1
|
Ong CJ, Chatzidakis S, Ong JJ, Feske S. Updates in Management of Large Hemispheric Infarct. Semin Neurol 2024. [PMID: 38759959 DOI: 10.1055/s-0044-1787046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
This review delves into updates in management of large hemispheric infarction (LHI), a condition affecting up to 10% of patients with supratentorial strokes. While traditional management paradigms have endured, recent strides in research have revolutionized the approach to acute therapies, monitoring, and treatment. Notably, advancements in triage methodologies and the application of both pharmacological and mechanical abortive procedures have reshaped the acute care trajectory for patients with LHI. Moreover, ongoing endeavors have sought to refine strategies for the optimal surveillance and mitigation of complications, notably space-occupying mass effect, which can ensue in the aftermath of LHI. By amalgamating contemporary guidelines with cutting-edge clinical trial findings, this review offers a comprehensive exploration of the current landscape of acute and ongoing patient care for LHI, illuminating the evolving strategies that underpin effective management in this critical clinical domain.
Collapse
Affiliation(s)
- Charlene J Ong
- Department of Neurology, Chobanian and Avedisian School of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, Massachusetts
| | - Stefanos Chatzidakis
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jimmy J Ong
- Department of Neurology, Sidney Kimmel Medical College, Philadelphia, Pennsylvania
- Department of Neurology, Jefferson Einstein Hospital, Philadelphia, Pennsylvania
| | - Steven Feske
- Department of Neurology, Chobanian and Avedisian School of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Department of Neurology, Boston Medical Center, 1 Boston Medical Center PI, Boston, Massachusetts
| |
Collapse
|
2
|
Geraghty JR, Testai FD. Advances in neurovascular research: Scientific highlights from the 2024 international stroke conference. J Stroke Cerebrovasc Dis 2024; 33:107671. [PMID: 38447784 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Indexed: 03/08/2024] Open
Affiliation(s)
- Joseph R Geraghty
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Fernando D Testai
- Department of Neurology & Rehabilitation, University of Illinois College of Medicine, Chicago, IL, USA
| |
Collapse
|
3
|
Selman CJ, Lee KJ, Ferguson KN, Whitehead CL, Manley BJ, Mahar RK. Statistical analyses of ordinal outcomes in randomised controlled trials: a scoping review. Trials 2024; 25:241. [PMID: 38582924 PMCID: PMC10998402 DOI: 10.1186/s13063-024-08072-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 03/22/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND Randomised controlled trials (RCTs) aim to estimate the causal effect of one or more interventions relative to a control. One type of outcome that can be of interest in an RCT is an ordinal outcome, which is useful to answer clinical questions regarding complex and evolving patient states. The target parameter of interest for an ordinal outcome depends on the research question and the assumptions the analyst is willing to make. This review aimed to provide an overview of how ordinal outcomes have been used and analysed in RCTs. METHODS The review included RCTs with an ordinal primary or secondary outcome published between 2017 and 2022 in four highly ranked medical journals (the British Medical Journal, New England Journal of Medicine, The Lancet, and the Journal of the American Medical Association) identified through PubMed. Details regarding the study setting, design, the target parameter, and statistical methods used to analyse the ordinal outcome were extracted. RESULTS The search identified 309 studies, of which 144 were eligible for inclusion. The most used target parameter was an odds ratio, reported in 78 (54%) studies. The ordinal outcome was dichotomised for analysis in 47 ( 33 % ) studies, and the most common statistical model used to analyse the ordinal outcome on the full ordinal scale was the proportional odds model (64 [ 44 % ] studies). Notably, 86 (60%) studies did not explicitly check or describe the robustness of the assumptions for the statistical method(s) used. CONCLUSIONS The results of this review indicate that in RCTs that use an ordinal outcome, there is variation in the target parameter and the analytical approaches used, with many dichotomising the ordinal outcome. Few studies provided assurance regarding the appropriateness of the assumptions and methods used to analyse the ordinal outcome. More guidance is needed to improve the transparent reporting of the analysis of ordinal outcomes in future trials.
Collapse
Affiliation(s)
- Chris J Selman
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia.
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia.
| | - Katherine J Lee
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Kristin N Ferguson
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Clare L Whitehead
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
| | - Brett J Manley
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Newborn Research, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
| | - Robert K Mahar
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC, 3052, Australia
| |
Collapse
|
4
|
Beretta S, Carone D, Pedrazzini FA, Chauveau F, Cho TH. Head down positioning before recanalization in acute ischemic stroke. Eur Stroke J 2024; 9:277-278. [PMID: 37658693 PMCID: PMC10916825 DOI: 10.1177/23969873231198331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2023] Open
Affiliation(s)
- Simone Beretta
- Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy
- Department of Neuroscience, Fondazione IRCCS San Gerardo Monza, Monza, Italy
| | - Davide Carone
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | | | - Fabien Chauveau
- Lyon Neuroscience Research Center, CNRS UMR5292, INSERM U1028, Université Claude Bernard Lyon 1, Lyon, France
| | - Tae-Hee Cho
- Neurovascular Unit, Hospices Civils de Lyon, Lyon, France
| |
Collapse
|
5
|
Caille A, Billot L, Kasza J. Practical and methodological challenges when conducting a cluster randomized trial: Examples and recommendations. JOURNAL OF EPIDEMIOLOGY AND POPULATION HEALTH 2024; 72:202199. [PMID: 38477480 DOI: 10.1016/j.jeph.2024.202199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/19/2024] [Accepted: 01/19/2024] [Indexed: 03/14/2024]
Abstract
The use of cluster randomized trial design to answer research questions is increasing. This design and associated variants such as the cluster randomized crossover and stepped wedge are useful to assess complex interventions in a pragmatic way but when adopting such designs, one may face specific implementation challenges. This article summarizes common challenges faced when conducting cluster randomized trials, cluster randomized crossover trials, and stepped wedge trials, and provides recommendations.
Collapse
Affiliation(s)
- Agnès Caille
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, Tours, France; INSERM CIC 1415, CHRU de Tours, Tours, France.
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Jessica Kasza
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| |
Collapse
|
6
|
Biose IJ, Oremosu J, Bhatnagar S, Bix GJ. Promising Cerebral Blood Flow Enhancers in Acute Ischemic Stroke. Transl Stroke Res 2023; 14:863-889. [PMID: 36394792 PMCID: PMC10640530 DOI: 10.1007/s12975-022-01100-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/18/2022] [Accepted: 10/20/2022] [Indexed: 11/18/2022]
Abstract
Ischemic stroke presents a major global economic and public health burden. Although recent advances in available endovascular therapies show improved functional outcome, a good number of stroke patients are either ineligible or do not have access to these treatments. Also, robust collateral flow during acute ischemic stroke independently predicts the success of endovascular therapies and the outcome of stroke. Hence, adjunctive therapies for cerebral blood flow (CBF) enhancement are urgently needed. A very clear overview of the pial collaterals and the role of genetics are presented in this review. We review available evidence and advancement for potential therapies aimed at improving CBF during acute ischemic stroke. We identified heme-free soluble guanylate cyclase activators; Sanguinate, remote ischemic perconditioning; Fasudil, S1P agonists; and stimulation of the sphenopalatine ganglion as promising potential CBF-enhancing therapeutics requiring further investigation. Additionally, we outline and discuss the critical steps required to advance research strategies for clinically translatable CBF-enhancing agents in the context of acute ischemic stroke models.
Collapse
Affiliation(s)
- Ifechukwude Joachim Biose
- Department of Neurosurgery, Clinical Neuroscience Research Center, Tulane University School of Medicine, 131 S. Robertson, Ste 1300, Room 1349, New Orleans, LA, 70112, USA
| | - Jadesola Oremosu
- School of Medicine, Tulane University, New Orleans, LA, 70112, USA
| | - Somya Bhatnagar
- School of Medicine, Tulane University, New Orleans, LA, 70112, USA
| | - Gregory Jaye Bix
- Department of Neurosurgery, Clinical Neuroscience Research Center, Tulane University School of Medicine, 131 S. Robertson, Ste 1300, Room 1349, New Orleans, LA, 70112, USA.
- Tulane Brain Institute, Tulane University, New Orleans, LA, 70112, USA.
- Department of Neurology, Tulane University School of Medicine, New Orleans, LA, 70112, USA.
- Department of Microbiology and Immunology, Tulane University School of Medicine, New Orleans, LA, 70112, USA.
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, 70122, USA.
| |
Collapse
|
7
|
Yanase L, Clark D, Baraban E, Stuchiner T. A Retrospective Analysis of Ischemic Stroke Patients Supports That Very Early Mobilization Within 24 Hours After Intravenous Alteplase Is Safe and Possibly Beneficial. J Neurosci Nurs 2023; 55:188-193. [PMID: 37815279 DOI: 10.1097/jnn.0000000000000731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
ABSTRACT BACKGROUND: Stroke care guidelines recommend early mobilization of acute ischemic stroke patients, but there are sparse data regarding early mobilization of stroke patients receiving thrombolytic therapy. We developed the Providence Early Mobility for Stroke (PEMS) protocol to mobilize patients to their highest individual tolerance within 24 hours of stroke admission in 2010, and it has been in continuous use at our primary and comprehensive stroke centers for over a decade. In this study, we evaluated the PEMS protocol in all patients treated with intravenous alteplase without endovascular treatment. METHODS : This retrospective study includes 318 acute ischemic stroke patients treated with alteplase who were admitted to 2 urban stroke centers between January 2013 and December of 2017 and were mobilized with the PEMS protocol within 24 hours of receiving alteplase. Safety of PEMS was assessed by change in National Institutes of Health Stroke Scale at 24 hours by time first mobilized. Using multivariate and logistic regression models, we analyzed time first mobilized and 90-day modified Rankin scale (mRS). RESULTS : Median time first mobilized was 9 hours from administration of alteplase. For every hour delay in mobilization, the odds of being slightly or moderately disabled (mRS, 2-3) at 90 days increased by 7% (adjusted odds ratio, 1.07; P = .004), and the odds of being severely disabled or dead (mRS, 4-6) at 90 days increased by 7% (adjusted odds ratio, 1.07; P = .02). In addition, for every hour delay in mobilization, 24-hour National Institutes of Health Stroke Scale increased by 1.8%. DISCUSSION: Our results support that the PEMS protocol is safe, and possibly beneficial, for acute ischemic stroke patients treated with intravenous alteplase. Our protocol differs from other very early mobility protocols because it does not prescribe a "dose" of activity. Instead, each patient was mobilized to his/her individual highest degree as soon as it was safe to do so.
Collapse
|
8
|
Sheriff FG, Ahmad A, Inam ME, Khatri R, Maud A, Rodriguez GJ. A systematic review on the assessment of cerebral autoregulation in patients with Large Vessel Occlusion. Front Neurol 2023; 14:1287873. [PMID: 38046584 PMCID: PMC10693431 DOI: 10.3389/fneur.2023.1287873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 11/02/2023] [Indexed: 12/05/2023] Open
Abstract
As the majority of large vessel occlusion (LVO) patients are not treated with revascularization therapies or efficiently revascularized, complementary management strategies are needed. In this article we explore the importance of cerebral autoregulation (CA) assessment in the prediction and/or modification of infarct growth and hemorrhagic transformation. In patients with LVO, these are important factors that affect prognosis. A systematic search of the PubMed, EMBASE databases and a targeted Google search was conducted, resulting in the inclusion of 34 relevant articles. There is an agreement that CA is impaired in patients with LVO; several factors have been identified such as time course, revascularization status, laterality, disease subtype and location, some of which may be potentially modifiable and affect outcomes. The personalized CA assessment of these patients suggests potential for better understanding of the inter-individual variability. Further research is needed for the development of more accurate, noninvasive techniques for continuous monitoring and personalized thresholds for CA.
Collapse
Affiliation(s)
- Faheem G. Sheriff
- Department of Neurology, Section of Interventional Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | | | - Mehmet E. Inam
- University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Rakesh Khatri
- Department of Neurology, Section of Interventional Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | - Alberto Maud
- Department of Neurology, Section of Interventional Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | - Gustavo J. Rodriguez
- Department of Neurology, Section of Interventional Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| |
Collapse
|
9
|
Tunc EM, Utarnachitt RB, Latimer A, Calhoun A, Gamache D, Wall J. Air Medical Transport of a 12-Year-Old Girl With Cerebral Gas Embolism Due to Helium Inhalation. Air Med J 2023; 42:377-379. [PMID: 37716812 DOI: 10.1016/j.amj.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/04/2023] [Indexed: 09/18/2023]
Abstract
This case report describes the initial care and transport considerations of a pediatric patient who suffered from cerebral gas embolism sustained after inhalation of helium from a pressurized tank. The patient demonstrated neurologic symptoms necessitating hyperbaric oxygen therapy and required fixed wing air transport across a mountain range from a rural community hospital to a tertiary center for the treatment. We review the pathophysiology of cerebral gas embolism and strategies for transporting patients with cerebral gas embolism and other trapped gas.
Collapse
Affiliation(s)
- Emine M Tunc
- Seattle Children's Hospital, Seattle, WA; Pediatrics, University of Washington School of Medicine, Seattle, WA.
| | - Richard B Utarnachitt
- Emergency Medicine, University of Washington School of Medicine, Seattle, WA; Airlift Northwest Critical Care Transport Team, Seattle, WA
| | - Andrew Latimer
- Emergency Medicine, University of Washington School of Medicine, Seattle, WA; Airlift Northwest Critical Care Transport Team, Seattle, WA
| | - Ashley Calhoun
- Airlift Northwest Critical Care Transport Team, Seattle, WA
| | | | - Jessica Wall
- Seattle Children's Hospital, Seattle, WA; Pediatrics, University of Washington School of Medicine, Seattle, WA; Emergency Medicine, University of Washington School of Medicine, Seattle, WA; Airlift Northwest Critical Care Transport Team, Seattle, WA
| |
Collapse
|
10
|
Oki K, Nakajima M, Koyama T, Oyama N, Koga M, Hayase M, Ohta T, Omori T, Matsumoto K, Iguchi Y, Fujimoto S, Kakuda W, Ogasawara K. Timing of Initiation of Acute Stroke Rehabilitation and Management Corresponding to Complications at Primary Stroke Centers in Japan: A Nationwide Cross-Sectional Web-Based Questionnaire Survey. Cerebrovasc Dis 2023; 53:125-135. [PMID: 37399792 DOI: 10.1159/000530873] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 04/22/2023] [Indexed: 07/05/2023] Open
Abstract
INTRODUCTION Many guidelines now recommend early rehabilitation for acute stroke patients. However, evidence remains lacking regarding the specific timings for initiation of various rehabilitation steps and management when complications are encountered in acute stroke rehabilitation. This survey aimed to investigate actual clinical situations in acute stroke rehabilitation in Japan and to improve the medical systems for rehabilitation and plan further studies. METHODS This nationwide, cross-sectional, web-based questionnaire survey was administered between February 7, 2022, and April 21, 2022, targeting all primary stroke centers (PSCs) in Japan. Among several components of the survey, this paper focused on the timing of the initiation of three rehabilitation steps (passive bed exercise; head elevation; and out-of-bed mobilization), along with the management of rehabilitation (continued or suspended) in the event of complications during acute stroke rehabilitation. We also investigated the influence of facility features on these contents. RESULTS Responses were obtained from 639 of the 959 PSCs surveyed (response rate: 66.6%). In cases of ischemic stroke and intracerebral hemorrhage, most PSCs initiated passive bed exercise on day 1, head elevation on day 1, and out-of-bed mobilization on day 2 (with day of admission defined as day 1). In cases with subarachnoid hemorrhage, rehabilitation steps were delayed compared to other stroke subtypes or showed wide variation depending on the facility. Passive bed exercise was accelerated by the presence of protocols for rehabilitation and weekend rehabilitation. Out-of-bed mobilization was accelerated by the presence of a stroke care unit. Facilities with board-certified rehabilitation doctors were cautious regarding the initiation of head elevation. Most PSCs suspended rehabilitation training in the event of symptomatic systemic/neurological complications. CONCLUSION Our survey revealed the actual situation of acute stroke rehabilitation in Japan and indicated that some facility features appear to influence early increases in physical activity levels and early mobilization. Our survey provides fundamental data to improve the medical systems for acute stroke rehabilitation in the future.
Collapse
Affiliation(s)
- Koichi Oki
- Department of Neurology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Makoto Nakajima
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Tetsuo Koyama
- Department of Rehabilitation Medicine, Nishinomiya Kyoritsu Neurosurgical Hospital, Nishinomiya, Japan
| | - Naoki Oyama
- Department of Stroke Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Makoto Hayase
- Department of Neurosurgery, Japanese Red Cross Fukui Hospital, Fukui, Japan
| | - Tsuyoshi Ohta
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tomohiro Omori
- Division of Rehabilitation Medicine, International University of Health and Welfare Narita Hospital, Narita, Japan
| | - Koichi Matsumoto
- Division of Rehabilitation Medicine, General Tokyo Hospital, Tokyo, Japan
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shigeru Fujimoto
- Division of Neurology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Wataru Kakuda
- Department of Rehabilitation Medicine, International University of Health and Welfare School of Medicine, Narita, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University, Morioka, Japan
| |
Collapse
|
11
|
Ma L, Hu X, Song L, Chen X, Ouyang M, Billot L, Li Q, Malavera A, Li X, Muñoz-Venturelli P, de Silva A, Thang NH, Wahab KW, Pandian JD, Wasay M, Pontes-Neto OM, Abanto C, Arauz A, Shi H, Tang G, Zhu S, She X, Liu L, Sakamoto Y, You S, Han Q, Crutzen B, Cheung E, Li Y, Wang X, Chen C, Liu F, Zhao Y, Li H, Liu Y, Jiang Y, Chen L, Wu B, Liu M, Xu J, You C, Anderson CS. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet 2023; 402:27-40. [PMID: 37245517 PMCID: PMC10401723 DOI: 10.1016/s0140-6736(23)00806-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/03/2023] [Accepted: 04/17/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Early control of elevated blood pressure is the most promising treatment for acute intracerebral haemorrhage. We aimed to establish whether implementing a goal-directed care bundle incorporating protocols for early intensive blood pressure lowering and management algorithms for hyperglycaemia, pyrexia, and abnormal anticoagulation, implemented in a hospital setting, could improve outcomes for patients with acute spontaneous intracerebral haemorrhage. METHODS We performed a pragmatic, international, multicentre, blinded endpoint, stepped wedge cluster randomised controlled trial at hospitals in nine low-income and middle-income countries (Brazil, China, India, Mexico, Nigeria, Pakistan, Peru, Sri Lanka, and Viet Nam) and one high-income country (Chile). Hospitals were eligible if they had no or inconsistent relevant, disease-specific protocols, and were willing to implement the care bundle to consecutive patients (aged ≥18 years) with imaging-confirmed spontaneous intracerebral haemorrhage presenting within 6 h of the onset of symptoms, had a local champion, and could provide the required study data. Hospitals were centrally randomly allocated using permuted blocks to three sequences of implementation, stratified by country and the projected number of patients to be recruited over the 12 months of the study period. These sequences had four periods that dictated the order in which the hospitals were to switch from the control usual care procedure to the intervention implementation of the care bundle procedure to different clusters of patients in a stepped manner. To avoid contamination, details of the intervention, sequence, and allocation periods were concealed from sites until they had completed the usual care control periods. The care bundle protocol included the early intensive lowering of systolic blood pressure (target <140 mm Hg), strict glucose control (target 6·1-7·8 mmol/L in those without diabetes and 7·8-10·0 mmol/L in those with diabetes), antipyrexia treatment (target body temperature ≤37·5°C), and rapid reversal of warfarin-related anticoagulation (target international normalised ratio <1·5) within 1 h of treatment, in patients where these variables were abnormal. Analyses were performed according to a modified intention-to-treat population with available outcome data (ie, excluding sites that withdrew during the study). The primary outcome was functional recovery, measured with the modified Rankin scale (mRS; range 0 [no symptoms] to 6 [death]) at 6 months by masked research staff, analysed using proportional ordinal logistic regression to assess the distribution in scores on the mRS, with adjustments for cluster (hospital site), group assignment of cluster per period, and time (6-month periods from Dec 12, 2017). This trial is registered at Clinicaltrials.gov (NCT03209258) and the Chinese Clinical Trial Registry (ChiCTR-IOC-17011787) and is completed. FINDINGS Between May 27, 2017, and July 8, 2021, 206 hospitals were assessed for eligibility, of which 144 hospitals in ten countries agreed to join and were randomly assigned in the trial, but 22 hospitals withdrew before starting to enrol patients and another hospital was withdrawn and their data on enrolled patients was deleted because regulatory approval was not obtained. Between Dec 12, 2017, and Dec 31, 2021, 10 857 patients were screened but 3821 were excluded. Overall, the modified intention-to-treat population included 7036 patients enrolled at 121 hospitals, with 3221 assigned to the care bundle group and 3815 to the usual care group, with primary outcome data available in 2892 patients in the care bundle group and 3363 patients in the usual care group. The likelihood of a poor functional outcome was lower in the care bundle group (common odds ratio 0·86; 95% CI 0·76-0·97; p=0·015). The favourable shift in mRS scores in the care bundle group was generally consistent across a range of sensitivity analyses that included additional adjustments for country and patient variables (0·84; 0·73-0·97; p=0·017), and with different approaches to the use of multiple imputations for missing data. Patients in the care bundle group had fewer serious adverse events than those in the usual care group (16·0% vs 20·1%; p=0·0098). INTERPRETATION Implementation of a care bundle protocol for intensive blood pressure lowering and other management algorithms for physiological control within several hours of the onset of symptoms resulted in improved functional outcome for patients with acute intracerebral haemorrhage. Hospitals should incorporate this approach into clinical practice as part of active management for this serious condition. FUNDING Joint Global Health Trials scheme from the Department of Health and Social Care, the Foreign, Commonwealth & Development Office, and the Medical Research Council and Wellcome Trust; West China Hospital; the National Health and Medical Research Council of Australia; Sichuan Credit Pharmaceutic and Takeda China.
Collapse
Affiliation(s)
- Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Hu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Lili Song
- The George Institute for Global Health China, Beijing, China; The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Xiaoying Chen
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Menglu Ouyang
- The George Institute for Global Health China, Beijing, China; The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Qiang Li
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Alejandra Malavera
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Xi Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Paula Muñoz-Venturelli
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Clinical Research Center, Faculty of Medicine Clinica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Asita de Silva
- Clinical Trials Unit, Faculty of Medicine, University of Kelaniya, Colombo, Sri Lanka
| | | | - Kolawole W Wahab
- Department of Medicine, University of Ilorin & University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Jeyaraj D Pandian
- Neurology Department, Christian Medical College and Hospital, Ludhiana, India
| | - Mohammad Wasay
- Department of Medicine, The Aga Khan University, Karachi, Pakistan
| | - Octavio M Pontes-Neto
- Department of Neurology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Carlos Abanto
- The Cerebrovascular Disease Research Center, National Institute of Neurological Sciences, Lima, Peru
| | - Antonio Arauz
- Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suarez, Mexico City, Mexico
| | - Haiping Shi
- Department of Neurosurgery, Suining Central Hospital, Suining, China
| | - Guanghai Tang
- Department of Neurology, Liaoning Thrombus Treatment Centre of Integrated Chinese and Western Medicine, Shenyang, China
| | - Sheng Zhu
- Department of Neurosurgery, Dazhu County People's Hospital, Dazhou, China
| | - Xiaochun She
- Department of Neurosurgery, Jiangsu Rudong County People's Hospital, Nantong, China
| | - Leibo Liu
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Yuki Sakamoto
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Shoujiang You
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Qiao Han
- Department of Neurology, Suzhou Hospital of Traditional Chinese Medicine, Suzhou, China
| | - Bernard Crutzen
- Department of Radiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Department of Radiology, Grand Hôpital de Charleroi, Charleroi, Belgium
| | - Emily Cheung
- Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Yunke Li
- The George Institute for Global Health China, Beijing, China
| | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Chen Chen
- The George Institute for Global Health China, Beijing, China; The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Department of Neurology, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Feifeng Liu
- Department of Neurology, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Yang Zhao
- The George Institute for Global Health China, Beijing, China
| | - Hao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yan Jiang
- Department of Nursing and Evidence-based Nursing Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lei Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Bo Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Ming Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jianguo Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China.
| | - Craig S Anderson
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China; The George Institute for Global Health China, Beijing, China; The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Clinical Research Center, Faculty of Medicine Clinica Alemana Universidad del Desarrollo, Santiago, Chile; Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia; Heart Health Research Center, Beijing, China.
| |
Collapse
|
12
|
Che Y, Lu T, Wang T, Zhao H, Song X, Zhan Q, Zhang C, Pan H, Yang K, Wang B. A Meta-analysis of the Clinical Efficacy of the Head-of-Bed Elevation for Patients With Acquired Brain Injury. J Neurosci Nurs 2023; 55:91-96. [PMID: 37094377 DOI: 10.1097/jnn.0000000000000703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
ABSTRACT BACKGROUND: Acquired brain injury is caused by traumatic or nontraumatic factors and causes changes in cognition. Several reviews have described the influence of the head-of-bed (HOB) elevation on clinical indexes such as intracranial pressure (ICP) and cerebral perfusion pressure (CPP). However, the conclusions were inconsistent. Therefore, we aimed to evaluate the effects of HOB elevation in the care of the patients with ABI. METHODS: Two researchers independently screened the literature and extracted data. We searched PubMed, EMBASE, the Cochrane Library, Web of Science, and the Chinese Biological Literature Database to collect eligible randomized controlled trials published after September 2021. Reporting quality and methodological quality of the included studies were assessed by using the Preferred Reporting Items for Systematic Reviews and Meta-analysis and the Cochrane risk-of-bias tool. RESULTS : Eight studies were included in the meta-analysis. The results showed that, compared with the flat position, HOB elevation of 30° or 45° can significantly reduce ICP (mean difference [MD], -2.40 mm Hg; 95% confidence interval [CI], -3.19 to -1.61; P < .00001). However, there were no statistical differences in CPP (MD, -1.09; 95% CI, -3.93 to 1.75; P = .45), degree of disability at 90 days (relative risk, 1.01; 95% CI, 0.94-1.08; P = .83), and mean arterial pressure (MD, -0.44; 95% CI, -10.27 to 9.93; P = .93). CONCLUSION: Head-of-bed elevation of 30° can reduce ICP and maintain CPP, and may be an effective noninvasive nursing practice for the prognosis and rehabilitation of ABI patients. Owing to the lack of high-quality, large-sample randomized controlled trials, more rigorous trials are needed to support this conclusion.
Collapse
|
13
|
Chen HS, Zhang NN, Cui Y, Li XQ, Zhou CS, Ma YT, Zhang H, Jiang CH, Li RH, Wan LS, Jiao Z, Xiao HB, Li Z, Yan TG, Wang DL, Nguyen TN. A randomized trial of Trendelenburg position for acute moderate ischemic stroke. Nat Commun 2023; 14:2592. [PMID: 37147320 PMCID: PMC10163013 DOI: 10.1038/s41467-023-38313-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 04/25/2023] [Indexed: 05/07/2023] Open
Abstract
We aim to explore the effect of head-down position (HDP), initiated within 24 hours of onset, in moderate anterior circulation stroke patients with probable large artery atherosclerosis (LAA) etiology. This investigator-initiated, multi-center trial prospective, randomized, open-label, blinded-endpoint, multi-center and phase-2 trial was conducted in China and completed in 2021. Eligible patients were randomly assigned (1:1) into the HDP group receiving -20° Trendelenburg, or control group receiving standard care according to national guideline. The primary endpoint was proportion of modified Rankin Scale (mRS) of 0 to 2 at 90 days, which is a scale for measuring the degree of disability after stroke. 90-day mRS was assessed by a certified staff member who was blinded to group assignment. A total of 96 patients were randomized (47 in HDP group and 49 in control group) and 94 (97.9%) patients were included in the final analysis: 46 in HDP group and 48 in control group. The proportion of favorable outcome was 65.2% (30/46) in the HDP group versus 50.0% (24/48) in the control group (unadjusted: OR 2.05 [95%CI 0.87-4.82], P = 0.099). No severe adverse event was attributed to HDP procedures. This work suggests that the head-down position seems safe and feasible, but does not improve favorable functional outcome in acute moderate stroke patients with LAA. This trial was registered with ClinicalTrials.gov, NCT03744533.
Collapse
Affiliation(s)
- Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, 110016, China.
| | - Nan-Nan Zhang
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, 110016, China
| | - Yu Cui
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, 110016, China
| | - Xiao-Qiu Li
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, 110016, China
| | - Cheng-Shu Zhou
- Department of Neurology, Anshan Changda Hospital, Anshan, 114000, China
| | - Yu-Tong Ma
- Department of Neurology, Beipiao Central Hospital, Beipiao, 122100, China
| | - Hong Zhang
- Department of Neurology, Fukuang General Hospital of Liaoning Health Industry Group, Fushun, 113005, China
| | - Chang-Hao Jiang
- Department of Neurology, The Traditional Medicine Hospital of Dalian Lvshunkou, Dalian, 116045, China
| | - Run-Hui Li
- Department of Neurology, Central Hospital affiliated to Shenyang Medical College, Shenyang, 110024, China
| | - Li-Shu Wan
- Department of Neurology, Dandong First Hospital, Dandong, 118015, China
| | - Zhen Jiao
- Department of Neurology, Anshan Central Hospital, Anshan, 114000, China
| | - Hong-Bo Xiao
- Department of Neurology, Anshan Central Hospital, Anshan, 114000, China
| | - Zhuo Li
- Department of Neurology, Panjin Central Hospital, Panjin, 124010, China
| | - Ting-Guang Yan
- Department of Neurology, Chaoyang Central Hospital, Chaoyang, 122099, China
| | - Duo-Lao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Thanh N Nguyen
- Neurology, Radiology, Boston Medical Center, Boston, MA, USA
| |
Collapse
|
14
|
Richards CT, Oostema JA, Chapman SN, Mamer LE, Brandler ES, Alexandrov AW, Czap AL, Martinez-Gutierrez JC, Martin-Gill C, Panchal AR, McMullan JT, Zachrison KS. Prehospital Stroke Care Part 2: On-Scene Evaluation and Management by Emergency Medical Services Practitioners. Stroke 2023; 54:1416-1425. [PMID: 36866672 PMCID: PMC10133016 DOI: 10.1161/strokeaha.123.039792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 02/02/2023] [Indexed: 03/04/2023]
Abstract
The prehospital phase is a critical component of delivering high-quality acute stroke care. This topical review discusses the current state of prehospital acute stroke screening and transport, as well as new and emerging advances in prehospital diagnosis and treatment of acute stroke. Topics include prehospital stroke screening, stroke severity screening, emerging technologies to aid in the identification and diagnosis of acute stroke in the prehospital setting, prenotification of receiving emergency departments, decision support for destination determination, and the capabilities and opportunities for prehospital stroke treatment in mobile stroke units. Further evidence-based guideline development and implementation of new technologies are critical for ongoing improvements in prehospital stroke care.
Collapse
Affiliation(s)
- Christopher T. Richards
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - J. Adam Oostema
- Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI
| | | | - Lauren E. Mamer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Ethan S. Brandler
- Department of Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Anne W. Alexandrov
- College of Nursing, University of Tennessee Health Science Center, Memphis, TN
| | - Alexandra L. Czap
- Department of Neurology, University of Texas Houston McGovern Medical School, Houston, TX
| | | | | | - Ashish R. Panchal
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jason T. McMullan
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kori S. Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
15
|
Sanjuan E, Pancorbo O, Santana K, Miñarro O, Sala V, Muchada M, Boned S, Juega JM, Pagola J, García-Tornel Á, Requena M, Rodríguez-Villatoro N, Rodríguez-Luna D, Deck M, Ribo M, Molina CA, Meler P, Romero V, Dalmases G, Rodríguez-Samaniego MT, Calleja L, Gutierrez T, Peña L, Gallego JC, Lorenzo E, Gonzalez Y, Moreno R, Rubiera M. Management of acute stroke. Specific nursing care and treatments in the stroke unit. Neurologia 2023:S2173-5808(23)00022-6. [PMID: 37120108 DOI: 10.1016/j.nrleng.2020.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/29/2020] [Indexed: 05/01/2023] Open
Abstract
OBJECTIVE This study provides a series of updated, evidence-based recommendations for the management of acute stroke. We aim to lay a foundation for the development of individual centres' internal protocols, serving as a reference for nursing care. METHODS We review the available evidence on acute stroke care. The most recent national and international guidelines were consulted. Levels of evidence and degrees of recommendation are based on the Oxford Centre for Evidence-Based Medicine classification. RESULTS The study describes prehospital acute stroke care, the operation of the code stroke protocol, care provided by the stroke team upon the patient's arrival at hospital, reperfusion treatments and their limitations, admission to the stroke unit, nursing care in the stroke unit, and discharge from hospital. CONCLUSIONS These guidelines provide general, evidence-based recommendations to guide professionals who care for patients with acute stroke. However, limited data are available on some aspects, showing the need for continued research on acute stroke management.
Collapse
Affiliation(s)
- E Sanjuan
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.
| | - O Pancorbo
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - K Santana
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - O Miñarro
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - V Sala
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M Muchada
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - S Boned
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - J M Juega
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - J Pagola
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Á García-Tornel
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M Requena
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - N Rodríguez-Villatoro
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - D Rodríguez-Luna
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M Deck
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M Ribo
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - C A Molina
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - P Meler
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - V Romero
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - G Dalmases
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M T Rodríguez-Samaniego
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - L Calleja
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - T Gutierrez
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - L Peña
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - J C Gallego
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - E Lorenzo
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Y Gonzalez
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - R Moreno
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M Rubiera
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| |
Collapse
|
16
|
Mazzoleni V, Padovani A, Morotti A. Emergency management of intracerebral hemorrhage. J Crit Care 2023; 74:154232. [PMID: 36565647 DOI: 10.1016/j.jcrc.2022.154232] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
Acute intracerebral hemorrhage is a medical emergency with high mortality and morbidity. Neuroimaging has a fundamental role in the etiological diagnosis, patients monitoring and in the risk stratification of hematoma expansion and poor outcome. The cornerstones of medical treatment in the acute phase are blood pressure lowering and coagulopathy reversal. Prevention of hematoma expansion is the main goal of these therapies and their efficacy is strongly time-dependent with a narrow time window. This review provides an update on the etiological diagnostic workup, acute treatment and prognosis of intracerebral hemorrhage.
Collapse
Affiliation(s)
- Valentina Mazzoleni
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Brescia, Italy.
| | - Alessandro Padovani
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Brescia, Italy; Department of Neurological Sciences and Vision, Neurology Unit, ASST-Spedali Civili, Brescia, Italy
| | - Andrea Morotti
- Department of Neurological Sciences and Vision, Neurology Unit, ASST-Spedali Civili, Brescia, Italy
| |
Collapse
|
17
|
Li JX, Wang X, Henry A, Anderson CS, Hammond N, Harris K, Liu H, Loffler K, Myburgh J, Pandian J, Smyth B, Venkatesh B, Carcel C, Woodward M. Sex differences in pain expressed by patients across diverse disease states: individual patient data meta-analysis of 33,957 participants in 10 randomized controlled trials. Pain 2023:00006396-990000000-00275. [PMID: 36972472 DOI: 10.1097/j.pain.0000000000002884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 12/28/2022] [Indexed: 03/29/2023]
Abstract
ABSTRACT The experience of pain is determined by many factors and has a significant impact on quality of life. This study aimed to determine sex differences in pain prevalence and intensity reported by participants with diverse disease states in several large international clinical trials. Individual participant data meta-analysis was conducted using EuroQol-5 Dimension (EQ-5D) questionnaire pain data from randomised controlled trials published between January 2000 and January 2020 and undertaken by investigators at the George Institute for Global Health. Proportional odds logistic regression models, comparing pain scores between females and males and fitted with adjustments for age and randomized treatment, were pooled in a random-effects meta-analysis. In 10 trials involving 33,957 participants (38% females) with EQ-5D pain score data, the mean age ranged between 50 and 74. Pain was reported more frequently by females than males (47% vs 37%; P < 0.001). Females also reported greater levels of pain than males (adjusted odds ratio 1.41, 95% CI 1.24-1.61; P < 0.001). In stratified analyses, there were differences in pain by disease group (P for heterogeneity <0.001), but not by age group or region of recruitment. Females were more likely to report pain, and at a higher level, compared with males across diverse diseases, all ages, and geographical regions. This study reinforces the importance of reporting sex-disaggregated analysis to identify similarities and differences between females and males that reflect variable biology and may affect disease profiles and have implications for management.
Collapse
|
18
|
Zhao ZA, Zhang NN, Cui Y, Chen HS. The effect of head-down tilt in experimental acute ischemic stroke. Eur J Neurol 2023; 30:155-161. [PMID: 36256506 DOI: 10.1111/ene.15597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 09/30/2022] [Accepted: 10/10/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Collateral therapeutics exert a promising protective effect on the outcome of acute ischemic stroke. Cerebral blood flow (CBF) may be modulated by different head positioning. The current study aimed to determine the effect of head-down tilt (HDT) on stroke in a rodent model. METHODS The model of middle cerebral artery occlusion and reperfusion (MCAO/R) was used in this study. Neurological deficit scoring, 2,3,5-triphenyltetrazolium chloride staining, brain water content, perivascular aquaporin protein-4 (AQP4) localization, pericyte marker platelet-derived growth factor receptor β (PDGFRβ), and CBF velocity were evaluated at 24 h after MCAO/R and HDT treatment. RESULTS In the rat model of MCAO/R, brain infarct volume and neurological deficit score were significantly alleviated in the -30° and -60° groups compared to those in the lying flat (0°) group. Compared with the 0° group, an increase in CBF velocity was detected in the -30° group through two-photon microscopy imaging at 24 h after MCAO/R. Compared with the SHAM group, a decrease in PDGFRβ was observed in both the MCAO/R and HDT treatment (-30°) groups. The integrated optical density of PDGFRβ was found to be higher in the HDT treatment (-30°) group than in the MCAO/R group. An impairment in perivascular AQP4 polarity and an increase in brain water content were observed after MCAO/R, which were not exacerbated by HDT treatment (-30°). CONCLUSIONS Our findings suggest that HDT treatment at certain degrees may exert a neuroprotective effect after MCAO/R through improving CBF velocity and the protection of pericytes.
Collapse
Affiliation(s)
- Zi-Ai Zhao
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Nan-Nan Zhang
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yu Cui
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| |
Collapse
|
19
|
Deseoe J, Schwarz A, Pipping T, Lehmann A, Veerbeek JM, Luft AR, Wegener S, Globas C, Held JPO. Cerebral blood flow velocity progressively decreases with increasing levels of verticalization in healthy adults. A cross-sectional study with an observational design. Front Neurol 2023; 14:1149673. [PMID: 37139076 PMCID: PMC10149656 DOI: 10.3389/fneur.2023.1149673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 03/20/2023] [Indexed: 05/05/2023] Open
Abstract
Background Autoregulation of the cerebral vasculature keeps brain perfusion stable over a range of systemic mean arterial pressures to ensure brain functioning, e.g., in different body positions. Verticalization, i.e., transfer from lying (0°) to upright (70°), which causes systemic blood pressure drop, would otherwise dramatically lower cerebral perfusion pressure inducing fainting. Understanding cerebral autoregulation is therefore a prerequisite to safe mobilization of patients in therapy. Aim We measured the impact of verticalization on cerebral blood flow velocity (CBFV) and systemic blood pressure (BP), heart rate (HR) and oxygen saturation in healthy individuals. Methods We measured CBFV in the middle cerebral artery (MCA) of the dominant hemisphere in 20 subjects using continuous transcranial doppler ultrasound (TCD). Subjects were verticalized at 0°, -5°, 15°, 30°, 45° and 70° for 3-5 min each, using a standardized Sara Combilizer chair. In addition, blood pressure, heart rate and oxygen saturation were continuously monitored. Results We show that CBFV progressively decreases in the MCA with increasing degrees of verticalization. Systolic and diastolic BP, as well as HR, show a compensatory increase during verticalization. Conclusion In healthy adults CBFV changes rapidly with changing levels of verticalization. The changes in the circulatory parameters are similar to results regarding classic orthostasis. Registration ClinicalTrials.gov, identifier: NCT04573114.
Collapse
Affiliation(s)
- Julian Deseoe
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Anne Schwarz
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Theodor Pipping
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Aurelia Lehmann
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Janne M. Veerbeek
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Neurocenter, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Andreas R. Luft
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Christoph Globas
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- *Correspondence: Christoph Globas
| | - Jeremia P. O. Held
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Rehabilitation Center Triemli Zurich, Valens Clinics, Zurich, Switzerland
| |
Collapse
|
20
|
Dusenbury W, Malkoff MD, Schellinger PD, Köhrmann M, Arthur AS, Elijovich L, Alexandrov AV, Tsivgoulis G, Alexandrov AW. International beliefs and head positioning practices in patients with spontaneous hyperacute intracerebral hemorrhage. Ther Adv Neurol Disord 2023; 16:17562864231161162. [PMID: 36993938 PMCID: PMC10041589 DOI: 10.1177/17562864231161162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 02/15/2023] [Indexed: 03/31/2023] Open
Abstract
Background Prior to the conduct of the Head Position in Stroke Trial (HeadPoST), an international survey (n = 128) revealed equipoise for selection of head position in acute ischemic stroke. Objectives We aimed to determine whether equipoise exists for head position in spontaneous hyperacute intracerebral hemorrhage (ICH) patients following HeadPoST. Design This is an international, web-distributed survey focused on head positioning in hyperacute ICH patients. Methods A survey was constructed to examine clinicians' beliefs and practices associated with head positioning of hyperacute ICH patients. Survey items were developed with content experts, piloted, and then refined before distributing through stroke listservs, social media, and purposive snowball sampling. Data were analyzed using descriptive statistics and χ2 test. Results We received 181 responses representing 13 countries on four continents: 38% advanced practice providers, 32% bedside nurses, and 30% physicians; overall, participants had median 7 [interquartile range (IQR) = 3-12] years stroke experience with a median of 100 (IQR = 37.5-200) ICH admissions managed annually. Participants disagreed that HeadPoST provided 'definitive evidence' for head position in ICH and agreed that their 'written admission orders include 30-degree head positioning', with 54% citing hospital policies for this head position in hyperacute ICH. Participants were unsure whether head positioning alone could influence ICH longitudinal outcomes. Use of serial proximal clinical and technology measures during the head positioning intervention were identified by 82% as the most appropriate endpoints for future ICH head positioning trials. Conclusion Interdisciplinary providers remain unconvinced by HeadPoST results that head position does not matter in hyperacute ICH. Future trials examining the proximal effects of head positioning on clinical stability in hyperacute ICH are warranted.
Collapse
Affiliation(s)
| | - Marc D. Malkoff
- University of Tennessee Health Science Center, Memphis, TN, USA
| | | | | | - Adam S. Arthur
- University of Tennessee Health Science Center, Memphis, TN, USA
- Semmes-Murphey Neurosurgery, Memphis, TN, USA
| | - Lucas Elijovich
- University of Tennessee Health Science Center, Memphis, TN, USA
- Semmes-Murphey Neurosurgery, Memphis, TN, USA
| | - Andrei V. Alexandrov
- University of Tennessee Health Science Center, Memphis, TN, USA
- Banner University Hospital, University of Arizona College of Medicine, Phoenix, AZ
| | - Georgios Tsivgoulis
- National and Kapodistrian University of Athens, Athens, Greece
- University of Tennessee Health Science Center, Memphis, TN, USA
| | | |
Collapse
|
21
|
Gettel CJ, Yiadom MYA, Bernstein SL, Grudzen CR, Nath B, Li F, Hwang U, Hess EP, Melnick ER. Pragmatic clinical trial design in emergency medicine: Study considerations and design types. Acad Emerg Med 2022; 29:1247-1257. [PMID: 35475533 PMCID: PMC9790188 DOI: 10.1111/acem.14513] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 04/04/2022] [Accepted: 04/25/2022] [Indexed: 01/25/2023]
Abstract
Pragmatic clinical trials (PCTs) focus on correlation between treatment and outcomes in real-world clinical practice, yet a guide highlighting key study considerations and design types for emergency medicine investigators pursuing this important study type is not available. Investigators conducting emergency department (ED)-based PCTs face multiple decisions within the planning phase to ensure robust and meaningful study findings. The PRagmatic Explanatory Continuum Indicator Summary 2 (PRECIS-2) tool allows trialists to consider both pragmatic and explanatory components across nine domains, shaping the trial design to the purpose intended by the investigators. Aside from the PRECIS-2 tool domains, ED-based investigators conducting PCTs should also consider randomization techniques, human subjects concerns, and integration of trial components within the electronic health record. The authors additionally highlight the advantages, disadvantages, and rationale for the use of four common randomized study design types to be considered in PCTs: parallel, crossover, factorial, and stepped-wedge. With increasing emphasis on the conduct of PCTs, emergency medicine investigators will benefit from a rigorous approach to clinical trial design.
Collapse
Affiliation(s)
- Cameron J. Gettel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT, USA
| | - Maame Yaa A.B. Yiadom
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Bidisha Nath
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Geriatrics Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA
| | - Erik P. Hess
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Edward R. Melnick
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| |
Collapse
|
22
|
Acute Hospital Management of Pediatric Stroke. Semin Pediatr Neurol 2022; 43:100990. [PMID: 36344020 DOI: 10.1016/j.spen.2022.100990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 08/13/2022] [Accepted: 08/14/2022] [Indexed: 11/24/2022]
Abstract
The field of pediatric stroke has historically been hampered by limited evidence and small patient cohorts. However the landscape of childhood stroke is rapidly changing due in part to increasing awareness of the importance of pediatric stroke and the emergence of dedicated pediatric stroke centers, care pathways, and alert systems. Acute pediatric stroke management hinges on timely diagnosis confirmed by neuroimaging, appropriate consideration of recanalization therapies, implementation of neuroprotective measures, and attention to secondary prevention. Because pediatric stroke is highly heterogenous in etiology, management strategies must be individualized. Determining a child's underlying stroke etiology is essential to appropriately tailoring hyperacute stroke management and determining best approach to secondary prevention. Herein, we review the methods of recognition, diagnosis, management, current knowledge gaps and promising research for pediatric stroke.
Collapse
|
23
|
Zhao ZA, Zhang NN, Tao L, Cui Y, Li M, Qi SL, Chen HS. Effect of head-down tilt on clinical outcome and cerebral perfusion in ischemic stroke patients: A case series. Front Neurol 2022; 13:992885. [PMID: 36226083 PMCID: PMC9548884 DOI: 10.3389/fneur.2022.992885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/08/2022] [Indexed: 11/17/2022] Open
Abstract
Background The effect of head position on stroke is not clear. The current study aimed to observe the effect of head-down tilt on acute ischemic stroke (AIS) patients with large vessel occlusion. Methods We observed the influence of head-down tilt position on clinical outcomes, myocardial enzymogram and N-terminal pro b-type Natriuretic Peptide in 4 AIS patients who suffered early neurological deterioration (END). Cerebral perfusion imaging was performed in 3 patients using arterial spin labeling. Results In series of AIS patients with END, head down tilt (-20°) prevented further neurological deterioration and improved clinical outcomes. An increase in cerebral blood flow was observed by arterial spin labeling after head down tilt treatment. No obvious adverse events occurred. Conclusion The case series suggest that head-down tilt may improve clinical outcome in AIS patients through increasing the cerebral perfusion with no obvious adverse events. The finding needs to be confirmed in future clinical trials.
Collapse
Affiliation(s)
- Zi-Ai Zhao
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Nan-Nan Zhang
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Lin Tao
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yu Cui
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Meng Li
- School of Sino-Dutch Biomedical and Information Engineering, Northeastern University, Shenyang, China
| | - Shou-Liang Qi
- School of Sino-Dutch Biomedical and Information Engineering, Northeastern University, Shenyang, China
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
- *Correspondence: Hui-Sheng Chen
| |
Collapse
|
24
|
Alexandrov AW. The Sky's the Limit: Expanding Nursing's Contribution to Acute Stroke Science. Am J Crit Care 2022; 31:266-274. [PMID: 35773192 DOI: 10.4037/ajcc2022109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Stroke is the number one cause of preventable disability in adults in the United States. Significant advances have occurred in medications and technology supporting rapid stroke diagnosis and treatment during the past 30 years, along with blurring of the lines of what traditionally constituted nursing or medical research. Ischemic stroke is a disease of vascular insufficiency that mirrors myocardial infarction more than any other neurologic diagnosis. My primary program of research is focused on exploration of methods to improve intracranial blood flow in patients with hyperacute ischemic stroke who have viable, yet vulnerable, brain tissue to prevent worsening or enable improvement of stroke symptoms. I am also examining augmentation of recombinant tissue plasminogen activator treatment and stimulation of both arteriogenesis and angiogenesis with external counter-pulsation in patients with intracranial atherosclerosis. My secondary program of research focuses on methods to improve stroke systems of care, including improvement of advance practice providers' contributions to acute stroke care, use of innovative mobile stroke units, and improvement of quality core measure processes. Lessons learned along the way are highlighted, along with the value of interdisciplinary "team science" to build knowledge and enhance the care of highly vulnerable patients with acute stroke.
Collapse
Affiliation(s)
- Anne W Alexandrov
- Anne W. Alexandrov is a professor of nursing and neurology and chief nurse practitioner, Acute Stroke Team and Mobile Stroke Unit, University of Tennessee Health Science Center, Memphis, Tennessee; a principal partner at Health Outcomes Institute, LLC, and a professor, NET SMART Program, Fountain Hills, Arizona
| |
Collapse
|
25
|
English C, Hill K, Cadilhac DA, Hackett ML, Lannin NA, Middleton S, Ranta A, Stocks NP, Davey J, Faux SG, Godecke E, Campbell BCV. Living clinical guidelines for stroke: updates, challenges and opportunities. Med J Aust 2022; 216:510-514. [PMID: 35569098 PMCID: PMC9542680 DOI: 10.5694/mja2.51520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Dominique A Cadilhac
- Monash University Melbourne VIC
- Florey Institute of Neuroscience and Mental Health Melbourne VIC
| | - Maree L Hackett
- The George Institute for Global Health, Faculty of Medicine University of NSW Sydney NSW
- University of Central Lancashire Preston UK
| | | | - Sandy Middleton
- Nursing Research Institute Australian Catholic University and St Vincent’s Health Australia Sydney NSW
- Australian Catholic University Sydney NSW
| | | | | | | | - Steven G Faux
- St Vincent's Hospital Sydney NSW
- University of NSW Sydney NSW
| | - Erin Godecke
- Edith Cowan University Perth WA
- Sir Charles Gairdner Hospital Perth WA
| | - Bruce CV Campbell
- Melbourne Brain Centre at Royal Melbourne Hospital Melbourne VIC
- University of Melbourne Melbourne VIC
| |
Collapse
|
26
|
Minelli C, Bazan R, Pedatella MTA, Neves LDO, Cacho RDO, Magalhães SCSA, Luvizutto GJ, Moro CHC, Lange MC, Modolo GP, Lopes BC, Pinheiro EL, de Souza JT, Rodrigues GR, Fabio SRC, do Prado GF, Carlos K, Teixeira JJM, Barreira CMA, Castro RDS, Quinan TDL, Damasceno E, Almeida KJ, Pontes-Neto OM, Dalio MTRP, Camilo MR, Tosin MHDS, Oliveira BC, de Oliveira BGRB, de Carvalho JJF, Martins SCO. Brazilian Academy of Neurology practice guidelines for stroke rehabilitation: part I. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:634-652. [PMID: 35946713 PMCID: PMC9387194 DOI: 10.1590/0004-282x-anp-2021-0354] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/21/2021] [Accepted: 01/18/2022] [Indexed: 06/15/2023]
Abstract
The Guidelines for Stroke Rehabilitation are the result of a joint effort by the Scientific Department of Neurological Rehabilitation of the Brazilian Academy of Neurology aiming to guide professionals involved in the rehabilitation process to reduce functional disability and increase individual autonomy. Members of the group participated in web discussion forums with predefined themes, followed by videoconference meetings in which issues were discussed, leading to a consensus. These guidelines, divided into two parts, focus on the implications of recent clinical trials, systematic reviews, and meta-analyses in stroke rehabilitation literature. The main objective was to guide physicians, physiotherapists, speech therapists, occupational therapists, nurses, nutritionists, and other professionals involved in post-stroke care. Recommendations and levels of evidence were adapted according to the currently available literature. Part I discusses topics on rehabilitation in the acute phase, as well as prevention and management of frequent conditions and comorbidities after stroke.
Collapse
Affiliation(s)
- Cesar Minelli
- Hospital Carlos Fernando Malzoni, Matão SP, Brazil
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Neurociências e Ciências do Comportamento, Ribeirão Preto SP, Brazil
| | - Rodrigo Bazan
- Universidade Estadual Paulista, Faculdade de Medicina de Botucatu, Botucatu SP, Brazil
| | - Marco Túlio Araújo Pedatella
- Hospital Israelita Albert Einstein, Unidade Goiânia, Goiânia GO, Brazil
- Hospital Santa Helena, Goiânia GO, Brazil
- Hospital Encore, Goiânia GO, Brazil
- Hospital Geral de Goiânia, Goiania GO, Brazil
- Hospital de Urgência de Goiânia, Goiânia GO, Brazil
| | | | - Roberta de Oliveira Cacho
- Universidade Federal do Rio Grande do Norte, Faculdade de Ciências da Saúde do Trairi, Santa Cruz RN, Brazil
| | | | - Gustavo José Luvizutto
- Universidade Federal do Triângulo Mineiro, Departamento de Fisioterapia Aplicada, Uberaba MG, Brazil
| | - Carla Heloísa Cabral Moro
- Neurológica Joinville, Joinville SC, Brazil
- Hospital Municipal de Joinville, Joinville SC, Brazil
- Associação Brasil AVC, Joinville SC, Brazil
| | | | | | | | | | - Juli Thomaz de Souza
- Universidade Estadual Paulista, Faculdade de Medicina de Botucatu, Botucatu SP, Brazil
| | - Guilherme Riccioppo Rodrigues
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Neurociências e Ciências do Comportamento, Ribeirão Preto SP, Brazil
| | | | | | - Karla Carlos
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo SP, Brazil
| | | | | | - Rodrigo de Souza Castro
- Hospital Israelita Albert Einstein, Unidade Goiânia, Goiânia GO, Brazil
- Hospital Encore, Goiânia GO, Brazil
| | | | - Eduardo Damasceno
- Hospital Santa Helena, Goiânia GO, Brazil
- Hospital Encore, Goiânia GO, Brazil
- Hospital Geral de Goiânia, Goiania GO, Brazil
- Hospital Orion, Goiania GO, Brazil
| | | | - Octávio Marques Pontes-Neto
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Neurociências e Ciências do Comportamento, Ribeirão Preto SP, Brazil
| | - Marina Teixeira Ramalho Pereira Dalio
- Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Centro de Cirurgia de Epilepsia de Ribeirão Preto, Ribeirão Preto SP, Brazil
| | - Millene Rodrigues Camilo
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Neurociências e Ciências do Comportamento, Ribeirão Preto SP, Brazil
| | | | | | | | | | - Sheila Cristina Ouriques Martins
- Rede Brasil AVC, Porto Alegre RS, Brazil
- Hospital Moinhos de Vento, Departamento de Neurologia, Porto Alegre RS, Brazil
- Hospital de Clínicas de Porto Alegre, Departamento de Neurologia, Porto Alegre RS, Brazil
| |
Collapse
|
27
|
Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2022; 53:e282-e361. [PMID: 35579034 DOI: 10.1161/str.0000000000000407] [Citation(s) in RCA: 305] [Impact Index Per Article: 152.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - William J Mack
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison
| | | | | | - Ilana M Ruff
- AHA Stroke Council Stroke Performance Measures Oversight Committee liaison
| | | | | | | | - Kevin N Sheth
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison.,AAN representative
| | | | | | | |
Collapse
|
28
|
Lobo Chaves MA, Gittins M, Bray B, Vail A, Smith CJ. The Timing of Stroke Care Processes and Development of Stroke Associated Pneumonia: A National Registry Cohort Study. Front Neurol 2022; 13:875893. [PMID: 35493828 PMCID: PMC9043446 DOI: 10.3389/fneur.2022.875893] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 03/23/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction Timely stroke care can result in significant improvements in stroke recovery. However, little is known about how stroke care processes relate to complications such as the development of stroke associated pneumonia (SAP). Here we investigated associations between stroke care processes, their timing and development of SAP. Methods We obtained patient-level data from the Sentinel Stroke National Audit Programme for all confirmed strokes between 1st April 2013 and 31st December 2018. SAP was identified if new antibiotic initiation for pneumonia occurred within the first 7 days of admission. Time to key stroke care processes in the pre-hospital, hyperacute and acute phase were investigated. A mixed effects logistic regression model estimated the association between SAP [Odds ratios (OR) with 95% CI] and each process of care after controlling for pre-determined confounders such as age, stroke severity and comorbidities. Results SAP was identified in 8.5% of 413,133 patients in 169 stroke units. A long time to arrival at a stroke unit after symptom onset or time last seen well [OR (95% CI) = 1.29 (1.23–1.35)], from admission to assessment by a stroke specialist [1.10 (1.06–1.14)] and from admission to assessment by a physiotherapist [1.16 (1.12–1.21)] were all independently associated with SAP. Short door to needle times were associated with lower odds of SAP [0.90 (0.83–0.97)]. Conclusion Times from stroke onset and admission to certain key stroke care processes were associated with SAP. Understanding how timing of these care processes relate to SAP may enable development of preventive interventions to reduce antibiotic use and improve clinical outcomes.
Collapse
Affiliation(s)
- Marco Antonio Lobo Chaves
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
- Geoffrey Jefferson Brain Research Centre, Manchester, United Kingdom
- *Correspondence: Marco Antonio Lobo Chaves
| | - Matthew Gittins
- Geoffrey Jefferson Brain Research Centre, Manchester, United Kingdom
- Centre for Biostatistics, University of Manchester, Manchester, United Kingdom
| | - Benjamin Bray
- School of Population Health and Environmental Sciences, King's College London, London, United Kingdom
| | - Andy Vail
- Geoffrey Jefferson Brain Research Centre, Manchester, United Kingdom
- Centre for Biostatistics, University of Manchester, Manchester, United Kingdom
| | - Craig J. Smith
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
- Geoffrey Jefferson Brain Research Centre, Manchester, United Kingdom
- Manchester Centre for Clinical Neurosciences, Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Salford Royal National Health Service (NHS) Foundation Trust, Salford, United Kingdom
| |
Collapse
|
29
|
Kim SY, Kimmelman J. Practical steps to identifying the research risk of pragmatic trials. Clin Trials 2022; 19:211-216. [PMID: 35348360 DOI: 10.1177/17407745211063476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pragmatic randomized clinical trials that compare two or more purportedly "within the standard of care" interventions attempt to provide real-world evidence for policy and practice decisions. There is considerable debate regarding their research risk status, which in turn could lead to debates about appropriate consent requirements. Yet no practical guidance for identifying the research risks of pragmatic randomized clinical trials is available. METHODS We developed a practical, four-step process for identifying and evaluating the research risk of pragmatic trials that can be applied to those pragmatic randomized clinical trials that compare two or more "standard of care" or "accepted" interventions. RESULTS Using a variety of examples of standard of care pragmatic randomized clinical trials (ranging from trials comparing: insurance coverage conditions, patient reminders for health screens, intensive care unit procedures, post-stroke interventions, and drugs for life-threatening conditions), we illustrate in a four-step process how any pragmatic randomized clinical trial purportedly comparing standard interventions can be evaluated for their research risks. CONCLUSION Although determining the risk status of a standard of care pragmatic randomized clinical trial is only one necessary element in the ethical oversight of such pragmatic randomized clinical trials, it is a central element. Our four-step process of pragmatic randomized clinical trial risk determination provides a practical, transparent, and systematic approach with likely low risk of bias.
Collapse
Affiliation(s)
- Scott Yh Kim
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Jonathan Kimmelman
- Division of Ethics and Policy, School of Population and Global Health, McGill University, Montreal, QC, Canada
| |
Collapse
|
30
|
Riberholt CG, Olsen MH, Berg RMG, Møller K. Mobilising patients with severe acquired brain injury in intensive care (MAWERIC) - Protocol for a randomised cross-over trial. Contemp Clin Trials 2022; 116:106738. [PMID: 35331944 DOI: 10.1016/j.cct.2022.106738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 02/21/2022] [Accepted: 03/17/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION In the early phase after severe brain injury, patients are often bedridden in an attempt to control intracranial homeostasis; however, prolonged immobilisation may trigger complications. There is limited knowledge about the physiological effects of mobilisation in this early phase. OBJECTIVE To investigate changes in brain tissue oxygen tension when patients are mobilised using a Sara Combilizer® in the early phase after severe brain injury, in a randomised cross-over design. METHODS Patients with traumatic brain injury, subarachnoid haemorrhage or intracranial haematoma, will be randomised to early mobilisation or rest (no mobilisation = control) on the first day that the patient is deemed to be fit for mobilisation, and the opposite on the next day. On both days, patients will undergo continuous multimodal monitoring measuring brain tissue oxygen tension (primary outcome), invasive blood pressure, heart rate, middle cerebral artery blood flow velocity by transcranial Doppler ultrasound, intracranial pressure, and microdialysis markers of cerebral oxidative metabolism. DISCUSSION Intensive care unit patients with acute brain injury are frequently immobilised in the early phase after the ictus. The optimal timing and intensity of mobilisation is unknown. The present study attempts to establish if early mobilisation is safe with respect to intracranial homeostasis. Protocol version 1.1. Date: 19.02.2022. Ethical registration: H-21002728; approved on August 11, 2021. GDPR registration: P-2021 - 105; approved on February 10, 2021. CLINICALTRIALS govidentifier:NCT05038930; approved on September 8, 2021. Electronic case report file: REDCap-database; created on August 13, 2021.
Collapse
Affiliation(s)
- Christian Gunge Riberholt
- Department of Neurorehabilitation, Traumatic Brain Injury, The Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Denmark; Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Denmark.
| | - Markus Harboe Olsen
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ronan M G Berg
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital, Rigshospitalet, Denmark; Centre for Physical Activity Research, Copenhagen University Hospital, Rigshospitalet, Denmark; Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, United Kingdom
| | - Kirsten Møller
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
31
|
Prust ML, Nutakki A, Habanyama G, Chishimba L, Chomba M, Mataa M, Yumbe K, Zimba S, Gottesman RF, Bahouth MN, Saylor DR. Aspiration Pneumonia in Adults Hospitalized With Stroke at a Large Academic Hospital in Zambia. Neurol Clin Pract 2022; 11:e840-e847. [PMID: 34992967 DOI: 10.1212/cpj.0000000000001111] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 05/06/2021] [Indexed: 01/19/2023]
Abstract
Background and Objectives Preventing complications of stroke such as poststroke aspiration pneumonia (PSAP) may improve stroke outcomes in resource-limited settings. We investigated the incidence and associated mortality of PSAP in Zambia. Methods We conducted a prospective cohort study of adults with stroke at University Teaching Hospital (Lusaka, Zambia) between December 2019 and March 2020. NIH Stroke Scale, Glasgow Coma Scale, and Modified Rankin Scale scores and 9 indicators of possible PSAP were collected serially over each participant's admission. PSAP was defined as ≥4 indicators present, and possible PSAP as 2%-3% present. T tests and χ2 tests were used to compare clinical parameters across PSAP groups. Logistic regression was used to assess the relative effects of age, sex, PSAP status, and initial stroke severity on inpatient mortality. Results We enrolled 125 participants. Mean age was 60 ± 16 years, 61% were female, 55% of strokes were ischemic, and the baseline NIH Stroke Scale score was 19.7 ± 8.7. Thirty-eight (30%) had PSAP, and 32 (26%) had possible PSAP. PSAP was associated with older age and more adverse stroke severity scores. Fifty-nine percent of participants with PSAP died compared with 39% with possible PSAP and 8% with no PSAP. PSAP status independently predicted inpatient mortality after controlling for age, sex, and initial stroke severity. Swallow screening was not performed for any participant. Discussion PSAP is common and life threatening in Zambia, especially among older participants with severe stroke presentations. PSAP was associated with significantly increased mortality independent of initial stroke severity, suggesting that interventions to mitigate PSAP may improve stroke outcomes in Zambia and other resource-limited settings.
Collapse
Affiliation(s)
- Morgan L Prust
- Department of Neurology (MLP), Division of Neurocritical Care, Columbia University Medical Center, New York, NY; Rush University Medical College (AN), Chicago, IL; Department of Medicine (GH, LC, MC, MM, DRS), University of Zambia School of Medicine, Lusaka; Department of Medicine (KY, SZ, DRS), University Teaching Hospital, University of Zambia, Lusaka; and Department of Neurology (RFG, MNB, DRS), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aparna Nutakki
- Department of Neurology (MLP), Division of Neurocritical Care, Columbia University Medical Center, New York, NY; Rush University Medical College (AN), Chicago, IL; Department of Medicine (GH, LC, MC, MM, DRS), University of Zambia School of Medicine, Lusaka; Department of Medicine (KY, SZ, DRS), University Teaching Hospital, University of Zambia, Lusaka; and Department of Neurology (RFG, MNB, DRS), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gloria Habanyama
- Department of Neurology (MLP), Division of Neurocritical Care, Columbia University Medical Center, New York, NY; Rush University Medical College (AN), Chicago, IL; Department of Medicine (GH, LC, MC, MM, DRS), University of Zambia School of Medicine, Lusaka; Department of Medicine (KY, SZ, DRS), University Teaching Hospital, University of Zambia, Lusaka; and Department of Neurology (RFG, MNB, DRS), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lorraine Chishimba
- Department of Neurology (MLP), Division of Neurocritical Care, Columbia University Medical Center, New York, NY; Rush University Medical College (AN), Chicago, IL; Department of Medicine (GH, LC, MC, MM, DRS), University of Zambia School of Medicine, Lusaka; Department of Medicine (KY, SZ, DRS), University Teaching Hospital, University of Zambia, Lusaka; and Department of Neurology (RFG, MNB, DRS), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mashina Chomba
- Department of Neurology (MLP), Division of Neurocritical Care, Columbia University Medical Center, New York, NY; Rush University Medical College (AN), Chicago, IL; Department of Medicine (GH, LC, MC, MM, DRS), University of Zambia School of Medicine, Lusaka; Department of Medicine (KY, SZ, DRS), University Teaching Hospital, University of Zambia, Lusaka; and Department of Neurology (RFG, MNB, DRS), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Moses Mataa
- Department of Neurology (MLP), Division of Neurocritical Care, Columbia University Medical Center, New York, NY; Rush University Medical College (AN), Chicago, IL; Department of Medicine (GH, LC, MC, MM, DRS), University of Zambia School of Medicine, Lusaka; Department of Medicine (KY, SZ, DRS), University Teaching Hospital, University of Zambia, Lusaka; and Department of Neurology (RFG, MNB, DRS), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kunda Yumbe
- Department of Neurology (MLP), Division of Neurocritical Care, Columbia University Medical Center, New York, NY; Rush University Medical College (AN), Chicago, IL; Department of Medicine (GH, LC, MC, MM, DRS), University of Zambia School of Medicine, Lusaka; Department of Medicine (KY, SZ, DRS), University Teaching Hospital, University of Zambia, Lusaka; and Department of Neurology (RFG, MNB, DRS), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stanley Zimba
- Department of Neurology (MLP), Division of Neurocritical Care, Columbia University Medical Center, New York, NY; Rush University Medical College (AN), Chicago, IL; Department of Medicine (GH, LC, MC, MM, DRS), University of Zambia School of Medicine, Lusaka; Department of Medicine (KY, SZ, DRS), University Teaching Hospital, University of Zambia, Lusaka; and Department of Neurology (RFG, MNB, DRS), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rebecca F Gottesman
- Department of Neurology (MLP), Division of Neurocritical Care, Columbia University Medical Center, New York, NY; Rush University Medical College (AN), Chicago, IL; Department of Medicine (GH, LC, MC, MM, DRS), University of Zambia School of Medicine, Lusaka; Department of Medicine (KY, SZ, DRS), University Teaching Hospital, University of Zambia, Lusaka; and Department of Neurology (RFG, MNB, DRS), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mona N Bahouth
- Department of Neurology (MLP), Division of Neurocritical Care, Columbia University Medical Center, New York, NY; Rush University Medical College (AN), Chicago, IL; Department of Medicine (GH, LC, MC, MM, DRS), University of Zambia School of Medicine, Lusaka; Department of Medicine (KY, SZ, DRS), University Teaching Hospital, University of Zambia, Lusaka; and Department of Neurology (RFG, MNB, DRS), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Deanna R Saylor
- Department of Neurology (MLP), Division of Neurocritical Care, Columbia University Medical Center, New York, NY; Rush University Medical College (AN), Chicago, IL; Department of Medicine (GH, LC, MC, MM, DRS), University of Zambia School of Medicine, Lusaka; Department of Medicine (KY, SZ, DRS), University Teaching Hospital, University of Zambia, Lusaka; and Department of Neurology (RFG, MNB, DRS), Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
32
|
Tatlisumak T, Putaala J. General Stroke Management and Stroke Units. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00055-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
33
|
Picard JM, Schmidt C, Sheth KN, Bösel J. Critical Care of the Patient With Acute Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00056-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
34
|
Zhao D, Yao C. Pragmatic Clinical Studies: An Emerging Clinical Research Discipline for Improving Evidence-Based Practice of Cardiovascular Diseases in Asia. Korean Circ J 2022; 52:401-413. [PMID: 35656900 PMCID: PMC9160648 DOI: 10.4070/kcj.2022.0100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 04/13/2022] [Indexed: 11/11/2022] Open
Abstract
Pragmatic clinical studies, as an emerging clinical research discipline, include a wide range of studies that are largely embedded with routine clinical practice aiming to evaluate comparative effectiveness and safety of different clinical intervention strategies. In this review, we described the evolution of the conceptual framework of pragmatic clinical studies, shared perspectives on the importance of pragmatic clinical studies for cardiovascular diseases as a complement to conventional randomized controlled trials, as well as highlighted the specific importance of pragmatic clinical research in improving evidence-based practice for cardiovascular disease managements in Asia. Pragmatic clinical studies, an emerging clinical research discipline, include a wide range of studies that are largely embedded with routine clinical practice and aim to evaluate the comparative effectiveness and safety of different clinical intervention strategies. Increased availability and quality of electronic medical/health records drives the development of pragmatic clinical studies. In this review, we describe evolution of the conceptual framework of pragmatic clinical studies and share perspectives on the importance of pragmatic clinical studies in evidence-based practice for cardiovascular diseases, as a complement to conventional randomized controlled trials. We also highlight specific needs of pragmatic clinical studies in improving evidence-based practice for cardiovascular disease in Asian countries. The main challenges of pragmatic clinical studies are discussed briefly in this review.
Collapse
Affiliation(s)
- Dong Zhao
- Capital Medical University Beijing Anzhen Hospital-Beijing Institute of Heart, Lung & Blood Vessel Diseases, Beijing, China
| | - Chen Yao
- Peking University Clinical Research Institute. Peking University First Hospital, Beijing, China
| |
Collapse
|
35
|
Song L, Hu X, Ma L, Chen X, Ouyang M, Billot L, Li Q, Muñoz-Venturelli P, Abanto C, Pontes-Neto OM, Antonio A, Wasay M, Silva AD, Thang NH, Pandian JD, Wahab KW, You C, Anderson CS. INTEnsive care bundle with blood pressure reduction in acute cerebral hemorrhage trial (INTERACT3): study protocol for a pragmatic stepped-wedge cluster-randomized controlled trial. Trials 2021; 22:943. [PMID: 34930428 PMCID: PMC8686093 DOI: 10.1186/s13063-021-05881-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 10/08/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Early intensive blood pressure (BP) lowering remains the most promising treatment for acute intracerebral hemorrhage (ICH), despite discordant results between clinical trials and potential variation in the treatment effects by approach to control BP. As the third in a series of clinical trials on this topic, the INTEnsive care bundle with blood pressure Reduction in Acute Cerebral hemorrhage Trial (INTERACT3) aims to determine the effectiveness of a goal-directed care bundle protocol of early physiological control (intensive BP lowering, glycemic control, and pyrexia treatment) and reversal of anticoagulation, in acute ICH. METHODS INTERACT3 is a pragmatic, international, multicenter, stepped-wedge (4 phases/3 steps), cluster-randomized controlled trial to determine the effectiveness of a multifaceted care package in adult (age ≥ 18 years) patients (target 8360) with acute ICH (< 6 h of onset) recruited from 110 hospitals (average of 19 consecutive patients per phase) in low- and middle-income countries. After a control phase, each hospital implements the intervention (intensive BP lowering, target systolic < 140 mmHg; glucose control, target 6.1-7.8 mmol/L and 7.8-10.0 mmol/L in those without and with diabetes mellitus, respectively; anti-pyrexia treatment to target body temperature ≤ 37.5 °C; and reversal of anticoagulation, target international normalized ratio < 1.5 within 1 h). Information will be obtained on demographic and baseline clinical characteristics, in-hospital management, and 7-day outcomes. Central trained blinded assessors will conduct telephone interviews to assess physical function and health-related quality of life at 6 months. The primary outcome is the modified Rankin scale (mRS) at 6 months analyzed using ordinal logistic regression. The sample size of 8360 subjects provides 90% power (α = 0.05) to detect a 5.6% absolute improvement (shift) in the primary outcome of the intervention versus control standard care, with various assumptions. DISCUSSION As the largest clinical trial in acute ICH, INTERACT3 is on schedule to provide an assessment of the effectiveness of a widely applicable goal-directed care bundle for a serious condition in which a clearly proven treatment has yet to be established. TRIAL REGISTRATION ClinicalTrials.gov NCT03209258. Registered on 1 July 2017. Chinese Trial Registry ChiCTR-IOC-17011787. Registered on 28 June 2017.
Collapse
Affiliation(s)
- Lili Song
- The George Institute China, Peking University Health Science Center, Room 011, Unit 2, Tayuan Diplomatic Office Building, No. 14 Liangmahe Nan Lu, Chaoyang District, Beijing, China
- The George Institute for Global Health, Faculty of Medicine, UNSW, Level 5, King Street, Newtown, NSW, 2042, Australia
| | - Xin Hu
- Department of Neurosurgery, West China Hospital, Sichuan University, NO.43, St. Guoxuexiang, Chengdu, China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, NO.43, St. Guoxuexiang, Chengdu, China
| | - Xiaoying Chen
- The George Institute for Global Health, Faculty of Medicine, UNSW, Level 5, King Street, Newtown, NSW, 2042, Australia
| | - Menglu Ouyang
- The George Institute China, Peking University Health Science Center, Room 011, Unit 2, Tayuan Diplomatic Office Building, No. 14 Liangmahe Nan Lu, Chaoyang District, Beijing, China
- The George Institute for Global Health, Faculty of Medicine, UNSW, Level 5, King Street, Newtown, NSW, 2042, Australia
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine, UNSW, Level 5, King Street, Newtown, NSW, 2042, Australia
| | - Qiang Li
- The George Institute for Global Health, Faculty of Medicine, UNSW, Level 5, King Street, Newtown, NSW, 2042, Australia
| | - Paula Muñoz-Venturelli
- The George Institute for Global Health, Faculty of Medicine, UNSW, Level 5, King Street, Newtown, NSW, 2042, Australia
- Clinical Research Center, Faculty of Medicine, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Carlos Abanto
- The Cerebrovascular Disease Research Center, National Institute of Neurological Sciences, Cercado de Lima, Peru
| | | | - Arauz Antonio
- Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suarez, Mexico City, Mexico
| | - Mohammad Wasay
- Department of Medicine, The Aga Khan University, Karachi, Pakistan
| | - Asita de Silva
- Clinical Trials Unit, Faculty of Medicine, University of Kelaniya, Colombo, Sri Lanka
| | | | | | - Kolawole Wasiu Wahab
- Department of Medicine, University of Ilorin & University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, NO.43, St. Guoxuexiang, Chengdu, China.
| | - Craig S Anderson
- The George Institute China, Peking University Health Science Center, Room 011, Unit 2, Tayuan Diplomatic Office Building, No. 14 Liangmahe Nan Lu, Chaoyang District, Beijing, China.
- The George Institute for Global Health, Faculty of Medicine, UNSW, Level 5, King Street, Newtown, NSW, 2042, Australia.
- Department of Neurosurgery, West China Hospital, Sichuan University, NO.43, St. Guoxuexiang, Chengdu, China.
- Sydney Medical School, University of Sydney, Sydney, Australia.
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia.
| |
Collapse
|
36
|
Casey JD, Courtright KR, Rice TW, Semler MW. What can a learning healthcare system teach us about improving outcomes? Curr Opin Crit Care 2021; 27:527-536. [PMID: 34232148 PMCID: PMC8744083 DOI: 10.1097/mcc.0000000000000857] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW This review describes the learning healthcare system paradigm, recent examples, and future directions. Patients, clinicians, and health systems frequently encounter decisions between available treatments, technologies, and healthcare delivery methods with little or no evidence about the comparative effectiveness and safety of the available options. Learning healthcare systems endeavor to recognize such knowledge gaps, integrate comparative effectiveness research - including clinical trials - into clinical care to address the knowledge gaps, and seamlessly implement the results into practice to improve care and patient outcomes. RECENT FINDINGS Recent studies comparing the effectiveness of diagnostic tests and treatments, using information technology to identify patients likely to experience an outcome or benefit from an intervention, and evaluating models of healthcare delivery have demonstrated how a learning healthcare system approach can reduce arbitrary variation in care, decrease cost, and improve patient outcomes. SUMMARY Learning healthcare systems have the potential to answer questions of importance to patients, clinicians, and health system leaders, improve efficiency of healthcare delivery, and improve patient outcomes. Achieving this goal will require realignment of the culture around clinical care, institutional and federal investment, expanded stakeholder engagement, tailored ethical and regulatory guidance, and methodologic advances in information technology and biostatistics.
Collapse
Affiliation(s)
- Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Katherine R Courtright
- Division of Pulmonary, Allergy, and Critical Care, Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
37
|
Langhorne P. The Stroke Unit Story: Where Have We Been and Where Are We Going? Cerebrovasc Dis 2021; 50:636-643. [PMID: 34547746 DOI: 10.1159/000518934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 06/17/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The concept of stroke unit care has been discussed for over 50 years, but it is only in the last 25 years that clear evidence of its effectiveness has emerged to inform these discussions. SUMMARY This review outlines the history of the concept of stroke units to improve recovery after stroke and their evaluation in clinical trials. It describes the first systematic review of stroke unit trials published in 1993, the establishment of a collaborative research group (the Stroke Unit Trialists' Collaboration), the subsequent analyses and updates of the evidence base, and the efforts to implement stroke unit care in routine settings. The final section considers some of the remaining challenges in this area of research and clinical practice. Key Messages: Good quality evidence confirms that stroke patients who are looked after in a stroke unit are more likely to survive and be independent and living at home 1 year after their stroke. The apparent benefits are independent of patient age, sex, stroke type, or initial stroke severity. The benefits are most obvious in units based in a discrete ward (stroke ward). The current challenges include integrating effective stroke units with more recent systems to deliver hyper-acute stroke interventions and implementing stroke units in lower resource regions.
Collapse
Affiliation(s)
- Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, Academic Section of Geriatric Medicine, University of Glasgow, Glasgow, United Kingdom
| |
Collapse
|
38
|
Beishon LC, Minhas JS. Cerebral Autoregulation and Neurovascular Coupling in Acute and Chronic Stroke. Front Neurol 2021; 12:720770. [PMID: 34539560 PMCID: PMC8446264 DOI: 10.3389/fneur.2021.720770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/11/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lucy C. Beishon
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Jatinder S. Minhas
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester, United Kingdom
| |
Collapse
|
39
|
Wang J, Cao J, Zhang S, Ahn C. A flexible sample size solution for longitudinal and crossover cluster randomized trials with continuous outcomes. Contemp Clin Trials 2021; 109:106543. [PMID: 34450326 DOI: 10.1016/j.cct.2021.106543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/23/2021] [Accepted: 08/18/2021] [Indexed: 10/20/2022]
Abstract
Longitudinal cluster randomized trial (LCRT) and crossover cluster randomized trial (CCRT) are two variants of cluster randomized trials. In LCRTs, clusters of subjects are randomly assigned to different treatment groups and each subject has repeated measurements over the study period. In CCRTs, clusters of subjects are randomly assigned to different sequences. Within each sequence, clusters receive all treatments in a particular order. Both LCRTs and CCRTs lead to complicated correlation structures that involve longitudinal and intracluster correlations. Generalized linear mixed model (GLMM) and generalized estimating equation (GEE) approaches have been frequently employed in data analysis and sample size estimation. In this study we propose closed-form sample size and power formulas for LCRTs and CCRTs based on the GEE approach. These formulas are flexible to incorporate unbalanced randomization, different missing patterns, arbitrary correlation structures, and randomly varying cluster sizes, providing a practical yet robust sample size solution. Simulation studies show that the proposed methods achieve good performance with empirical powers and type I errors close to their nominal values.
Collapse
Affiliation(s)
- Jijia Wang
- Department of Applied Clinical Research, UT Southwestern Medical Center, Dallas, TX, United States of America
| | - Jing Cao
- Department of Statistical Science, Southern Methodist University, Dallas, TX, United States of America
| | - Song Zhang
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, United States of America.
| | - Chul Ahn
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, United States of America
| |
Collapse
|
40
|
Molina-Fuentes MF, Neumann R, Behringer W, Franz M, Schulze PC, Witte OW, Günther A, Klingner C, Lehmkuhl L, Steiniger B, Teichgräber U, Rod JE, Mayer TE. Feasibility of the Big 5-Jena eCS Protocol : First Experience Implementing a New Extended CT Protocol in the Initial Diagnostics of Ischemic Stroke. Clin Neuroradiol 2021; 31:901-909. [PMID: 34379134 PMCID: PMC8356684 DOI: 10.1007/s00062-021-01058-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 06/18/2021] [Indexed: 10/25/2022]
Abstract
PURPOSE The most common protocols in the initial diagnostic of acute ischemic stroke do not assess cardiogenic or aortic causes of embolism. These are usually evaluated later by transthoracic (TTE) or transesophageal (TEE) echocardiography. This study aimed to evaluate the feasibility of a diagnostic tool for thoracic cardiovascular thrombi according to the first experience with a new extended cardio-stroke protocol (Big 5-Jena eCS protocol) in acute stroke patients. METHODS Retrospective analyses of the tomography scans database of the Jena University Hospital were performed. We included a total of 67 patients in the feasibility analyses, based on the evaluation of three outcomes. RESULTS Primary outcome: the Big 5-Jena eCS protocol was able to detect thoracic cardiovascular thrombi in a total of 20 patients in different locations including the arch of the aorta, the aortic valve, the left atrium, the left atrial appendage, the left ventricle, and the pulmonary arteries. Secondary outcome: implementating the protocol did not result in a significant elevation of the radiation exposure compared to traditional protocols. Tertiary outcome: the new protocol identified seven cases that were considered negative by echocardiography. CONCLUSION The implementation of an extended cardio-stroke protocol is feasible, no significantly time-consuming, acquiring assessable imaging, and maintaining radiation exposure acceptable. The Big 5-Jena eCS protocol was also able to detect some thrombi not reported by TTE or TEE; however, due to our data's explorative character, a conclusive comparison with cardiac ultrasound is not possible. A prospective pilot study and clinical trials should be conducted to assess the diagnostic accuracy of this protocol compared to echocardiography and determine the potential impact on diagnostic and treatment decisions.
Collapse
Affiliation(s)
- Moisés F Molina-Fuentes
- Department of Neuroradiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany. .,Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany. .,Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany.
| | - Rotraud Neumann
- Department of Neuroradiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany.,Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Wilhelm Behringer
- Emergency Department, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Marcus Franz
- Department of Internal Medicine, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - P Christian Schulze
- Department of Internal Medicine, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Otto W Witte
- Hans Berger Department of Neurology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Albrecht Günther
- Hans Berger Department of Neurology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Carsten Klingner
- Hans Berger Department of Neurology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Lukas Lehmkuhl
- Clinic for Radiology, Rhön-Klinikum Campus Bad Neustadt, Bad Neustadt a. d. Saale, Germany
| | - Beatrice Steiniger
- Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Ulf Teichgräber
- Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - J E Rod
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Thomas E Mayer
- Department of Neuroradiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany.,Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| |
Collapse
|
41
|
Impact of Head-of-Bed Posture on Brain Oxygenation in Patients with Acute Brain Injury: A Prospective Cohort Study. Neurocrit Care 2021; 35:662-668. [PMID: 34312789 PMCID: PMC8312355 DOI: 10.1007/s12028-021-01240-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 03/20/2021] [Indexed: 12/31/2022]
Abstract
Background Therapeutic head positioning plays a role in the management of patients with acute brain injury. Although intracranial pressure (ICP) is typically lower in an upright posture than in a flat position, limited data exist concerning the effect of upright positioning on brain oxygenation and circulation. We sought to determine the impact of supine (0°) and semirecumbent (15° and 30°) postures on ICP, brain oxygenation, and brain circulation. Methods An observational cohort study was conducted between February 2012 and September 2015. Twenty-three patients with severe acute brain injury were successively observed at head elevations of 30°, 15°, and 0°. Postural-induced changes in ICP, cerebral perfusion pressure, brain tissue oxygenation pressure, and transcranial Doppler findings were simultaneously measured during three repeated experiments: 24 h after admission to the intensive care unit (exp1), 24 h later (exp2), and 96 h later (exp3). Cerebral perfusion pressure, arterial blood gases, hemoglobin content, and body temperature remained unchanged during the three experiments. Results Using linear random-slope mixed models, we found that during the early phase of acute brain injury (exp1), lowering the head posture from 30° to 15°, and then to 0°, was associated with a gradual mean ICP increase of 2.6 mm Hg (1.4–3.7 mm Hg; P < 0.001); and from 30° to 0°, an increase of 7.4 mm Hg (6.3–8.6 mm Hg; P < 0.001). Furthermore, brain tissue oxygenation pressure and mean blood flow velocity improved when the head posture was lowered from 30° to 0° by 1.2 mm Hg (0.2–2.3 mm Hg) and 4.1 cm/s (0.0–8.2 cm/s), respectively (both P < 0.05). Conclusions Changing the positioning of stable patients with acute brain injury resulted in opposite changes of ICP versus brain oxygenation and circulation. This information supports the concept of an individualized approach to head positioning that is based on the multimodal monitoring of brain parameters.
Collapse
|
42
|
Ouyang M, Roffe C, Billot L, Song L, Wang X, Muñoz-Venturelli P, Lavados PM, Robinson T, Middleton S, Olavarría VV, Watkins CL, Lee TH, Brunser AM, Pontes-Neto OM, Hackett ML, Anderson CS. Oxygen desaturation and adverse outcomes in acute stroke: Secondary analysis of the HeadPoST study. Clin Neurol Neurosurg 2021; 207:106796. [PMID: 34246993 DOI: 10.1016/j.clineuro.2021.106796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/29/2021] [Accepted: 07/03/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Uncertainty exists over the prognostic significance of low arterial oxygen saturation (SaO2) in acute stroke. We aimed to determine the strength of association of SaO2 and adverse outcomes among participants of the international Head Positioning in acute Stroke Trial (HeadPoST). METHODS Post-hoc analyzes of HeadPoST, a pragmatic cluster-crossover randomized trial of lying flat versus sitting up head positioning in 11,093 patients (age ≥18 years) with acute stroke at 114 hospitals in 9 countries during 2015-2016. Associations of the lowest recorded SaO2 level, as a continuous measure and as a cut-point for desaturation (SaO2 <93%), in the first 24 h and clinical outcomes of death or dependency (modified Rankin scale [mRS] scores 3-6) and any serious adverse event (SAE) at 90 days, were assessed in generalized linear mixed models adjusted for baseline and in-hospital management confounders. RESULTS There was an inverse J-shaped association between SaO2 and death or dependency, with a nadir for optimal outcome at 96-97%. Patients with SaO2 desaturation were older, and had greater neurological impairment, premorbid disability and cardiorespiratory disease. Desaturation was not clearly associated with death or dependency (adjusted odds ratio [aOR] 1.19, 95% confidence interval [CI] 0.95-1.48) but was with SAEs (aOR 1.34, 95% CI 1.07-1.68), without heterogeneity by head position, cardiac-respiratory comorbidity, or other pre-specified subgroups. CONCLUSIONS Any change in SaO2 outside of 96-97% is associated with poorer outcome after acute stroke. CLINICAL TRIAL REGISTRATION HeadPoST is registered at ClinicalTrials.gov (NCT02162017).
Collapse
Affiliation(s)
- Menglu Ouyang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia; The George Institute China at Peking University Health Science Center, Beijing, China
| | - Christine Roffe
- Stroke Research, School of Medicine, Keele University, Staffordshire, UK
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Lili Song
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia; The George Institute China at Peking University Health Science Center, Beijing, China
| | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Paula Muñoz-Venturelli
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia; Unidad de Neurología Vascular, Servicio de Neurología, Departmento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Chile; Clinical Research Center, Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Pablo M Lavados
- Unidad de Neurología Vascular, Servicio de Neurología, Departmento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Chile
| | - Thompson Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health (Sydney) Australia, Australian Catholic University, Sydney, Australia
| | - Verónica V Olavarría
- Unidad de Neurología Vascular, Servicio de Neurología, Departmento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Chile
| | - Caroline L Watkins
- Faculty of Health and Care, University of Central Lancashire, Preston, Lancashire, UK
| | - Tsong-Hai Lee
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Alejandro M Brunser
- Unidad de Neurología Vascular, Servicio de Neurología, Departmento de Neurología y Psiquiatría, Clínica Alemana de Santiago, Chile
| | - Octavio M Pontes-Neto
- Stroke Service - Neurology Division, Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirão Preto, SP, Brazil
| | - Maree L Hackett
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia; Faculty of Health and Care, University of Central Lancashire, Preston, Lancashire, UK
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia; The George Institute China at Peking University Health Science Center, Beijing, China; Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, Australia; Heart Health Research Center, Beijing, China.
| |
Collapse
|
43
|
Pandian JD, Verma SJ, Arora D, Sharma M, Dhaliwal R, Khatter H, Huilgol R, Sylaja PN, Dhasan A, Renjith V, Pathak A, Pai A, Sharma A, Vaishnav A, Ray B, Khurana D, Mittal G, Kulkarni G, Sebastian I, Roy J, Kumaravelu S, John L, Kate M, Srivastava MV, Kempegowda MB, Borah N, Ramrakhiani N, Rai N, Ojha P, Bhatia R, Das R, Sureshbabu S, Jabeen SA, Bhoi S, Aaron S, Sarma P, Saroja AO, Abraham S, Sharma S, Sulena S, Gorthi S, Nagarjunakonda S, Narayan S, Mathew T, George T, Vijaya P, Huded V, Nambiar V, Reddy YM. INSTRuCT: Protocol, Infrastructure, and Governance. Stroke 2021; 52:e574-e580. [PMID: 34167324 DOI: 10.1161/strokeaha.120.033149] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Very few large scale multicentric stroke clinical trials have been done in India. The Indian Council of Medical Research funded INSTRuCT (Indian Stroke Clinical Trial Network) as a task force project with the objectives to establish a state-of-the-art stroke clinical trial network and to conduct pharmacological and nonpharmacological stroke clinical trials relevant to the nation and globally. The purpose of the article is to enumerate the structure of multicentric stroke network, with emphasis on its scope, challenges and expectations in India. METHODS Multiple expert group meetings were conducted by Indian Council of Medical Research to understand the scope of network to perform stroke clinical trials in the country. Established stroke centers with annual volume of 200 patients with stroke with prior experience of conducting clinical trials were included. Central coordinating center, standard operating procedures, data and safety monitoring board were formed. DISCUSSION In first phase, 2 trials were initiated namely, SPRINT (Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in India) and Ayurveda treatment in the rehabilitation of patients with ischemic stroke in India (RESTORE [Rehabilitation of Ischemic stroke Patients in India: A Randomized controlled trial]). In second phase, 4 trials have been approved. SPRINT trial was the first to be initiated. SPRINT trial randomized first patient on April 28, 2018; recruited 3048 patients with an average of 128.5 per month so far. The first follow-up was completed on May 27, 2019. RESTORE trial randomized first patient on May 22, 2019; recruited 49 patients with an average of 3.7 per month so far. The first follow-up was completed on August 30, 2019. CONCLUSIONS In next 5 years, INSTRuCT will be able to complete high-quality large scale stroke trials which are relevant globally. REGISTRATION URL: http://www.ctri.nic.in/; Unique Identifier: CTRI/2017/05/008507.
Collapse
Affiliation(s)
- Jeyaraj Durai Pandian
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India. (J.D.P., S.J.V., D.A., H.K., R.H., M.K.)
| | - Shweta Jain Verma
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India. (J.D.P., S.J.V., D.A., H.K., R.H., M.K.)
| | - Deepti Arora
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India. (J.D.P., S.J.V., D.A., H.K., R.H., M.K.)
| | - Meenakshi Sharma
- Non-Communicable Diseases Section, Indian Council of Medical Research, New Delhi, India (M.S., R. Dhaliwal)
| | - Rupinder Dhaliwal
- Non-Communicable Diseases Section, Indian Council of Medical Research, New Delhi, India (M.S., R. Dhaliwal)
| | - Himani Khatter
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India. (J.D.P., S.J.V., D.A., H.K., R.H., M.K.)
| | - Rahul Huilgol
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India. (J.D.P., S.J.V., D.A., H.K., R.H., M.K.)
| | - P N Sylaja
- Department of Neurology, Sri Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram, Kerala, India. (P.N.S., A.D., V.R.)
| | - Aneesh Dhasan
- Department of Neurology, Sri Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram, Kerala, India. (P.N.S., A.D., V.R.)
| | - Vishnu Renjith
- Department of Neurology, Sri Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram, Kerala, India. (P.N.S., A.D., V.R.)
| | - Abhishek Pathak
- Department of Neurology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India (A. Pathak)
| | - Aparna Pai
- Department of Neurology, Kasturba Medical College and Hospital, Manipal, Karnataka, India (A. Pai, S.G.)
| | - Arvind Sharma
- Department of Neurology, Zydus Hospital, Ahmedabad, Gujarat, India (A.S.)
| | - Anand Vaishnav
- Vadodara Institute of Neurosciences, Vadodara, Gujarat, India (A.V.)
| | - Biman Ray
- Bangur Institute of Neurosciences, Kolkata, India (B.R.)
| | - Dheeraj Khurana
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India (D.K.)
| | - Gaurav Mittal
- Department of Neurology, St Stephens Hospital, Delhi, India (G.M., I.S., S. Sureshbabu)
| | - Girish Kulkarni
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India (G.K.)
| | - Ivy Sebastian
- Department of Neurology, St Stephens Hospital, Delhi, India (G.M., I.S., S. Sureshbabu)
| | - Jayanta Roy
- Department of Neurology, Institute of Neurosciences, Kolkata, West Bengal, India (J.R.)
| | | | - Lydia John
- Department of Medicine, Baptist Christian Hospital, Tezpur, Assam, India (L.J., S. Abraham)
| | - Mahesh Kate
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India. (J.D.P., S.J.V., D.A., H.K., R.H., M.K.)
| | - M V Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India (M.V.S., R.B.)
| | | | - Nomal Borah
- Department of Neurology, Guwahati Neurological Research Centre, Dispur, India (N.B., R. Das)
| | - Neetu Ramrakhiani
- Department of Neurology, Fortis Escorts Hospital, Jaipur, Rajasthan, India (N. Ramrakhiani)
| | - Nirendra Rai
- Department of Neurology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India (N. Rai)
| | - Pawan Ojha
- Department of Neurology, Grant Government Medical College and Sir J.J. Group of Hospitals College, Mumbai, India (P.O.)
| | - Rohit Bhatia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India (M.V.S., R.B.)
| | - Rupjyoti Das
- Department of Neurology, Guwahati Neurological Research Centre, Dispur, India (N.B., R. Das)
| | - Sachin Sureshbabu
- Department of Neurology, St Stephens Hospital, Delhi, India (G.M., I.S., S. Sureshbabu)
| | - Shaikh Afshan Jabeen
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India (S.A.J.)
| | - Sanjeev Bhoi
- Department of Neurology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India (S.B.,)
| | - Sanjith Aaron
- Department of Neurology, Christian Medical College, Vellore, Tamil Nadu, India (S. Aaron, T.G.)
| | - Prabhakaran Sarma
- Achutha Menon Center for Health Science Studies, Sri Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram, Kerala, India. (P.S.)
| | | | - Sherly Abraham
- Department of Medicine, Baptist Christian Hospital, Tezpur, Assam, India (L.J., S. Abraham)
| | - Sudhir Sharma
- Department of Neurology, Indira Gandhi Medical College & Hospital, Shimla, Himachal Pradesh, India (S. Sharma)
| | - Sulena Sulena
- Department of Neurology, GGS Medical College, Faridkot, Punjab, India (S. Sulena)
| | - Sankar Gorthi
- Department of Neurology, Kasturba Medical College and Hospital, Manipal, Karnataka, India (A. Pai, S.G.)
| | | | - Sunil Narayan
- Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India (S. Narayan)
| | - Thomas Mathew
- Department of Neurology, St John's Medical College, Bangalore, Karnataka, India (T.M.)
| | - Tina George
- Department of Neurology, Christian Medical College, Vellore, Tamil Nadu, India (S. Aaron, T.G.)
| | - Pamidimukkala Vijaya
- Department of Neurology, Lalitha Super Speciality Hospital, Guntur, Andhra Pradesh, India (P.V.)
| | - Vikram Huded
- Department of Neurology, Mazumdar Shaw Medical Centre, Narayana Hrudayalaya, Bangalore, Karnataka, India (V.H.)
| | - Vivek Nambiar
- Department of Neurology, Amrita Institute of Medical Sciences, Kochi, Kerala, India (V.N.)
| | - Y Muralidhar Reddy
- Department of Neurology, CARE Hospital, Hyderabad, Telangana, India (M.R.)
| |
Collapse
|
44
|
Implementing stakeholder engagement to explore alternative models of consent: An example from the PREP-IT trials. Contemp Clin Trials Commun 2021; 22:100787. [PMID: 34195467 PMCID: PMC8239736 DOI: 10.1016/j.conctc.2021.100787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 05/10/2021] [Accepted: 05/16/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Cluster randomized crossover trials are often faced with a dilemma when selecting an optimal model of consent, as the traditional model of obtaining informed consent from participant's before initiating any trial related activities may not be suitable. We describe our experience of engaging patient advisors to identify an optimal model of consent for the PREP-IT trials. This paper also examines surrogate measures of success for the selected model of consent. Methods The PREP-IT program consists of two multi-center cluster randomized crossover trials that engaged patient advisors to determine an optimal model of consent. Patient advisors and stakeholders met regularly and reached consensus on decisions related to the trial design including the model for consent. Patient advisors provided valuable insight on how key decisions on trial design and conduct would be received by participants and the impact these decisions will have. Results Patient advisors, together with stakeholders, reviewed the pros and cons and the requirements for the traditional model of consent, deferred consent, and waiver of consent. Collectively, they agreed upon a deferred consent model, in which patients may be approached for consent after their fracture surgery and prior to data collection. The consent rate in PREP-IT is 80.7%, and 0.67% of participants have withdrawn consent for participation. Discussion Involvement of patient advisors in the development of an optimal model of consent has been successful. Engagement of patient advisors is recommended for other large trials where the traditional model of consent may not be optimal.
Collapse
|
45
|
Strong B, Pudar J, Thrift AG, Howard VJ, Hussain M, Carcel C, de Los Campos G, Reeves MJ. Sex Disparities in Enrollment in Recent Randomized Clinical Trials of Acute Stroke: A Meta-analysis. JAMA Neurol 2021; 78:666-677. [PMID: 33900363 DOI: 10.1001/jamaneurol.2021.0873] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Importance The underenrollment of women in randomized clinical trials represents a threat to the validity of the evidence supporting clinical guidelines and potential disparities in access to novel treatments. Objective To determine whether women were underenrolled in contemporary randomized clinical trials of acute stroke therapies published in 9 major journals after accounting for their representation in underlying stroke populations. Data Sources MEDLINE was searched for acute stroke therapeutic trials published between January 1, 2010, and June 11, 2020. Study Selection Eligible articles reported the results of a phase 2 or 3 randomized clinical trial that enrolled patients with stroke and/or transient ischemic attack and examined a therapeutic intervention initiated within 1 month of onset. Data Extraction Data extraction was performed by 2 independent authors in duplicate. Individual trials were matched to estimates of the proportion of women in underlying stroke populations using the Global Burden of Disease database. Main Outcomes and Measures The primary outcome was the enrollment disparity difference (EDD), the absolute difference between the proportion of trial participants who were women and the proportion of strokes in the underlying disease populations that occurred in women. Random-effects meta-analyses of the EDD were performed, and multivariable metaregression was used to explore the associations of trial eligibility criteria with disparity estimates. Results The search returned 1529 results, and 115 trials (7.5%) met inclusion criteria. Of 121 105 randomized patients for whom sex was reported, 52 522 (43.4%) were women. The random-effects summary EDD was -0.053 (95% CI, -0.065 to -0.040), indicating that women were underenrolled by 5.3 percentage points. This disparity persisted across virtually all geographic regions, intervention types, and stroke types, apart from subarachnoid hemorrhage (0.117 [95% CI, 0.084 to 0.150]). When subarachnoid hemorrhage trials were excluded, the summary EDD was -0.067 (95% CI, -0.078 to -0.057). In the multivariable metaregression analysis, an upper age limit of 80 years as an eligibility criterion was associated with a 6-percentage point decrease in the enrollment of women. Conclusions and Relevance Further research is needed to understand the causes of the underenrollment of women in acute stroke trials. However, to maximize representation, investigators should avoid imposing age limits on enrollment.
Collapse
Affiliation(s)
- Brent Strong
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Julia Pudar
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Amanda G Thrift
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Virginia J Howard
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham
| | - Murtaza Hussain
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Cheryl Carcel
- George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Gustavo de Los Campos
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing
| |
Collapse
|
46
|
Abstract
This article aims to provide a comprehensive overview of key advances on various aspects of hyper-acute management of acute ischaemic stroke. These include neuroimaging, acute stroke unit care, management of blood pressure, reperfusion therapy including intravenous thrombolysis, mechanical thrombectomy and decompressive hemicraniectomy for malignant stroke syndrome. The challenge ahead is to ensure these evidence-based treatments are now being delivered and implemented to maximise the benefits across the population.
Collapse
Affiliation(s)
| | | | - Jonathan Birns
- St Thomas' Hospital, London, UK and deputy head of School of Medicine, Health Education England, London, UK
| |
Collapse
|
47
|
Nogueira RC, Beishon L, Bor-Seng-Shu E, Panerai RB, Robinson TG. Cerebral Autoregulation in Ischemic Stroke: From Pathophysiology to Clinical Concepts. Brain Sci 2021; 11:511. [PMID: 33923721 PMCID: PMC8073938 DOI: 10.3390/brainsci11040511] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/02/2021] [Accepted: 04/09/2021] [Indexed: 11/17/2022] Open
Abstract
Ischemic stroke (IS) is one of the most impacting diseases in the world. In the last decades, new therapies have been introduced to improve outcomes after IS, most of them aiming for recanalization of the occluded vessel. However, despite this advance, there are still a large number of patients that remain disabled. One interesting possible therapeutic approach would be interventions guided by cerebral hemodynamic parameters such as dynamic cerebral autoregulation (dCA). Supportive hemodynamic therapies aiming to optimize perfusion in the ischemic area could protect the brain and may even extend the therapeutic window for reperfusion therapies. However, the knowledge of how to implement these therapies in the complex pathophysiology of brain ischemia is challenging and still not fully understood. This comprehensive review will focus on the state of the art in this promising area with emphasis on the following aspects: (1) pathophysiology of CA in the ischemic process; (2) methodology used to evaluate CA in IS; (3) CA studies in IS patients; (4) potential non-reperfusion therapies for IS patients based on the CA concept; and (5) the impact of common IS-associated comorbidities and phenotype on CA status. The review also points to the gaps existing in the current research to be further explored in future trials.
Collapse
Affiliation(s)
- Ricardo C. Nogueira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, São Paulo 01246-904, Brazil;
- Department of Neurology, Hospital Nove de Julho, São Paulo 01409-002, Brazil
| | - Lucy Beishon
- Cerebral Haemodynamics in Ageing and Stroke Medicine Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK; (L.B.); (R.B.P.); (T.G.R.)
| | - Edson Bor-Seng-Shu
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, São Paulo 01246-904, Brazil;
| | - Ronney B. Panerai
- Cerebral Haemodynamics in Ageing and Stroke Medicine Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK; (L.B.); (R.B.P.); (T.G.R.)
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, University of Leicester, Leicester LE5 4PW, UK
| | - Thompson G. Robinson
- Cerebral Haemodynamics in Ageing and Stroke Medicine Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK; (L.B.); (R.B.P.); (T.G.R.)
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, University of Leicester, Leicester LE5 4PW, UK
| |
Collapse
|
48
|
Chaves ML, Gittins M, Bray B, Vail A, Smith CJ. Variation of stroke-associated pneumonia in stroke units across England and Wales: A registry-based cohort study. Int J Stroke 2021; 17:155-162. [PMID: 33724106 PMCID: PMC8821977 DOI: 10.1177/17474930211006297] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Pneumonia is common in stroke patients and is associated with worse clinical outcomes. Prevalence of stroke-associated pneumonia varies between studies, and reasons for this variation remain unclear. We aimed to describe the variation of observed stroke-associated pneumonia in England and Wales and explore the influence of patient baseline characteristics on this variation. Methods Patient data were obtained from the Sentinel Stroke National Audit Programme for all confirmed strokes between 1 April 2013 and 31 December 2018. Stroke-associated pneumonia was defined by new antibiotic initiation for pneumonia within the first seven days of admission. The probability of stroke-associated pneumonia occurrence within stroke units was estimated and compared using a multilevel mixed model with and without adjustment for patient-level characteristics at admission. Results Of the 413,133 patients included, median National Institutes of Health Stroke Scale was 4 (IQR: 2–10) and 42.3% were aged over 80 years. Stroke-associated pneumonia was identified in 8.5% of patients. The median within stroke unit stroke-associated pneumonia prevalence was 8.5% (IQR: 6.1–11.5%) with a maximum of 21.4%. The mean and variance of the predicted stroke-associated pneumonia probability across stroke units decreased from 0.08 (0.68) to 0.05 (0.63) when adjusting for patient admission characteristics. This difference in the variance suggests that clinical characteristics account for 5% of the observed variation in stroke-associated pneumonia between units. Conclusions Patient-level clinical characteristics contributed minimally to the observed variation of stroke-associated pneumonia between stroke units. Additional explanations for the observed variation in stroke-associated pneumonia need to be explored which could reduce variation in antibiotic use for stroke patients.
Collapse
Affiliation(s)
- Ma Lobo Chaves
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK
| | - Matthew Gittins
- Centre for Biostatistics, University of Manchester, Manchester, UK
| | - Benjamin Bray
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Andy Vail
- Centre for Biostatistics, University of Manchester, Manchester, UK
| | - Craig J Smith
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK.,Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK
| |
Collapse
|
49
|
Hernandez S, Kittelty K, Hodgson CL. Rehabilitating the neurological patient in the ICU: what is important? Curr Opin Crit Care 2021; 27:120-130. [PMID: 33395083 DOI: 10.1097/mcc.0000000000000804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To describe recent literature evaluating the effectiveness of early rehabilitation in neurocritical care patients. RECENT FINDINGS There is a drive for early rehabilitation within the ICU; however, there are unique considerations for the neurocritically ill patient that include hemiplegia, cognitive impairments and impaired conscious state that can complicate rehabilitation. Additionally, neurological complications, such as hemorrhage expansion and cerebral edema can lead to the risk of further neurological damage. It is, therefore, important to consider the effect of exercise and position changes on cerebral hemodynamics in patients with impaired cerebral autoregulation. There is a paucity of evidence to provide recommendations on timing of early rehabilitation postneurological insult. There are also mixed findings on the effectiveness of early mobilization with one large, multicenter RCT demonstrating the potential harm of early and intensive mobilization in stroke patients. Conversely, observational trials have found early rehabilitation to be well tolerated and feasible, reduce hospital length of stay and improve functional outcomes in neurological patients admitted to ICU. SUMMARY Further research is warranted to determine the benefits and harm of early rehabilitation in neurological patients. As current evidence is limited, and given recent findings in stroke studies, careful consideration should be taken when prescribing exercises in neurocritically ill patients.
Collapse
Affiliation(s)
- Sabrina Hernandez
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne
- Discipline of Physiotherapy, Department of Allied Health, The Royal Melbourne Hospital
| | - Katherine Kittelty
- Department of Physiotherapy, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne
- Department of Physiotherapy, The Alfred Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
50
|
Karceski S. After a Stroke: How Quickly Should Exercise Begin? Neurology 2021; 96:e1269-e1271. [PMID: 38124243 DOI: 10.1212/wnl.0000000000011468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|