Medical complications in patients with stroke: data validity in a stroke registry and a hospital discharge registry

Effect of single versus multiple prophylactic antibiotic doses on prosthetic joint infections following primary total hip arthroplasty in patients with osteoarthritis at public and private hospitals in Denmark: protocol for a nationwide cross-over, cluster randomised, non-inferiority trial [The Pro-Hip-Quality Trial]

INTRODUCTION

A feared complication after total hip arthroplasty (THA) is prosthetic joint infection (PJI), associated with high morbidity and mortality. Prophylactic antibiotics can reduce the risk of PJI. However, there is no consensus on the dosages and current recommendations are based on a low evidence level. The objective is to compare the effect of a single versus multiple doses of prophylactic antibiotics administered within 24 hours on PJI.

METHODS AND ANALYSIS

The study is designed as a cross-over, cluster randomised, non-inferiority trial. All clinical centres use both antibiotic practices (1 year of each intervention). All Danish orthopaedic surgery departments will be involved: Based on quality databases, 2-year cohorts of approximately 20 000 primary THAs conducted at 39 public and private hospitals, will be included.

INCLUSION CRITERIA

age ≥18 years, all indications for THA except patients operated due to acute or sequelae from proximal femoral or pelvic fractures or bone tumour or metastasis. The primary outcome is PJI within 90 days after primary THA. Secondary outcomes include (1) serious adverse events, (2) potential PJI, (3) length of hospitalisation stay, (4) cardiovascular events, (5) hospital-treated infections, (6) community-based antibiotic use, (7) opioid use and (8) use of acetaminophen and non-steroidal anti-inflammatory drugs. All outcome measures will be extracted from national databases. Analyses will be based on the intention-to-treat population. Non-inferiority will be shown if the upper limit of the two-sided 95% CI for the OR is less than 1.32 for the single dose as compared with multiple doses. The results will establish best practice on antibiotic prophylaxis dosages in the future.

ETHICS AND DISSEMINATION

This study has been approved by Committees on Health Research Ethics for The Capital Region of Denmark (21069108) and The Danish Medicines Agency (2021091723). All results will be presented in peer-reviewed medical journals and international conferences.

TRIAL REGISTRATION NUMBER

NCT05530551.

The Association between Perceived Annoyances in the Indoor Home Environment and Respiratory Infections: A Danish Cohort Study with up to 19 Years of Follow-Up

The increasing prevalence of reported annoyances in the indoor environment threatens public health. This study aimed to investigate the association between perceived annoyances from the home environment and respiratory infections among individuals with and without asthma or chronic obstructive pulmonary disease (COPD). A total of 16,688 individuals from the Danish Health and Morbidity Survey initiated in 2000 were grouped according to their patterns of perceived annoyances. Information on respiratory infections (all causes, bacterial, viral, and those leading to hospital admissions) was obtained from Danish registers up to 19 years after the survey. Poisson regression of incidence rates (IRs) was applied to estimate incidence rate ratios (IRRs). Annoyances significantly increased the IR for respiratory infections of all causes and bacterial respiratory infections in individuals without asthma or COPD, adjusted IRR 1.16 (95% CI: 1.01, 1.34) and 1.15 (95% CI: 1.02, 1.31), respectively. However, no difference was observed for viral respiratory infections nor hospital admissions. Individuals with asthma or COPD and a high level of annoyances had a non-significantly increased IR in all four analyses of respiratory infections. These findings provide support for perceived annoyances as an important risk factor for respiratory infections.

Rehabilitation assisted by Space technology-A SAHC approach in immobilized patients-A case of stroke

Introduction: The idea behind the presentation of this case relates to utilizing space technology in earth applications with mutual benefit for both patients confined to bed and astronauts. Deconditioning and the progressiveness of skeletal muscle loss in the absence of adequate gravity stimulus have been of physiological concern. A robust countermeasure to muscle disuse is still a challenge for both immobilized patients and astronauts in long duration space missions. Researchers in the space medicine field concluded that artificial gravity (AG) produced by short-radius centrifugation on a passive movement therapy device, combined with exercise, has been a robust multi-system countermeasure as it re-introduces an acceleration field and gravity load. Methods: A short-arm human centrifuge (SAHC) alone or combined with exercise was evaluated as a novel, artificial gravity device for an effective rehabilitation strategy in the case of a stroke patient with disability. The results reveal valuable information on an individualized rehabilitation strategy against physiological deconditioning. A 73-year-old woman was suddenly unable to speak, follow directions or move her left arm and leg. She could not walk, and self-care tasks required maximal assistance. Her condition was getting worse over the years, also she was receiving conventional rehabilitation treatment. Intermittent short-arm human centrifuge individualized protocols were applied for 5 months, three times a week, 60 treatments in total. Results: It resulted in significant improvement in her gait, decreased atrophy with less spasticity on the left body side, and ability to walk at least 100 m with a cane. Balance and muscle strength were improved significantly. Cardiovascular parameters improved responding to adaptations to aerobic exercise. Electroencephalography (EEG) showed brain reorganization/plasticity evidenced through functional connectivity alterations and activation in the cortical regions, especially of the precentral and postcentral gyrus. Stroke immobility-related disability was also improved. Discussion: These alterations were attributed to the short-arm human centrifuge intervention. This case study provides novel evidence supporting the use of the short-arm human centrifuge as a promising therapeutic strategy in patients with restricted mobility, with application to astronauts with long-term muscle disuse in space.

The association between socioeconomic status and the 30- and 90-day risk of infection after total hip arthroplasty : a registry-based cohort study of 103,901 patients with osteoarthritis

AIMS

The aim of this study was to examine whether socioeconomic status (SES) is associated with a higher risk of infections following total hip arthroplasty (THA) at 30 and 90 days.

METHODS

We obtained individual-based information on SES markers (cohabitation, education, income, and savings) on 103,901 THA patients from Danish health registries between 1 January 1995 and 31 December 2017. The primary outcome measure was any hospital-treated infection (i.e. all infections). The secondary outcomes were further specified to specific hospital-treated infections (pneumonia, urinary tract infection, and periprosthetic joint infection). The primary timepoint was within 90 days. In addition, the outcomes were further evaluated within 30 days. We calculated the cumulative incidence, and used the pseudo-observation method and generalized linear regression to estimate adjusted risk ratios (RRs) with 95% confidence intervals (CIs) for each marker.

RESULTS

The cumulative incidence of any infection at 90 days was highest in patients who lived alone (1.5% (95% CI 1.3 to 1.6)) versus cohabitant (0.7% (95% CI 0.7 to 0.8)), had the lowest educational achievement (1.1% (95% CI 1.0 to 1.2)) versus highest (0.7% (95% CI 0.5 to 0.8)), had the lowest income (1.6% (95% CI 1.5 to 1.70)) versus highest (0.4% (95% CI 0.3 to 0.5)), or had lowest savings (1.3% (95% CI 1.2 to 1.4)) versus highest (0.7% (95% CI 0.6 to 0.8)). Within 90 days, the RRs for any infection were 1.3 (95% CI 1.2 to 1.4) for patients living alone versus cohabiting, 1.2 (95% CI 1.0 to 1.3) for low education achievement versus high, 1.7 (95% CI 1.4 to 2.1) for low income versus high income, and 1.5 (95% CI 1.4 to 1.8) for low savings versus high savings. The same trends were also seen for any infections within the first 30 days.

CONCLUSION

Our study provides evidence that socioeconomic inequality adversely influences the risk of infection after THA, thus contributing to healthcare disparities and inequalities. We found that living alone, low educational achievement, low income, or low savings were associated with higher risks of infections within the first 30 and 90 days after THA. Therefore, the development of targeted intervention strategies with the aim of increasing awareness of patients identified as being at greatest risk is needed to mitigate the impact of SES on the risk of infections following THA. Cite this article: Bone Joint J 2022;104-B(2):221-226.

Usefulness of NIHSS score as a predictor of non-neurological in-hospital complications in stroke

INTRODUCTION

Patients with stroke are at risk of developing non-neurological in-hospital complications (NNIHC) during hospitalization. The NIHSS is a scale used and validated to determine stroke severity, treatment, and prognosis. We evaluated the relationship between the NIHSS score obtained on admission and the development of NNIHC during hospital stay.

METHODS

Observational study of prospective cohorts. Patients admitted consecutively for stroke, to an intermediate care ward, in Argentina between 08/01/2017 and 02/29/20 were included. The patients were divided into Group1 (with NNIHC) and Group2 (without NNIHC).

RESULTS

The final n consisted of 78 individuals, 41% women. When comparing the means of the NIHSS score, differences were observed between the groups in the development of NNIHC in general (P=.050) and in the following specific complications: dysphagia (P=.014), aspiration pneumonia (P=.006), in-hospital pneumonia (P=.010) and intrahospital urinary infection (P=.004). The cut-off point of 10.5 presented the best predictive performance of NNIHC (AUC=.706; P=.016).

CONCLUSIONS

An NIHSS value ≥10.5 was related to the development of NNIHC in patients admitted for stroke.

The validity of the claims-based definition of rheumatoid arthritis evaluated in 64 hospitals in Japan

BACKGROUND

An administrative database covering a whole population such as the national database in Japan may be used to estimate the nationwide prevalence of diseases including rheumatoid arthritis (RA) when a well-validated definition of the disease is available. In Japan, the record linkage between the administrative database and medical charts in hospitals is strictly prohibited. A "hospital-based" validation study is one of few possible validation studies where claims kept inside the study hospital are rearranged into the database structure.

METHODS

We selected random samples of 19,734 patients from approximately 1.6 million patients who received medical care between February 2018 and January 2019 in one of the 64 hospitals of the Tokushukai Medical Group. We excluded patients whose observation period was less than 365 days and identified 334 patients who met the definition of "possible cases of RA" whose medical charts were then independently evaluated by two rheumatologists. In a sensitivity analysis, we assessed bias due to misclassifying some patients with RA who did not meet the definition of "possible cases of RA" as a patient with no RA.

RESULTS

The kappa coefficient between the two rheumatologists was 0.80. The prevalence of RA in the study population was estimated to be 0.56%. We found that [condition code of RA] and ([any disease-modifying antirheumatic drug] or [oral corticosteroid with no systemic autoimmune diseases (other than RA) and no polymyalgia rheumatica]) had a relatively high sensitivity (approximately 73%) and a high positive predictive value (approximately 80%). In a sensitivity analysis, we found that when some patients with RA who did not meet the definition of "possible cases of RA" were misclassified as a patient with no RA, then this would lead to underestimation of the prevalence of the definition-positive patients and the adjusted prevalence.

CONCLUSIONS

We recommend using the claims-based definition of RA (found in the current validation study) to estimate the prevalence of RA in Japan. We also suggest estimating the adjusted prevalence using the quantitative bias analysis method, since the prevalence of the disease in the "hospital-based" validation study is different from that in the administrative database.

TRIAL REGISTRATION

The current study is not a clinical trial and hence not subject to trial registration.

Determinants of Health Status After Stroke: A Cohort Study with Repeated Measurements

Background

Knowledge about the long-term course of health following stroke is sparse and relies mainly on studies with short follow-up or few measurements per patient. We aimed to describe the course and analyze the determinants of the course of physical and mental health status after stroke with repeated measurements in a large population-based cohort of first time Danish stroke patients.

Methods

We followed 2,414 first time stroke patients admitted to any hospital in the Central Denmark Region, Denmark, between October 1, 2008 and January 1, 2012, with five questionnaires over a 2 years period. Self-rated health was assessed by the SF-12 instrument. Information on possible clinical and patient-related determinants of self-rated health was obtained from questionnaires and national registers. The scores were analyzed at five selected fixed time-points and as well as longitudinally with mixed models.

Results

The SF-12 mental component summary score (MCS) increased with 0.89 points/year (95% CI=0.6–1.2), while the increase in the physically component summary score (PCS) did not reach statistical significance (0.13/year; 95% CI=−0.2–0.5). The most pronounced changes were seen in the Vitality and Role Physical SF-12 subscales, which both increased by 2.1 points/year. No statistically significant changes over time were found in the Physical Functioning and Bodily Pain subscales. Variables associated with increasing self-rated mental health (MCS) were no comorbidity, older age, male gender, and mild stroke severity. Variables associated with increasing ratings of physical health (PCS) were mild stroke severity, no comorbidity, higher educational level, and younger age. The negative impact of age increased significantly with time during the follow-up period for physical as well as mental health, while the effects of the other variables were stable over time. The results were similar in the two analytical approaches.

Conclusion

In a large, geographically well-defined population of first time stroke patients, the majority of SF-12 sub-scales and the mental component score improved slightly over time. Small improvements in self-rated mental health may be observed during the first 2 years after the stroke. Stroke is a disease with long-term consequences on a wide range of health aspects. Level as well as course differ between sub-groups, and treatment of comorbidity may be an important target with respect to rehabilitation.

Platelet Count within the Normal Range at Hospital Admission is Associated with Mortality in Patients with Community-Acquired Pneumonia

Background

Apart from their hemostatic role, platelets are immune cells that play a role in fighting infections. The presence of thrombocytopenia and thrombocytosis at hospital admission are predictors of mortality in community-acquired pneumonia patients. We hypothesized that variations in platelet counts within the normal range also may be associated with mortality in these patients.

Methods

The study included all adults in the North and Central Denmark Regions with a first acute hospital admission for community-acquired pneumonia during 2006-2012. We assessed the association between the first platelet count within ± 24 hours of admission (within the normal range of 150 to 400 x 10⁹/L) and 30-day mortality using Cox models. Analyses were adjusted for age, sex, Charlson Comorbidity Index score, hemoglobin level, leukocyte count, and creatinine level at admission.

Results

Among the 12,905 study patients, 30-day mortality was 12.4%. The mean platelet count upon admission was 250 × 10⁹/L. Compared with the 250-275 × 10⁹/L category, platelet counts of 151-175 were associated with a lower 30-day mortality (adjusted hazard ratio [aHR]: 0.79, 95% confidence interval [CI]: 0.63-0.99), while higher platelet counts were associated with a higher 30-day mortality (351-375 × 10⁹/L, aHR: 1.34, 95% CI: 1.07-1.68; 376-400× 10⁹/L, aHR: 1.21, 95% CI: 0.94-1.56).

Conclusion

Platelet counts, even within the normal range, are associated with mortality in adult patients hospitalized for community-acquired pneumonia.

A 2 DS 2 Score to Predict the Risk of Stroke-Associated Pneumonia in Acute Stroke: An Indian Perspective

Background  Stroke-associated pneumonia (SAP) is an important cause of poststroke morbidity and mortality. Several clinical risk scores predict the risk of SAP. In this study, we used the A ² DS ² score (age, atrial fibrillation, dysphagia, sex, and stroke severity) to assess the risk of SAP in patients admitted with acute stroke. Methods  A high (5-10) and a low (0-4) A ² DS ² score was assigned to patients with acute stroke admitted to the neurology ward. Univariate binary logistic regression analysis was performed to find the strength of association of SAP and A ² DS ² score. Results  There were 250 patients with acute stroke of which 46 developed SAP. Forty-four patients developed SAP in high score as against 2 in low-score group (odds ratio [OR] = 0.03, 95% confidence interval [CI] = 0.01-0.15, p = 0.0001). A ² DS ² score >5 had sensitivity of 82.6% and specificity of 65.1% to predict SAP. The mean A ² DS ² score in patients with pneumonia was 7.02 ± 1.40 compared to 4.75 ± 1.92 in patients without pneumonia ( p = 0.0001). Conclusions  A ² DS ² score has a high sensitivity of 82% in predicting the risk of SAP and is a useful tool to monitor patients after acute stroke. A ² DS ² score can help in timely detection and prevention of SAP and reduction in caregiver's burden.

Long-term risk and outcome of infection-related hospitalization in granulomatosis with polyangiitis: a nationwide population-based cohort study

OBJECTIVE

To assess the long-term risk and outcome of infection-related hospitalization (IH) among patients with granulomatosis with polyangiitis (GPA).

METHOD

We used administrative databases to establish a GPA cohort (n = 398), construct a comparison cohort of population controls (n = 3980), and collect clinical data. Cox regression analyses were used to determine hazard ratios (HRs) as a measure of relative risk. Follow-up began at date of GPA diagnosis and continued for up to 10 years.

RESULTS

GPA patients had a markedly increased long-term risk of IH compared to controls [HR (95% confidence interval) year 1: 9.5 (7.0-12.8); years 2-5: 3.2 (2.4-4.3); years 6-10: 2.6 (1.8-3.9)]. Increased long-term risks were found for hospital-treated pneumonia, urinary tract infection, sepsis, and skin infection. We did not observe a lower risk of IH for people diagnosed with GPA during 2005-2014 than for those diagnosed during 1995-2004. Mortality at 3 and 6 months after IH did not differ significantly between patients diagnosed with vasculitis during 2005-2014 and those diagnosed during 1995-2004. Charlson Comorbidity Index score ≥1 was identified as a predictor of pneumonia and urinary tract infection in the GPA cohort, but not of sepsis or skin infection.

CONCLUSION

Patients with GPA have a high risk of IH, even after prolonged follow-up. The long-term risk of IH and mortality after IH did not decline across recent calendar periods among Danish GPA patients. These observations underscore the need for clinical strategies to reduce the burden of infectious complications in GPA.

Noninfectious complications of acute stroke and their impact on hospital mortality in patients admitted to a stroke unit in Warsaw from 1995 to 2015

BACKGROUND

Medical complications often worsen the prognosis after stroke. Our aim was to investigate the association between particular noninfectious complications and hospital mortality of acute stroke patients admitted to an urban Polish stroke center, and changes in their occurrence from 1995 to 2015.

METHODS

This is a retrospective analysis of 5174 consecutive patients admitted for acute ischemic stroke or cerebral hemorrhage to a Polish urban stroke center between 1995 and 2015. The occurrence of complications was reported for years 1995-2000 (n=883), 2001-2006 (n=1567), 2006-2010 (n=1539) and 2011-2015 (n=1183). Odds ratios (OR) with 95% confidence interval (95% CI) for stroke unit death were calculated after adjustment for age, congestive heart failure (CHF), pre-existing disability, stroke type and baseline neurological deficit in three different time periods.

RESULTS

Over time there was a significant decrease in the occurrence of myocardial infarction (MI) (2.2%, 1.4%, 1.0% and 0.3%, respectively), exacerbated CHF (4.6%, 5.1%, 2.6% and 2.0%) and deep vein thrombosis (DVT) (4.6%, 2.7%, 1.2% and 1.1%). Adjusted odds for stroke unit death were increased by myocardial infarction (MI) (OR 17.5, 95% CI: 8.5-35.7), exacerbated CHF (OR 15.0, 95% CI: 9.8-23.0), pulmonary embolism (PE) (OR 11.5, 95% CI: 6.1-21.6), gastrointestinal bleeding (OR 9.2, 95% CI: 4.4-18.9) and recurrent stroke (OR 5.4, 95% CI: 3.1-9.3).

CONCLUSIONS

Over the last two decades Polish urban stroke units may have achieved a significant reduction of the occurrence of some noninfectious complications (i.e. MI, exacerbated CHF and DVT). However, the list of conditions associated with stroke unit mortality includes not only MI and exacerbated CHF but also PE, gastrointestinal bleeding and recurrent stroke.

Individual Prognosis of Symptom Burden and Functioning in Chronic Diseases: A Generic Method Based on Patient-Reported Outcome (PRO) Measures

Background

Information to the patient about the long-term prognosis of symptom burden and functioning is an integrated part of clinical practice, but relies mostly on the clinician’s personal experience. Relevant prognostic models based on patient-reported outcome (PRO) data with repeated measurements are rarely available.

Objective

The aim was to describe a generic method for individual long-term prognosis of symptom burden and functioning that implied few statistical presumptions, to evaluate an implementation for prognosis of depressive symptoms in stroke patients and to provide open access to a Web-based prototype of this implementation for individual use.

Methods

The method used to describe individual prognosis of a PRO outcome was based on the selection of a specific subcohort of patients who have the same score as the patient in question at the same time (eg, after diagnosis or treatment start), plus or minus one unit of minimal clinically important difference. This subcohort’s experienced courses were then used to provide quantitative measures of prognosis over time. A cohort of 1404 stroke patients provided data for a simulation study and a prototype for individual use. Members of the cohort answered questionnaires every 6 months for 3.5 years. Depressive symptoms were assessed by the Hospital Anxiety and Depression Scale (HADS) and a single item from the SF-12 (MH4) health survey. Four approaches were compared in a simulation study in which the prognosis for each member of the cohort was individually assessed.

Results

The mean standard deviations were 40% to 70% higher in simulated scores. Mean errors were close to zero, and mean absolute errors were between 0.46 and 0.66 SD in the four approaches. An approach in which missing HADS scores were estimated from the single-item SF-12 MH4 performed marginally better than methods restricted to questionnaires with a genuine HADS score, which indicates that data collected with shorter questionnaires (eg, in clinical practice) may be used together with longer versions with the full scale, given that the design includes at least two simultaneous measurements of the full scale and the surrogate measure.

Conclusions

This is the first description and implementation of a nonparametric method for individual PRO-based prognosis. Given that relevant PRO data have been collected longitudinally, the method may be applied to other patient groups and to any outcome related to symptom burden and functioning. This initial implementation has been deliberately made simple, and further elaborations as well as the usability and clinical validity of the method will be scrutinized in clinical practice. An implementation of the prototype is available online at www.prognosis.dk.

Positive predictive values of International Classification of Diseases, 10th revision codes for dermatologic events and hypersensitivity leading to hospitalization or emergency room visit among women with postmenopausal osteoporosis in the Danish and Swedish national patient registries

BACKGROUND

Clinical epidemiology research studies, including pharmacoepidemiology and pharmacovigilance studies, use routinely collected health data, such as diagnoses recorded in national health and administrative registries, to assess clinical effectiveness and safety of treatments. We estimated positive predictive values (PPVs) of International Classification of Diseases, 10th revision (ICD-10) codes for primary diagnoses of dermatologic events and hypersensitivity recorded at hospitalization or emergency room visit in the national patient registries of Denmark and Sweden among women with postmenopausal osteoporosis (PMO).

METHODS

This validation study included women with PMO identified from the Danish and Swedish national patient registries (2005-2014). Medical charts of the potential cases served as the gold standard for the diagnosis confirmation and were reviewed and adjudicated by physicians.

RESULTS

We obtained and reviewed 189 of 221 sampled medical records (86%). The overall PPV was 92.4% (95% confidence interval [CI], 85.1%-96.3%) for dermatologic events, while the PPVs for bullous events and erythematous dermatologic events were 52.5% (95% CI, 37.5%-67.1%) and 12.5% (95% CI, 2.2%-47.1%), respectively. The PPV was 59.0% (95% CI, 48.3%-69.0%) for hypersensitivity; however, the PPV of hypersensitivity increased to 100.0% (95% CI, 67.6%-100.0%) when restricting to diagnostic codes for anaphylaxis. The overall results did not vary by country.

CONCLUSION

Among women with PMO, the PPV for any dermatologic event recorded as the primary diagnosis at hospitalization or at an emergency room visit was high and acceptable for epidemiologic research in the Danish and Swedish national patient registries. The PPV was substantially lower for hypersensitivity leading to hospitalization or emergency room visit.

Risk of pneumonia and urinary tract infection within the first week after total hip arthroplasty and the impact on survival

Background

Pneumonia and urinary tract infections (UTIs) increase morbidity and mortality. There is little epidemiological evidence from large population-based studies on risk factors for these infections and subsequent mortality in total hip arthroplasty (THA) patients.

Aim

To examine the risk factors of postoperative pneumonia and UTI after THA and their impact on survival.

Patients and methods

We used the Danish Hip Arthroplasty Register to identify THAs due to osteoarthritis registered from 2000 to 2013. We collected data about comorbidities, mortality and infections in relation to primary hospitalization and potential predictive variables from administrative databases. Regression models were used to estimate associations between potential risk factors and infection, and subsequently, between infection and mortality.

Results

In total 84,812 THAs were included. The cumulative incidence of pneumonia and UTI within 7 days of the primary procedure were 0.21 (95% confidence interval [CI]: 0.18–0.25) and 0.29 (95% CI: 0.26–0.33), respectively. Patient-related risk factors for infection were being 80 years or older, gender and a comorbidity burden at time of surgery. The hazard ratio (HR) of dying within 90 days of the primary THA was 10.67 (95% CI: 5.79–19.57) compared to patients without pneumonia. For patients with UTIs, the HR was 1.64 (95% CI: 0.41–6.59) compared to those without a UTI.

Conclusion

Pneumonia was associated with an increased short-term risk of dying, despite adjustment for coexisting comorbidity and other potential confounders. Age, gender and comorbidity were the most important risk factors for pneumonia and UTIs. Individual initiatives to reduce the risk of pneumonia in select patient groups may be essential to the effort to optimize outcomes after a THA.

Stroke-Associated Pneumonia Risk Score: Validity in a French Stroke Unit

BACKGROUND

Stroke-associated pneumonia is a leading cause of in-hospital death and post-stroke outcome. Screening patients at high risk is one of the main challenges in acute stroke units. Several screening tests have been developed, but their feasibility and validity still remain unclear.

OBJECTIVE

The aim of our study was to evaluate the validity of four risk scores (Pneumonia score, A2DS2, ISAN score, and AIS-APS) in a population of ischemic stroke patients admitted in a French stroke unit.

METHODS

Consecutive ischemic stroke patients admitted to a stroke unit were retrospectively analyzed. Data that allowed to retrospectively calculate the different pneumonia risk scores were recorded. Sensitivity and specificity of each score were assessed for in-hospital stroke-associated pneumonia and mortality. The qualitative and quantitative accuracy and utility of each diagnostic screening test were assessed by measuring the Youden Index and the Clinical Utility Index.

RESULTS

Complete data were available for only 1960 patients. Pneumonia was observed in 8.6% of patients. Sensitivity and specificity were, respectively, .583 and .907 for Pneumonia score, .744 and .796 for A2DS2, and .696 and .812 for ISAN score. Data were insufficient to test AIS-APS. Stroke-associated pneumonia risk scores had an excellent negative Clinical Utility Index (.77-.87) to screen for in-hospital risk of pneumonia after acute ischemic stroke.

CONCLUSION

All scores might be useful and applied to screen stroke-associated pneumonia in stroke patients treated in French comprehensive stroke units.

The Danish National Patient Registry: a review of content, data quality, and research potential

Background

The Danish National Patient Registry (DNPR) is one of the world’s oldest nationwide hospital registries and is used extensively for research. Many studies have validated algorithms for identifying health events in the DNPR, but the reports are fragmented and no overview exists.

Objectives

To review the content, data quality, and research potential of the DNPR.

Methods

We examined the setting, history, aims, content, and classification systems of the DNPR. We searched PubMed and the Danish Medical Journal to create a bibliography of validation studies. We included also studies that were referenced in retrieved papers or known to us beforehand. Methodological considerations related to DNPR data were reviewed.

Results

During 1977–2012, the DNPR registered 8,085,603 persons, accounting for 7,268,857 inpatient, 5,953,405 outpatient, and 5,097,300 emergency department contacts. The DNPR provides nationwide longitudinal registration of detailed administrative and clinical data. It has recorded information on all patients discharged from Danish nonpsychiatric hospitals since 1977 and on psychiatric inpatients and emergency department and outpatient specialty clinic contacts since 1995. For each patient contact, one primary and optional secondary diagnoses are recorded according to the International Classification of Diseases. The DNPR provides a data source to identify diseases, examinations, certain in-hospital medical treatments, and surgical procedures. Long-term temporal trends in hospitalization and treatment rates can be studied. The positive predictive values of diseases and treatments vary widely (<15%–100%). The DNPR data are linkable at the patient level with data from other Danish administrative registries, clinical registries, randomized controlled trials, population surveys, and epidemiologic field studies – enabling researchers to reconstruct individual life and health trajectories for an entire population.

Conclusion

The DNPR is a valuable tool for epidemiological research. However, both its strengths and limitations must be considered when interpreting research results, and continuous validation of its clinical data is essential.

International multidisciplinary consensus conference on multimodality monitoring: ICU processes of care

There is an increased focus on evaluating processes of care, particularly in the high acuity and cost environment of intensive care. Evaluation of neurocritical-specific care and evidence-based protocol implementation are needed to effectively determine optimal processes of care and effect on patient outcomes. General quality measures to evaluate intensive care unit (ICU) processes of care have been proposed; however, applicability of these measures in neurocritical care populations has not been established. A comprehensive literature search was conducted for English language articles from 1990 to August 2013. A total of 1,061 articles were reviewed, with 145 meeting criteria for inclusion in this review. Care in specialized neurocritical care units or by neurocritical teams can have a positive impact on mortality, length of stay, and in some cases, functional outcome. Similarly, implementation of evidence-based protocol-directed care can enhance outcome in the neurocritical care population. There is significant evidence to support suggested quality indicators for the general ICU population, but limited research regarding specific use in neurocritical care. Quality indices for neurocritical care have been proposed; however, additional research is needed to further validate measures.

Risk of re-admission, reoperation, and mortality within 90 days of total hip and knee arthroplasty in fast-track departments in Denmark from 2005 to 2011

PURPOSE

To compare the risks of re-admission, reoperation, and mortality within 90 days of surgery in orthopedic departments with well-documented fast-track arthroplasty programs with those in all other orthopedic departments in Denmark from 2005 to 2011.

METHODS

We used the Danish hip and knee arthroplasty registers to identify patients with primary total hip arthroplasty or total knee arthroplasty. Information about re-admission, reoperation, and mortality within 90 days of surgery was obtained from administrative databases. The fast-track cohort consisted of 6 departments. The national comparison cohort consisted of all other orthopedic departments. Regression methods were used to calculate relative risk (RR) of adverse events, adjusting for age, sex, type of fixation, and comorbidity. Cohorts were divided into 3 time periods: 2005-2007, 2008-2009, and 2010-2011.

RESULTS

79,098 arthroplasties were included: 17,284 in the fast-track cohort and 61,814 in the national cohort. Median length of stay (LOS) was less for the fast-track cohort in all 3 time periods (4, 3, and 3 days as opposed to 6, 4, and 3 days). RR of re-admission due to infection was higher in the fast-track cohort in 2005-2007 (1.3, 95% CI: 1.1-1.6) than in the national cohort in the same time period. This was mainly due to urinary tract infections. RR of re-admission due to a thromboembolic event was lower in the fast-track cohort in 2010-2011 (0.7, CI: 0.6-0.9) than in the national cohort in the same time period. No differences were seen in the risk of reoperation and mortality between the 2 cohorts during any time period.

INTERPRETATION

The general reduction in LOS indicates that fast-track arthroplasty programs have been widely implemented in Denmark. At the same time, it appears that dedicated fast-track departments have been able to optimize the fast-track program further without any rise in re-admission, reoperation, and mortality rates.

Multiple sclerosis clinical course and cardiovascular disease risk - Swedish cohort study

BACKGROUND AND PURPOSE

Cardiovascular disease (CVD) risk amongst multiple sclerosis (MS) patients appears raised, but few studies have examined CVD risk amongst an unselected MS patient group. MS course may be relevant for CVD risk. Our aim was to assess CVD risk and variation by course in MS patients.

METHODS

The Multiple Sclerosis Register identified 7667 patients who received an MS diagnosis between 1964 and 2005. They were matched by age, period, region and sex with 76 045 members of the general population without MS using Swedish registers. Poisson regression compared the two cohorts to estimate the relative risk for CVD, overall, as well as grouped and individual CVD diagnoses.

RESULTS

MS patients had an increased adjusted relative risk (with 95% confidence intervals; number of MS cohort events) for CVD of 1.31 (1.22-1.41; n = 847), with some variation by course: relapsing-remitting 1.38 (1.17-1.62; n = 168); secondary progressive 1.30 (1.18-1.53; n = 405) and primary progressive 1.15 (0.93-1.41; n = 108). The association for the relapsing-remitting course was not significant after excluding the first year of follow-up. Overall incidence rates per 1000 person-years for CVD are 11.8 (11.06-12.66) for the MS cohort and 8.8 (8.60-9.05) for the non-MS cohort. The most pronounced association was for deep vein thrombosis: relapsing-remitting 2.16 (1.21-3.87; n = 14), secondary progressive 3.41 (2.45-4.75; n = 52) and primary progressive 3.57 (1.95-6.56; n = 15). MS was associated with ischaemic stroke but largely during the first year of follow-up. MS was associated with a decreased relative risk for angina pectoris and atrial fibrillation.

CONCLUSIONS

There is a significantly increased relative risk for CVD in MS, particularly for venous thromboembolic disorders in progressive MS, suggesting immobility as a possible factor. An increased frequency of ischaemic stroke in MS is most probably due to surveillance bias resulting from diagnostic investigations for MS. There is no increased relative risk for ischaemic heart disease in MS and atrial fibrillation appears to be less common than amongst the general population.

Validation of 14,500 operated knees registered in the Danish Knee Ligament Reconstruction Register: registration completeness and validity of key variables

Introduction

The aim of this study was to validate the registration in the Danish Knee Ligament Reconstruction Register (DKRR) by assessing the registration completeness of the anterior cruciate ligament (ACL) reconstruction code and detecting the validity of important key variables. Furthermore, we assessed data quality of patient-related outcome scores.

Material and methods

All operation codes for ACL reconstruction from 2005–2011 were identified in the Danish National Registry of Patients and were compared with the cases registered in the DKRR to compute the completeness of registration. We also assessed the validity of key variables in the DKRR using medical records as a reference standard to compute the positive predictive value. Finally, we assessed potential differences between responders and nonresponders to subjective patient-related outcome scores (Knee Injury and Osteoarthritis Outcome Score [KOOS] and Tegner scores) 1 year after surgery.

Results

The completeness of the registration of patients in the DKRR increased from 60% (2005) to 86% (2011). Large-volume hospitals had a higher completeness than small-volume hospitals. With a positive predictive value between 85%–100%, the validity of key variables was good. KOOS scores versus Tegner scores for responders and nonresponders were comparable.

Conclusion

The results show a good registration of ACL reconstruction procedures in the DKRR, but there is room for improvement mainly at small-volume hospitals. Overall, the validity of the key variables in the DKRR was good and no difference was found in KOOS and Tegner scores for responders versus nonresponders. Therefore, we conclude that the DKRR is a valid source for future research.

Differential case reporting in a national clinical quality database: an analysis of the impact on comparison of outcome between departments

INTRODUCTION

Selection biases due to difference in reporting may cause spurious findings. The purpose of this study was to illustrate the effect of case incompleteness on the differences in 180-day survival rate when comparing departments.

METHODS

Completeness was estimated as the proportion of patients reported to the Danish Lymphoma Database compared with the National Patient Registry. The effect of differential reporting between departments was investigated using plots were the proportion of patients who survived 180 days in the individual departments were compared with the national average as well as examining the association between the department and 180-day survival.

RESULTS

In total, 8015 patients were registered in the National Patient Registry with a lymphoma diagnosis. Of these, 1824 patients were not reported to the Danish Lymphoma database equaling a rate of completion of 77.2%. There were large differences between departments with regard to patient completeness (range, 52.4%-91.6%). The survival of the patients reported to the database was significantly better than those not reported and the differential reporting affected the department ranking.

CONCLUSION

Differential case reporting may cause spurious findings. To ensure valid conclusions validation against a gold standard and continuous feedback to data providers is important.

Craniectomy for malignant cerebral infarction: prevalence and outcomes in US hospitals

Object

Randomized trials have demonstrated the efficacy of craniectomy for the treatment of malignant cerebral edema following ischemic stroke. We sought to determine the prevalence and outcomes related to this by using a national database.

Methods

Patient discharges with ischemic stroke as the primary diagnosis undergoing craniectomy were queried from the US Nationwide Inpatient Sample from 1999 to 2008. A subpopulation of patients was identified that underwent thrombolysis. Two primary end points were examined: in-hospital mortality and discharge to home/routine care. To facilitate interpretations, adjusted prevalence was calculated from the overall prevalence and two age-specific logistic regression models. The predictive margin was then generated using a multivariate logistic regression model to estimate the probability of in-hospital mortality after adjustment for admission type, admission source, length of stay, total hospital charges, chronic comorbidities, and medical complications.

Results

After excluding 71,996 patients with the diagnosis of intracranial hemorrhage and posterior intracranial circulation occlusion, we identified 4,248,955 adult hospitalizations with ischemic stroke as a primary diagnosis. The estimated rates of hospitalizations in craniectomy per 10,000 hospitalizations with ischemic stroke increased from 3.9 in 1999–2000 to 14.46 in 2007–2008 (p for linear trend<0.001). Patients 60+ years of age had in-hospital mortality of 44% while the 18–59 year old group was found to be 24%(p = 0.14). Outcomes were comparable if recombinant tissue plasminogen activator had been administered.

Conclusions

Craniectomy is being increasingly performed for malignant cerebral edema following large territory cerebral ischemia. We suspect that the increase in the annual incidence of DC for malignant cerebral edema is directly related to the expanding collection of evidence in randomized trials that the operation is efficacious when performed in the correct patient population. In hospital mortality is high for all patients undergoing this procedure.

In-hospital medical complications, length of stay, and mortality among stroke unit patients

BACKGROUND AND PURPOSE

The relationship between in-hospital stroke-related medical complications and clinical outcome remains unclear. We examined whether medical complications were associated with length of stay (LOS) and mortality among stroke unit patients.

METHODS

Using population-based Danish medical registries, we performed a follow-up study among all patients with acute stroke admitted to stroke units in 2 counties between 2003 and 2009 (n=13 721). Data regarding in-hospital medical complications, including pneumonia, urinary tract infection, pressure ulcer, falls, deep venous thrombosis, pulmonary embolism, and severe constipation together with LOS and mortality were prospectively registered.

RESULTS

Overall, 25.2% of patients (n=3453) experienced 1 or more medical complications during hospitalization. The most common complications were urinary tract infection (15.4%), pneumonia (9.0%), and constipation (6.8%). Median LOS was 13 days (25th and 75th quartiles, 5 and 33). All medical complications were associated with longer LOS. The adjusted relative LOS extension ranged from 1.80 (95% CI, 1.54-2.11) for pneumonia to 3.06 (95% CI, 2.67-3.52) for falls. Patients with 1 or more complications had an increased 1-year mortality rate (adjusted mortality rate ratio [MRR], 1.20; 95% CI, 1.04-1.39). The association was mainly because of pneumonia, which was associated with higher mortality both after 30 days (adjusted MRR, 1.59; 95% CI, 1.31-1.93) and 1 year (adjusted MRR, 1.76; 95% CI, 1.45-2.14).

CONCLUSIONS

In-hospital medical complications were associated with longer LOS and some, in particular pneumonia, also with an increased mortality among patients with acute stroke.

Processes of Care and Medical Complications in Patients With Stroke

Background and Purpose—

The relationship between processes of care and the risk of medical complications in patients with stroke remains unclear. We therefore examined the association in a population-based follow-up study.

Methods—

We identified 11 757 patients admitted for stroke to stroke units in 2 Danish counties in 2003 to 2008. The examined processes of care included early admission to a stroke unit, early initiation of antiplatelet or oral anticoagulant therapy, early CT/MRI scan, and early assessment by a physiotherapist and an occupational therapist of nutritional risk and of swallowing function and early mobilization.

Results—

Overall, 25.3% (n=2969) of the patients experienced ≥1 medical complications during hospitalization. The most common medical complications were urinary tract infection (15.5%), pneumonia (8.8%), and constipation (7.0%). We found indications of an inverse dose–response relationship between the number of processes of care that the patients received and the risk of medical complications. The lowest risk of complications was found among patients who received all relevant processes of care compared with patients who failed to receive any of the processes (ie, adjusted ORs ranged from 0.42 [95% CI, 0.24 to 0.74] for pressure ulcer to 0.64 [95% CI, 0.44 to 0.93] for pneumonia). Of the individual processes of care, early mobilization was associated with the lowest risk of complications.

Conclusions—

Higher quality of acute stroke care was associated with a lower risk of medical complications.