TEE determined possible etiology in 158(48.4%) of them. In patients aged <55, 55–74, ≥75, TEE detected aortic arch plaques ≥4 mm thickness in 2(1.2%), 37(23.0%), and 33(40.2%) and plaques with superimposed thrombi in 0(0.0%), 5(3.1%), and 7(8.5%); left atrial appendage peak emptying flow velocity ≤30cm/s in 0(0.0%), 1(0.6%), and 2(2.4%), spontaneous echo contrast in 0(0.0%), 1(0.6%), and 6(7.3%), endocarditis in 0(0.0%), 0(0.0%), and 1(1.2%) and patent foramen ovale (PFO) plus atrial septum aneurysm (ASA) in 18(20.9%), 32(19.9%), and 14(17.1%), respectively. TEE changed secondary prevention in 16.4% of these patients following guidelines of 2010/11 and still 9.4% when applying the guidelines of 2020. Conclusions: TEE was highly valuable for determining stroke etiology and influenced individual secondary prevention based on available treatment guidelines and expert opinion in most cases. In young patients the impact of TEE was limited to the detection of septal anomalies. By contrast, in older patients TEE detected high numbers of complex aortic atheroma and potential indicators of paroxysmal atrial fibrillation.
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Affiliation(s)
- Christoph Strecker
- Department of Neurology and Neurophysiology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Felix Günther
- Department of Internal Medicine, Staufenburg Klinik, Durbach, Germany
| | - Andreas Harloff
- Department of Neurology and Neurophysiology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
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6
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Wutzler A, Krogias C, Grau A, Veltkamp R, Heuschmann PU, Haeusler KG. Stroke prevention in patients with acute ischemic stroke and atrial fibrillation in Germany - a cross sectional survey. BMC Neurol 2019; 19:25. [PMID: 30755168 PMCID: PMC6371606 DOI: 10.1186/s12883-019-1249-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 01/31/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is present in 15-20% of patients with acute ischemic stroke. Oral anticoagulation reduces the risk of AF-related recurrent stroke but clinical guideline recommendations are rather vague regarding its use in the acute phase of stroke. We aimed to assess the current clinical practice of medical stroke prevention in AF patients during the acute phase of ischemic stroke. METHODS In April 2017, a standardized anonymous questionnaire was sent to clinical leads of all 298 certified stroke units in Germany. RESULTS Overall, 154 stroke unit leads participated (response rate 52%). Anticoagulation in the acute phase of stroke is considered feasible in more than 90% of AF patients with ischemic stroke. Clinicians assume that about two thirds of all AF patients (range 20-100%) are discharged on oral anticoagulation. According to local preferences, acetylsalicylic acid is given orally in the majority of patients with delayed initiation of oral anticoagulation. A non-vitamin K-dependent oral anticoagulant (NOAC) is more often prescribed than a vitamin K-dependent oral anticoagulant (VKA). VKA is more often chosen in patients with previous VKA intake than in VKA naive patients. In the minority of patients, stroke unit leads discuss the prescription of a specific oral anticoagulant with the treating general practitioner. Adherence to medical stroke prevention after hospital discharge is not assessed on a regular basis in any patient by the majority of participating stroke centers. CONCLUSIONS Early secondary stroke prevention in AF patients in German stroke units is based on OAC use but prescription modalities vary in clinical practice.
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Affiliation(s)
- Alexander Wutzler
- Cardiovascular Center, St. Josef Hospital, University Hospital of the Ruhr-University Bochum, Bochum, Germany
| | - Christos Krogias
- Department of Neurology, St. Josef Hospital, University Hospital of the Ruhr-University Bochum, Bochum, Germany
| | - Anna Grau
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany
| | - Roland Veltkamp
- Department of Stroke Medicine, Department of Neurology, Alfried Krupp Krankenhaus, Essen, Germany & Department of Neurology, Imperial College London UK, University Hospital Heidelberg, Heidelberg, Germany
| | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany.,Comprehensive Heart Failure Center, University of Würzburg & Clinical Trial Centre Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Karl Georg Haeusler
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany.
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7
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Haas K, Purrucker JC, Rizos T, Heuschmann PU, Veltkamp R. Rationale and design of the Registry of Acute Stroke Under Novel Oral Anticoagulants-prime (RASUNOA-prime). Eur Stroke J 2018; 4:181-188. [PMID: 31259266 DOI: 10.1177/2396987318812644] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 08/08/2018] [Indexed: 01/01/2023] Open
Abstract
Background Anticoagulation with vitamin K antagonists and non-vitamin K antagonists oral anticoagulants (NOAC) is effective in stroke prevention in patients with atrial fibrillation. However, anticoagulation also poses a major challenge for emergency treatment of patients suffering ischaemic stroke or intracerebral haemorrhage. Aim The registry RASUNOA-prime is designed to describe current patterns of emergency management, clinical course and outcome of patients with atrial fibrillation experiencing an acute ischaemic stroke or intracerebral haemorrhage under different anticoagulation schemes prior to stroke (NOAC, vitamin K antagonists or no anticoagulation). Methods and design RASUNOA-prime (ClinicalTrials.gov, NCT02533960) is a prospective, investigator-initiated, multicentre, observational cohort study aiming to recruit 3000 patients with acute ischaemic stroke and atrial fibrillation, and 1000 patients with acute intracerebral haemorrhage and atrial fibrillation with different anticoagulation schemes pre-stroke. It is a non-interventional triple-armed study aiming at a balanced inclusion of ischaemic stroke and intracerebral haemorrhage patients according to the different anticoagulation schemes. Patients will be followed up for clinical course, management and outcome up to three months after the event. Findings in ischaemic stroke and intracerebral haemorrhage patients on NOAC will be compared with patients taking vitamin K antagonists or no anticoagulant pre-stroke. Study outcomes Primary endpoint for ischaemic stroke patients: occurrence of symptomatic intracerebral haemorrhage, for intracerebral haemorrhage patients: occurrence of secondary haematoma expansion. Secondary endpoints include assessment of coagulation, use of thrombolysis and/or mechanical thrombectomy, occurrence of complications, implementation of secondary prevention. Summary Describing the current patterns of early management as well as outcome of stroke patients with atrial fibrillation will help guide physicians to develop recommendations for emergency treatment of stroke patients under different anticoagulation schemes.
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Affiliation(s)
- Kirsten Haas
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany.,Comprehensive Heart Failure Centre, University of Würzburg, Würzburg, Germany.,Clinical Trial Center, University Hospital Würzburg, Würzburg, Germany
| | - Roland Veltkamp
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.,Department of Neurology, Alfried Krupp Hospital, Essen, Germany
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Nabavi DG, Koennecke HC, Ossenbrink M, Grau A, Busse O. Zertifizierungskriterien für Stroke-Units in Deutschland. DER NERVENARZT 2018; 90:335-342. [DOI: 10.1007/s00115-018-0633-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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9
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Expert opinion paper on atrial fibrillation detection after ischemic stroke. Clin Res Cardiol 2018; 107:871-880. [PMID: 29704214 DOI: 10.1007/s00392-018-1256-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 04/16/2018] [Indexed: 12/14/2022]
Abstract
This expert opinion paper on atrial fibrillation detection after ischemic stroke includes a statement of the "Heart and Brain" consortium of the German Cardiac Society and the German Stroke Society. This paper was endorsed by the Stroke Unit-Commission of the German Stroke Society and the German Atrial Fibrillation NETwork. In patients with ischemic stroke, detection of atrial fibrillation should usually lead to a change in secondary stroke prevention, since oral anticoagulation is superior to antiplatelet drugs. The detection of previously undiagnosed atrial fibrillation can be improved in patients with ischemic stroke to optimize stroke prevention. This paper summarizes the present knowledge on atrial fibrillation detection after ischemic stroke. We propose an interdisciplinary standard for a "structured analysis of ECG monitoring" on the stroke unit as well as a staged diagnostic scheme for the detection of atrial fibrillation. Since the optimal duration and mode of ECG monitoring has not yet been finally established, this paper is intended to give advice to physicians who are involved in stroke care. In line with the nature of an expert opinion paper, labeling of classes of recommendations is not provided, since many statements are based on the expert opinion, reported case series and clinical experience. Therefore, this paper is not intended as a guideline.
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Suntrup-Krueger S, Minnerup J, Muhle P, Claus I, Schröder JB, Marian T, Warnecke T, Kalic M, Berger K, Dziewas R. The Effect of Improved Dysphagia Care on Outcome in Patients with Acute Stroke: Trends from 8-Year Data of a Large Stroke Register. Cerebrovasc Dis 2018. [PMID: 29533960 DOI: 10.1159/000487811] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Early dysphagia screening and appropriate management are recommended by current guidelines to reduce complications and case fatality in acute stroke. However, data on the potential benefit of changes in dysphagia care on patient outcome are limited. Our objective was to assess the degree of implementation of dysphagia guidelines and determine the impact of modifications in dysphagia screening and treatment practices on disease complications and outcome in stroke patients over time. METHODS In this prospective register-based study ("Stroke Register of Northwestern Germany"), all adult stroke patients admitted to 157 participating hospitals between January, 2008 and December, 2015 were included (n = 674,423). Dysphagia incidence upon admission, the proportion of patients receiving a standardized swallowing screening, and the percentage of dysphagic patients being referred to a speech language therapist (SLT) for treatment were obtained per year. Pneumonia rate, modified Rankin Scale (mRS) at discharge, and in-hospital mortality were compared between groups of dysphagic vs. non-dysphagic patients over time. RESULTS Screening proportions continuously increased from 47.2% in 2008 to 86.6% in 2015. But the proportion diagnosed with dysphagia remained stable with about 19%. The number of dysphagic patients receiving SLT treatment grew from 81.6 up to 87.0%. Pneumonia incidence was higher in dysphagic stroke cases (adjusted OR 5.4 [5.2-5.5], p < 0.001), accompanied by a worse mRS at discharge (adjusted OR for mRS ≥3: 3.1 [3.0-3.1], p < 0.001) and higher mortality (adjusted OR 3.1 [3.0-3.2], p < 0.001). The order of magnitude of these end points did not change over time. CONCLUSION Although advances have been made in dysphagia care, prevalent screening and treatment practices remain insufficient to reduce pneumonia rate, improve functional outcome, and decrease case fatality in dysphagic stroke patients. More research is urgently needed to develop more effective swallowing therapies.
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Affiliation(s)
| | - Jens Minnerup
- Department of Neurology, University of Muenster, Muenster, Germany
| | - Paul Muhle
- Department of Neurology, University of Muenster, Muenster, Germany
| | - Inga Claus
- Department of Neurology, University of Muenster, Muenster, Germany
| | | | - Thomas Marian
- Department of Neurology, University of Muenster, Muenster, Germany
| | - Tobias Warnecke
- Department of Neurology, University of Muenster, Muenster, Germany
| | - Marianne Kalic
- Institute of Epidemiology and Social Medicine, University of Muenster, Muenster, Germany
| | - Klaus Berger
- Institute of Epidemiology and Social Medicine, University of Muenster, Muenster, Germany
| | - Rainer Dziewas
- Department of Neurology, University of Muenster, Muenster, Germany
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11
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Schlemm L, Ebinger M, Nolte CH, Endres M. Impact of Prehospital Triage Scales to Detect Large Vessel Occlusion on Resource Utilization and Time to Treatment. Stroke 2017; 49:439-446. [PMID: 29284734 DOI: 10.1161/strokeaha.117.019431] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 11/21/2017] [Accepted: 12/05/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE Prehospital stroke severity scales may help to triage acute ischemic stroke patients with large vessel occlusion (LVO) for direct transportation to a comprehensive stroke center. The impact on resource use and time to reperfusion treatment for patients with and without LVO is unknown. METHODS Based on empirical distributions of stroke symptom severity, prehospital delay times, and stroke symptom severity-dependent likelihood of LVO, we simulate prehospital incidents of stroke-like symptoms in abstract geographical environments to estimate the impact of prehospital triage strategies based on different cutoffs of the rapid arterial occlusion evaluation scale. RESULTS Compared with transporting each patient to the nearest stroke center, implementation of a prehospital triage strategy based on a rapid arterial occlusion evaluation scale cutoff score ≥5 is associated with more patients with suspected acute stroke at comprehensive stroke centers and less patients at primary stroke centers (+11.7% [95% confidence interval: +8.1% to +15.3%] and -18.4% [-19.1% to -17.7%], respectively). Mean time to groin puncture is reduced by 29.6 minutes (-35.2 to -24.7 minutes) while mean time to thrombolysis does not change significantly (±0.0 minutes [-0.3 to +0.3 minutes]). The total number of secondary transfers is reduced by 60.9% (-62.8% to -59.0%); mean time of ambulance use per patient is unchanged. Results are robust with regards to variation in model parameters. CONCLUSIONS Implementation of prehospital triage based on stroke severity scales would have strong impact on patient flow and distribution. The benefit of earlier thrombectomy for patients with LVO may outweigh the harm associated with delayed access to thrombolysis for some patients without LVO. Randomized trials using clinical stroke severity scales as a triage tool are needed to confirm our findings.
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Affiliation(s)
- Ludwig Schlemm
- From the Department of Neurology (L.S., M. Ebinger, C.H.N., M. Endres) and Center for Stroke Research Berlin (L.S., M. Ebinger, C.H.N., M. Endres), Charité - Universitätsmedizin Berlin, Germany; Berlin Institute of Health, Germany (L.S., C.H.N., M. Endres); London School of Economics and Political Science, United Kingdom (L.S.); Department of Neurology, MEDICAL PARK Berlin Humboldtmühle, Germany (M. Ebinger); DZHK (German Center for Cardiovascular Research), Partner Site, Berlin (M. Endres); and DZNE (German Center for Neurodegenerative Diseases), Partner Site, Berlin (M. Endres).
| | - Martin Ebinger
- From the Department of Neurology (L.S., M. Ebinger, C.H.N., M. Endres) and Center for Stroke Research Berlin (L.S., M. Ebinger, C.H.N., M. Endres), Charité - Universitätsmedizin Berlin, Germany; Berlin Institute of Health, Germany (L.S., C.H.N., M. Endres); London School of Economics and Political Science, United Kingdom (L.S.); Department of Neurology, MEDICAL PARK Berlin Humboldtmühle, Germany (M. Ebinger); DZHK (German Center for Cardiovascular Research), Partner Site, Berlin (M. Endres); and DZNE (German Center for Neurodegenerative Diseases), Partner Site, Berlin (M. Endres)
| | - Christian H Nolte
- From the Department of Neurology (L.S., M. Ebinger, C.H.N., M. Endres) and Center for Stroke Research Berlin (L.S., M. Ebinger, C.H.N., M. Endres), Charité - Universitätsmedizin Berlin, Germany; Berlin Institute of Health, Germany (L.S., C.H.N., M. Endres); London School of Economics and Political Science, United Kingdom (L.S.); Department of Neurology, MEDICAL PARK Berlin Humboldtmühle, Germany (M. Ebinger); DZHK (German Center for Cardiovascular Research), Partner Site, Berlin (M. Endres); and DZNE (German Center for Neurodegenerative Diseases), Partner Site, Berlin (M. Endres)
| | - Matthias Endres
- From the Department of Neurology (L.S., M. Ebinger, C.H.N., M. Endres) and Center for Stroke Research Berlin (L.S., M. Ebinger, C.H.N., M. Endres), Charité - Universitätsmedizin Berlin, Germany; Berlin Institute of Health, Germany (L.S., C.H.N., M. Endres); London School of Economics and Political Science, United Kingdom (L.S.); Department of Neurology, MEDICAL PARK Berlin Humboldtmühle, Germany (M. Ebinger); DZHK (German Center for Cardiovascular Research), Partner Site, Berlin (M. Endres); and DZNE (German Center for Neurodegenerative Diseases), Partner Site, Berlin (M. Endres)
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Nydahl P, Bartoszek G, Binder A, Paschen L, Margraf NG, Witt K, Ewers A. Prevalence for delirium in stroke patients: A prospective controlled study. Brain Behav 2017; 7:e00748. [PMID: 28828209 PMCID: PMC5561309 DOI: 10.1002/brb3.748] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 05/12/2017] [Accepted: 05/14/2017] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND AND PURPOSE This study investigates the prevalence of delirium in acute stroke patients on a primary stroke unit (SU) analyzing associated risk factors and clinical outcomes. METHOD Prospective, 4-month observational study from 2015 to 2016 on patients aged ≥18 years with stroke at a German university hospital's SU. The presence of delirium as first outcome was rated at three times daily using the Confusion Assessment Method (CAM). Secondary outcome measures were duration of delirium, rehabilitation in SU, length of stay in SU and hospital, complications, and mortality. Significant risk factors were used to conduct a confounder-matched case-control analysis. RESULTS 309 patients were included. The overall prevalence of delirium was 10.7% (33 patients) mostly on the first and second hospital day. Duration of delirium on SU was in median 1.0 day (Interquartile range: 0.3-2 days). In 39.4% of patients delirium was present in a short time interval (≤8 hr) and in 24% of patients delirium was diagnosed during nightshifts exclusively. Significant risk factors for delirium were dementia, age ≥72 years, severe neurological disability on admission, and increased C-reactive protein on admission. The case-control analysis showed that delirious patients had more complications and a trend toward a worse rehabilitation. CONCLUSIONS These results underline the importance of delirium screening in stroke patients specifically during the night. Since even short delirious episodes are associated with more complications and increased disability, future studies are needed to find delirium prevention strategies.
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Affiliation(s)
- Peter Nydahl
- Nursing research Campus Kiel University Hospital of Schleswig-Holstein Kiel Germany
| | - Gabriele Bartoszek
- Faculty of Health School of Nursing Science Witten/Herdecke University Witten Germany
| | - Andreas Binder
- Department of Neurology University Medical Center Schleswig-Holstein Christian-Albrechts University Kiel Kiel Germany
| | - Laura Paschen
- Department of Neurology University Medical Center Schleswig-Holstein Christian-Albrechts University Kiel Kiel Germany
| | - Nils G Margraf
- Department of Neurology University Medical Center Schleswig-Holstein Christian-Albrechts University Kiel Kiel Germany
| | - Karsten Witt
- Department of Neurology University Medical Center Schleswig-Holstein Christian-Albrechts University Kiel Kiel Germany.,School of Medicine and Health Sciences - European Medical School University Hospital of Neurology Medical Campus University of Oldenburg Germany
| | - Andre Ewers
- Institute of Nursing Science and Practice Paracelsus Medical University Salzburg Austria
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Hillmann S, Wiedmann S, Rücker V, Berger K, Nabavi D, Bruder I, Koennecke HC, Seidel G, Misselwitz B, Janssen A, Burmeister C, Matthis C, Busse O, Hermanek P, Heuschmann PU. Stroke unit care in germany: the german stroke registers study group (ADSR). BMC Neurol 2017; 17:49. [PMID: 28279162 PMCID: PMC5343401 DOI: 10.1186/s12883-017-0819-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 02/10/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Factors influencing access to stroke unit (SU) care and data on quality of SU care in Germany are scarce. We investigated characteristics of patients directly admitted to a SU as well as patient-related and structural factors influencing adherence to predefined indicators of quality of acute stroke care across hospitals providing SU care. METHODS Data were derived from the German Stroke Registers Study Group (ADSR), a voluntary network of 9 regional registers for monitoring quality of acute stroke care in Germany. Multivariable logistic regression analyses were performed to investigate characteristics influencing direct admission to SU. Generalized Linear Mixed Models (GLMM) were used to estimate the influence of structural hospital characteristics (percentage of patients admitted to SU, year of SU-certification, and number of stroke and TIA patients treated per year) on adherence to predefined quality indicators. RESULTS In 2012 180,887 patients were treated in 255 hospitals providing certified SU care participating within the ADSR were included in the analysis; of those 82.4% were directly admitted to a SU. Ischemic stroke patients without disturbances of consciousness (p < .0001), an interval onset to admission time ≤3 h (p < .0001), and weekend admission (p < .0001) were more likely to be directly admitted to a SU. A higher proportion of quality indicators within predefined target ranges were achieved in hospitals with a higher proportion of SU admission (p = 0.0002). Quality of stroke care could be maintained even if certification was several years ago. CONCLUSIONS Differences in demographical and clinical characteristics regarding the probability of SU admission were observed. The influence of structural characteristics on adherence to evidence-based quality indicators was low.
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Affiliation(s)
- Steffi Hillmann
- Institute of Clinical Epidemiology and Biometry (ICE-B) Würzburg, Josef-Schneider-Str. 2 / D7, 97080, Würzburg, Germany.
| | - Silke Wiedmann
- Institute of Clinical Epidemiology and Biometry (ICE-B) Würzburg, Josef-Schneider-Str. 2 / D7, 97080, Würzburg, Germany
- Comprehensive Heart Failure Center, University of Würzburg, Straubmühlweg 2a, 97078, Würzburg, Germany
| | - Viktoria Rücker
- Institute of Clinical Epidemiology and Biometry (ICE-B) Würzburg, Josef-Schneider-Str. 2 / D7, 97080, Würzburg, Germany
| | - Klaus Berger
- Quality Assurance Project"Stroke Register Northwest Germany", Institute of Epidemiology and Social Medicine, University of Münster, Albert-Schweitzer-Campus 1, Gebäude D3, 48149, Münster, Germany
| | - Darius Nabavi
- Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Rudower Straße 48, 12351, Berlin, Germany
| | - Ingo Bruder
- Office for Quality Assurance in Hospitals (GeQiK) Stuttgart at Baden-Wuerttembergische Hospital Federation, Stuttgart, Birkenwaldstr. 151, 70191, Stuttgart, Germany
| | | | - Günter Seidel
- Department of Neurology, Asklepios Klinik Nord, Hamburg,, Tangstedter Landstraße 400, 22417, Hamburg, Germany
| | - Björn Misselwitz
- Institute of Quality Assurance Hesse (GQH), Frankfurter Str. 10, 65760, Eschborn, Germany
| | - Alfred Janssen
- Quality Assurance in Stroke Management in North Rhine-Westphalia, Medical Association North Rhine, Tersteegenstr. 9, 40474, Düsseldorf, Germany
| | - Christoph Burmeister
- Institute of Quality Assurance Rhineland-Palatinate / SQMed, Wilhelm-Theodor-Römheld-Straße 34, 55130, Mainz, Germany
| | - Christine Matthis
- Quality Association for Acute Stroke Treatment Schleswig-Holstein (QugSS), Institute of Social Medicine and Epidemiology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Otto Busse
- German Stroke Society, Berlin, Reinhardtstr. 27C, 10117, Berlin, Germany
| | - Peter Hermanek
- Bavarian Permanent Working Party for Quality Assurance, Munich, Westenriederstr. 19, 80331, Munich, Germany
| | - Peter Ulrich Heuschmann
- Institute of Clinical Epidemiology and Biometry (ICE-B) Würzburg, Josef-Schneider-Str. 2 / D7, 97080, Würzburg, Germany
- Comprehensive Heart Failure Center, University of Würzburg, Straubmühlweg 2a, 97078, Würzburg, Germany
- Clinical Trial Center Würzburg, University Hospital Würzburg, Josef-Schneider-Str. 2 / D7, 97080, Würzburg, Germany
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