A comparison of the Glasgow Coma Scale and the Reaction Level Scale (RLS85)

Cognitive reserve and disparities in healthcare usage after traumatic brain injury and stroke: an observational cohort study

BACKGROUND

Individuals with more education commonly have better outcome after brain injury, often attributed to cognitive reserve. However, evidence suggests that individuals with more education have better access to specialized care, potentially affecting outcomes.

OBJECTIVE

To investigate differences in healthcare usage based on cognitive reserve and examine the relationship between healthcare usage and outcomes after stroke and traumatic brain injury.

DESIGN

An observational cohort study with healthcare usage data from 3 years before to 4 years after injury, interviewing patients 5-15 years after injury.

PATIENTS

A total of 83 participants suffering a stroke or traumatic brain injury.

RESULTS

Healthcare usage over time varied based on educational level (repeated measures ANOVA, F(2, 227) = 4.17, p = 0.008). The differences in healthcare usage between educational levels was significant during the injury year (F(81) = -5.47, p = 0.022). Higher education implied more healthcare usage. Linear regression, controlling for possible confounders, confirmed the relationship between education and healthcare usage, (β = 4.3, p = 0.022). Healthcare usage was significantly related to long-term life satisfaction, but not to return to work.

CONCLUSION

Individuals with more education received more healthcare in the year after traumatic brain injury or stroke. However, this was not related to long-term outcome regarding return to work, but we found a relationship between healthcare usage and life satisfaction.

Diverging Trends in Survival and Functional Outcome between Males and Females after Intracerebral Hemorrhage

BACKGROUND

Compared to ischemic stroke, sex differences in patient outcomes following intracerebral hemorrhage (ICH) are underreported. We aimed to determine sex differences in mortality and functional outcomes in a large, unselected Swedish cohort.

METHODS

In this observational study, data on 22,789 patients with spontaneous ICH registered in the Swedish Stroke Register between 2012 and 2019 were used to compare sex differences in 90-day mortality and functional outcome using multivariable Cox and logistic regression analyses, adjusting for relevant confounders. Multiple imputation was used to impute missing data.

RESULTS

The crude 90-day mortality rate was 36.7% in females (3,820/10,405) and 31.7% in males (3,929/12,384) (female hazard ratio [HR] 1.20 95% confidence interval [CI]: 1.15-1.25). In multivariable analysis, the HR for 90-day mortality following ICH in females was 0.89 (95% CI: 0.85-0.94). Age was an important driving factor for the effect of sex on mortality. After adjustment for age, vascular risk factors, and stroke severity, the 90-day functional outcome in pre-stroke independent patients was worse in females compared to males (odds ratio: 1.27 95% CI: 1.16-1.40).

CONCLUSION

In this large observational study, despite lower 90-day mortality, the female sex was independently associated with a worse functional outcome compared to males after ICH, even after adjusting for significant covariates. These diverging trends have not been previously reported for ICH. Given the observational design, our findings should be interpreted with caution, thus further external validation is warranted.

Trends in incidence and treatments of spontaneous subarachnoid hemorrhage- a 10 year hospital based study

BACKGROUND

Improved endovascular methods make it possible to treat complex ruptured aneurysms, but surgery is still needed in certain cases. We evaluated the effects on the clinical results of the changes in aneurysm treatment.

METHODS

The study cohort was 837 patients with spontaneous subarachnoid hemorrhage (SAH) and one or multiple aneurysms, admitted to Dept of Neurosurgery, Uppsala University Hospital from 2012 to 2021. Demography, location and treatment of aneurysms, neurologic condition at admission and discharge, mortality and last tier treatment of high intracranial pressure (ICP) was evaluated. Functional outcome was measured using the Extended Glasgow Outcome Scale (GOSE) Data concerning national incidences of stroke diseases was collected from open Swedish databases.

RESULTS

Endovascular methods were used in 666 cases (79.6%). In 111 (13.3%) with stents. Surgery was performed in 115 cases (13.7%) and 56 patients (6.7%) had no aneurysm treatment. The indications for surgery were a hematoma (51 cases, 44.3%), endovascular treatment not considered safe (47 cases, 40.9%), or had been attempted without success (13 cases, 11.3%). Treatment with stent devices increased, and with surgery decreased over time. There was a trend in decrease in hemicraniectomias over time. Both the patient group admitted awake (n = 681) and unconscious (n = 156) improved significantly in consciousness between admission and discharge. Favorable outcome (GOSE 5-8) was seen in 69% for patients admitted in Hunt & Hess I-II and 25% for Hunt & Hess III-V. Mortality at one year was 10.9% and 42.7% for those admitted awake and unconscious, respectively.The number of cases decreased during the study period, which was in line with Swedish national data.

CONCLUSIONS

The incidence of patients with SAH gradually decreased in our material, in line with national data. The treatment policy in our unit has been shifting to more use of endovascular methods. During the study period the use of hemicraniectomies decreased.

Effectiveness of an Algorithmic Approach to Ventilator Withdrawal at the End of Life: A Stepped Wedge Cluster Randomized Trial

Background: The transition to spontaneous breathing puts patients who are undergoing ventilator withdrawal at high risk for developing respiratory distress. A patient-centered algorithmic approach could standardize this process and meet unique patient needs because a single approach (weaning vs. one-step extubation) does not capture the needs of a heterogenous population undergoing this palliative procedure. Objectives: (1) Demonstrate that the algorithmic approach can be effective to ensure greater patient respiratory comfort compared to usual care; (2) determine differences in opioid or benzodiazepine use; (3) predict factors associated with duration of survival. Design/Settings/Measures: A stepped-wedge cluster randomized design at five sites was used. Sites crossed over to the algorithm in random order after usual care data were obtained. Patient comfort was measured with the Respiratory Distress Observation Scale© (RDOS) at baseline, at ventilator off, and every 15-minutes for an hour. Parenteral morphine and lorazepam equivalents from the onset of the process until patient death were calculated. Results: Usual care data n = 120, algorithm data n = 48. Gender and race were evenly distributed. All patients in the usual care arm underwent a one-step ventilator cessation; 58% of patients in the algorithm arm were weaned over an average of 18 ± 27 minutes as prescribed in the algorithm. Patients had significantly less respiratory distress in the intervention arm (F = 10.41, p = 0.0013, effective size [es] = 0.49). More opioids (t = -2.30, p = 0.023) and benzodiazepines (t = -2.08, p = 0.040) were given in the control arm. Conclusions: The algorithm was effective in ensuring patient respiratory comfort. Surprisingly, more medication was given in the usual care arm; however, less may be needed when distress is objectively measured (RDOS), and treatment is initiated as soon as distress develops as in the algorithm. Clinical Trial Registration number: NCT03121391.

Diverging Trends in the Incidence of Spontaneous Intracerebral Hemorrhage in Sweden 2010-2019: An Observational Study from the Swedish Stroke Register (Riksstroke)

INTRODUCTION

Although ischemic stroke incidence has decreased in Sweden over the past decade, trends in spontaneous intracerebral hemorrhage (ICH) incidence are less well delineated. In this time period, there has been a dramatic increase in use of oral anticoagulants (OAC). The aim of our study was to investigate incidence trends in spontaneous first-ever ICH in Sweden between 2010 and 2019, with a focus on non-OAC-associated and OAC-associated ICH.

METHODS

We included patients (≥18 years) with first-ever ICH registered in the hospital-based Swedish Stroke Register (Riksstroke) 2010-2019. Data were stratified by non-OAC and OAC ICH and analyzed for 2010-2012, 2013-2016, and 2017-2019. Incidence rates are shown as crude and age-specific per 100,000 person-years.

RESULTS

Between 2010 and 2019, 22,289 patients with first-ever ICH were registered; 18,325 (82.2%) patients with non-OAC ICH and 3,964 (17.8%) patients with OAC ICH. Annual crude incidence (per 100,000) of all first-ever ICH decreased by 10% from 29.5 (95% CI 28.8-30.3) to 26.7 (95% CI 26.0-27.3) between 2010-2012 and 2017-2019. The crude incidence rate of non-OAC ICH decreased by 20% from 25.7 (95% CI 25.0-26.3) to 20.7 (95% CI 20.1-21.2), whereas OAC ICH increased by 56% from 3.86 (95% CI 3.61-4.12) to 6.01 (95% CI 5.70-6.32). The proportion of OAC ICH of all first-ever ICH increased between 2010-2012 and 2017-2019 from 13.1% to 22.5% (p < 0.001). Proportional changes were largest in the age group ≥85 years with a decrease in non-OAC ICH by 32% from 155 (95% CI 146-164) to 106 (95% CI 98.6-113) and an increase in OAC ICH by 155% from 25.7 (95% CI 22.1-29.4) to 65.5 (95% CI 59.9-71.2).

CONCLUSION

Incidence of first-ever ICH in Sweden decreased by 10% between 2010 and 2019. We found diverging trends with a 20% decrease in non-OAC-associated ICH and a 56% increase in OAC-associated ICH. Further research on ICH epidemiology, analyzing non-OAC and OAC-associated ICH separately, is needed to follow up these diverging trends including underlying risk factors.

Estimating Sepsis Incidence Using Administrative Data and Clinical Medical Record Review

Importance

Despite the large health burden, reliable data on sepsis epidemiology are lacking; studies using International Statistical Classification of Diseases and Related Health Problems (ICD)-coded hospital discharge diagnosis for sepsis identification suffer from limited sensitivity. Also, ICD data do not allow investigation of underlying pathogens and antimicrobial resistance.

Objectives

To generate reliable epidemiological estimates by linking data from a population-based database to a reference standard of clinical medical record review.

Design, Setting, and Participants

This was a retrospective, observational cohort study using a population-based administrative database including all acute care hospitals of the Scania region in Sweden in 2019 and 2020 to identify hospital-treated sepsis cases by ICD codes. From this database, clinical medical records were also selected for review within 6 strata defined by ICD discharge diagnosis (both with and without sepsis diagnosis). Data were analyzed from April to October 2022.

Main outcomes and measures

Hospital and population incidences of sepsis, case fatality, antimicrobial resistance, and temporal dynamics due to COVID-19 were assessed, as well as validity of ICD-10 case identification methods compared with the reference standard of clinical medical record review.

Results

Out of 295 531 hospitalizations in 2019 in the Scania region of Sweden, 997 patient medical records were reviewed, among which 457 had sepsis according to clinical criteria. Of the patients with clinical sepsis, 232 (51%) were female, and 357 (78%) had at least 1 comorbidity. The median (IQR) age of the cohort was 76 (67-85) years. The incidence of sepsis in hospitalized patients according to the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) criteria in 2019 was 4.1% (95% CI, 3.6-4.5) by medical record review. This corresponds to an annual incidence rate of 747 (95% CI, 663-832) patients with sepsis per 100 000 population. No significant increase in sepsis during the COVID-19 pandemic nor a decrease in sepsis incidence when excluding COVID-19 sepsis was observed. Few sepsis cases caused by pathogens with antimicrobial resistance were found. The validity of ICD-10-based case identification in administrative data was low.

Conclusions and Relevance

In this cohort study of sepsis epidemiology, sepsis was a considerable burden to public health in Sweden. Supplying administrative data with information from clinical medical records can help to generate reliable data on sepsis epidemiology.

Use of healthcare before and after sepsis in Sweden: a case-control study

OBJECTIVES

The aim of this study was to compare readmissions and death between sepsis and non-sepsis hospitalisations the first year after discharge, and to investigate what diagnoses patients with sepsis present with at readmission. The aim was also to evaluate to what degree patients hospitalised for sepsis seek medical attention prior to hospitalisation.

DESIGN

Retrospective case-control study with data validated through clinical chart review. A disproportionate stratified sampling model was used to include a relatively larger number of sepsis hospitalisations.

SETTING

All eight public hospitals in region Scania, Sweden (1 January to 3 December 2019).

PARTICIPANTS

There were 447 patients hospitalised for sepsis (cases), and 541 hospitalised for other causes (control) identified through clinical chart review.

OUTCOME MEASURES

Cox regression was used to analyse readmission and death the year after discharge, and logistic regression was used to analyse healthcare the week prior to hospitalisation. Both analyses were made unadjusted, and adjusted for age, sex and comorbidities.

RESULTS

Out of patients who survived a sepsis hospitalisation, 48% were readmitted the year after discharge, compared with 39% for patients without sepsis (HR 1.50, 95% CI 1.03 to 2.19), p=0.04. The majority (52%) of readmissions occurred within 90 days and 75% within 180 days. The readmissions were most often caused by infection (32%), and 18% by cardiovascular disease. Finally, 34% of patients with sepsis had sought prehospital contact with a physician the week before hospitalisation, compared with 22% for patients without sepsis (OR 1.80, 95% CI 1.06 to 3.04), p=0.03.

CONCLUSION

Patients hospitalised for sepsis had a higher risk of readmission the year after discharge compared with patients without sepsis. The most common diagnoses at readmission were infection followed by cardiovascular disease. With better follow-up, some of these readmissions could potentially be prevented. Patients hospitalised for sepsis had sought prehospital contact the week prior to hospitalisation to a greater extent than patients without sepsis.

Predictors of do-not-attempt-resuscitation decisions in patients with infratentorial or large supratentorial intracerebral hemorrhages and consequences thereafter: a register-based, longitudinal study in Sweden

OBJECTIVES

Do-not-attempt-resuscitation (DNAR) decisions for patients with infratentorial or large supratentorial intracerebral hemorrhages (ICHs) pose clinical and ethical challenges. We aimed to investigate factors associated with DNAR decisions in patients with infratentorial or large (≥30 mL) supratentorial ICH, and differences in complications, treatment, and mortality.

MATERIALS & METHODS

This longitudinal, observational study comprised all patients treated for ICH at three stroke units in Gothenburg, Sweden, between November 2014 and June 2019. Patients were identified in the local stroke register, and additional data were collected from medical records and national registries. Mortality rates were followed 1 year after incident ICHs. Factors associated with DNAR decisions, and one-year mortality were explored.

RESULTS

Of 307 included patients, 164 received a DNAR decision. Most (75%) decisions were made within 24 h. DNAR decisions were associated with higher age, pre-stroke dependency, stroke severity, and intraventricular hemorrhage. Patients without DNAR decisions received thrombosis prophylaxis, oral antibiotics, and rehabilitative evaluations more frequently. The one-year survival probability was 0.16 (95% confidence interval [CI] 0.11-0.23) in patients with DNAR decisions, and 0.87 (95% CI 0.81-0.92) in patients without DNAR decision. DNAR decisions, higher age, stroke severity, hematoma volume, and comorbidities were associated with increased one-year mortality. Thrombosis prophylaxis and living alone were associated with a lower hazard.

CONCLUSION

The majority of DNAR decisions for patients with infratentorial or large supratentorial ICH were made within 48 h. Higher age, pre-stroke dependency, high stroke severity, and intraventricular hemorrhage predicted receiving a DNAR decision. DNAR decisions were strongly associated with increased short- and long-term mortality.

Diagnostic performance of biomarker S100B and guideline adherence in routine care of mild head trauma

BACKGROUND

The Scandinavian Neurotrauma Committee (SNC) has recommended the use of serum S100B as a biomarker for mild low-risk Traumatic brain injuries (TBI). This study aimed to assess the adherence to the SNC guidelines in clinical practice and the diagnostic performance of S100B in patients with TBI. The aims of this study were to examine adherence to the SNC guideline and the diagnostic accuracy of serum protein S100B.

METHODS

Data of consecutive patients of 18 years and above who presented to the emergency department (ED) at Helsingborg Hospital with isolated head injuries, were retrieved from hospital records. Patients with multitrauma, follow-up visits, and visits managed by a nurse without physician involvement were excluded.

RESULTS

A total of 1671 patients were included of which 93 (5.6%) had intracranial hemorrhage. CT scans were performed in 62% of patients. S100B was measured in 26% of patients and 30% of all measurements targeted the low-risk mild head injuries indicated by the guideline. S100B's recommended cut-off value (≥ 0.10 µg/L) had a 100% sensitivity, 47% specificity, 10.1% positive predictive value, and 100% negative predictive value-if applied to the target SNC category (SNC 4). If applied to all patients tested, the sensitivity was 93% for traumatic intracranial hemorrhage (TICH). Current ED practices were adherent to the SNC guideline in 55% of patients. Non-adherent practices occurred in 64% of patients with low-risk mild head injuries (SNC4) including overtesting or undertesting of S100B and CT scans.

CONCLUSION

Adherence to guidelines was low and associated with a higher admission rate than non-adherence practice but no significant increase in missed TICH or death associated with non-adherence to guideline was found. In routine care, we found that the sensitivity and NPV of serum protein S100B was excellent and safely ruled out TICH when measured in the patient category recommended by the guideline. However, measuring serum protein S100B in patients not recommended by the guideline rendered unacceptably low sensitivity with possible missed TICHs as a consequence. To further delineate the magnitude and impact of non-adherence, more studies are needed.

Patient factors associated with receiving reversal therapy in oral anticoagulant-related intracerebral hemorrhage

BACKGROUND

We aimed to describe baseline characteristics of patients with oral anticoagulant-related intracerebral hemorrhage (OAC-ICH) in Sweden and to identify predictive variables associated with receiving hemostatic treatment in the event of OAC-ICH.

METHODS

We performed an observational study based on data from Riksstroke and the Swedish Causes of Death Register to define baseline characteristics of patients with OAC-ICH who received reversal treatment compared with patients who did not receive reversal treatment during 2017-2019. Predictive analysis was performed using multivariable logistic regression to identify odds ratios for factors associated with receiving OAC reversal treatment.

RESULTS

We included 1902 patients ((n = 1146; OAC reversal treatment) (n = 756; no OAC reversal treatment)). The proportion of non-Vitamin K oral anticoagulant associated ICH (NOAC-ICH) patients who received reversal treatment was 48.4% and the proportion of Vitamin K antagonist-associated ICH (VKA-ICH) patients was 72.9%. Factors associated with a lower odds of receiving reversal treatment were increased age (OR = 0.98; 95% CI: 0.96-0.99), previous stroke (OR = 0.78; 95% CI: 0.62-0.98), comatose LOC (OR = 0.36;95%CI: 0.27-0.48; ref. = alert), pre-stroke dependency (OR = 0.72; 95% CI: 0.58-0.91), and NOAC treatment (OR = 0.34; 95% CI: 0.28-0.42). Care at a university hospital was not associated with higher odds of receiving reversal treatment compared to treatment at a county hospital.

CONCLUSION

Treatment with a reversal agent following OAC-ICH was related to several patient factors including type of OAC drug. We identified that only 48% of patients with NOAC-ICH received hemostatic treatment despite an increase in these cases. Further studies are required to guide the use of reversal therapies more precisely, particularly in NOAC-ICH.

Antiplatelet therapy contributes to a higher risk of traumatic intracranial hemorrhage compared to anticoagulation therapy in ground-level falls: a single-center retrospective study

BACKGROUND

Traumatic brain injury (TBI) is a common injury and constitutes up to 3% of emergency department (ED) visits. Current studies show that TBI is most commonly inflicted in older patients after ground-level falls. These patients often take medications affecting coagulation such as anticoagulants or antiplatelet drugs. Guidelines for ED TBI-management assume that anticoagulation therapy (ACT) confers a higher risk of traumatic intracranial hemorrhage (TICH) than antiplatelet therapy (APT). However, recent studies have challenged this. This study aimed to evaluate if oral anticoagulation and platelet inhibitors affected rate of TICH in head-trauma patients with ground-level falls.

METHODS

This was a retrospective review of medical records during January 1, 2017 to December 31, 2017 and January 1 2020 to December 31, 2020 of all patients seeking ED care because of head-trauma. Patients ≥ 18 years with ground-level falls were included.

RESULTS

The study included 1938 head-trauma patients with ground-level falls. Median age of patients with TICH was 81 years. The RR for TICH in APT-patients compared to patients without medication affecting coagulation was 1.72 (p = 0.01) (95% Confidence Interval (CI) 1.13-2.60) and 1.08 (p = 0.73), (95% CI 0.70-1.67) in ACT-patients. APT was independently associated with TICH in regression analysis (OR 1.59 (95% CI 1.02-2.49), p = 0.041).

CONCLUSION

This study adds to the growing evidence that APT-patients with ground-level falls might have as high or higher risk of TICH than ACT-patients. This is not addressed in the current guidelines which may need to be updated. We therefore recommend broad prospective studies.

Clinimetric study and review of the Reaction Level Scale

OBJECTIVES

Although the Reaction Level Scale (RLS) is still used for the assessment of the level of consciousness in distinct centers, its clinical characteristics and significance have been incompletely researched. In the current study, the clinimetric properties, the prognostic value, and the impact of the raters' background on the application of the RLS, in comparison with the Glasgow Coma Scale (GCS), are investigated.

MATERIALS AND METHODS

A systematic review on the available clinical evidence for the RLS was first carried out. Next, the RLS was translated into Greek, and patients with neurosurgical pathologies in need of consciousness monitoring were independently assessed with both RLS and GCS, by four raters (two consultants, one resident, and one nurse) within one hour. Interrater reliability, construct validity, and predictive value (mortality and poor outcome, at discharge and at 6 months) were evaluated.

RESULTS

Literature review retrieved 9 clinimetric studies related to the RLS, most of low quality, indicating that the scale has not been thoroughly studied. Both versions of the RLS (original and modified) showed high interrater reliability (κ_w >0.80 for all pairs of raters), construct validity (Spearman's p > .90 for all raters), and prognostic value (areas under the curve >0.85 for all raters and outcomes). However, except for broader patients' coverage, it failed to show any advantage over the GCS.

CONCLUSIONS

The RLS has not succeeded in showing any advantage over the GCS in terms of reliability and validity. Available evidence cannot justify its use in clinical practice as a substitute to the widely applied GCS.

Endovascular therapy in basilar artery occlusion in Sweden 2016-2019-a nationwide, prospective registry study

Purpose

We present the first nationwide study on endovascular therapy for basilar artery occlusion (BAO) from early hospital management to 3-month outcome.

Methods

Data were collected on all acute ischaemic stroke patients registered 2016–2019 in the two national quality registers for stroke care and endovascular therapy (EVT), receiving EVT for BAO and subclassified into proximal, middle and distal.

Results

In all, 251 patients were included: 69 proximal, 73 middle and 109 distal BAO. Patients with proximal BAO were younger (66, middle 71, distal 76, p < 0.0001), less often female (27.5%, middle 47.9%, distal 47.7%, p = 0.015), more often smokers (28.6%, middle 20.3%, distal 11.5%, p < 0.0001), and fewer had atrial fibrillation (13.2%, middle 24.7%, distal 48.6%, p < 0.0001). Level of consciousness and NIHSS score did not differ by BAO subtype and 52.2% were alert on admission. Time from groin puncture to revascularization was significantly longer in patients with proximal BAO (71, middle 46, distal 42 min, p < 0.0001), and angioplasty and/or stenting was more often performed in patients with proximal (43.4%) and middle (27.4%) than distal (6.4%) BAO (p < 0.0001). Cumulative 90-day mortality was 38.6% (proximal 50.7%, middle 32.9%, distal 34.9%, p = 0.02). Older and pre-stroke dependent patients had higher mortality, as did patients in whom angioplasty/stenting was performed.

Conclusion

We confirm a serious outcome in BAO despite endovascular therapies, and demonstrate important differences relating to occlusion location in baseline characteristics, procedural time, therapeutic measures and outcome. Further in-depth analyses of factors affecting outcome in BAO are warranted.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00234-021-02843-3.

Delirium in neurosurgery: a systematic review and meta-analysis

Delirium is a frequent occurring complication in surgical patients. Nevertheless, a scientific work-up of the clinical relevance of delirium after intracranial surgery is lacking. We conducted a systematic review (CRD42020166656) to evaluate the current diagnostic work-up, incidence, risk factors and health outcomes of delirium in this population. Five databases (Embase, Medline, Web of Science, PsycINFO, Cochrane Central) were searched from inception through March 31st, 2021. Twenty-four studies (5589 patients) were included for qualitative analysis and twenty-one studies for quantitative analysis (5083 patients). Validated delirium screening tools were used in 70% of the studies, consisting of the Confusion Assessment Method (intensive care unit) (45%), Delirium Observation Screening Scale (5%), Intensive Care Delirium Screening Checklist (10%), Neelon and Champagne Confusion Scale (5%) and Nursing Delirium Screening Scale (5%). Incidence of post-operative delirium after intracranial surgery was 19%, ranging from 12 to 26% caused by variation in clinical features and delirium assessment methods. Meta-regression for age and gender did not show a correlation with delirium. We present an overview of risk factors and health outcomes associated with the onset of delirium. Our review highlights the need of future research on delirium in neurosurgery, which should focus on optimizing diagnosis and assessing prognostic significance and management.

Prognosis of Intracerebral Hemorrhage Related to Antithrombotic Use: An Observational Study From the Swedish Stroke Register (Riksstroke)

BACKGROUND AND PURPOSE

To date, large studies comparing mortality and functional outcome of intracerebral hemorrhage (ICH) during oral anticoagulant (OAC), antiplatelet, and nonantithrombotic use are few and show discrepant results.

METHODS

We used data on 13 291 patients with ICH registered in Riksstroke between 2012 and 2016 to compare 90-day mortality and functional outcome following OAC-related ICH (n=2300), antiplatelet-related ICH (n=3637), and nonantithrombotic ICH (n=7354). Univariable and multivariable Cox regression analyses, with adjustment for relevant confounders, were used to compare 90-day mortality. Early (≤24 hours and 1-7 days) and late (8-90 days) mortality was also studied in subgroup analyses. Univariable and multivariable 90-day functional outcome, based on self-reported modified Rankin Scale, was determined using logistic regression.

RESULTS

Patients with antithrombotic treatment were more often prestroke dependent, older, and had a larger comorbidity burden compared with patients without antithrombotic treatment. At 90 days, antiplatelet and OAC were associated with an increased death rate in multivariable analysis (antiplatelet ICH: hazard ratio, 1.23 [95% CI, 1.14-1.33]; OAC ICH: hazard ratio, 1.40 [95% CI, 1.26-1.57]) compared with nonantithrombotic ICH (reference). OAC ICH and antiplatelet ICH were associated with higher risk of early mortality (≤24 hours: OAC ICH: hazard ratio, 1.93 [95% CI, 1.57-2.38]; antiplatelet ICH: hazard ratio, 1.32 [95% CI, 1.13-1.54]). In multivariable analysis, the odds ratios for the association of antiplatelet and OAC treatment on functional dependency (modified Rankin Scale score, 3-5) at 90 days were nonsignificant (antiplatelet: odds ratio, 1.07 [95% CI, 0.92-1.24]; OAC: odds ratio, 0.96 [95% CI, 0.76-1.22]).

CONCLUSIONS

In this large observational study, we found that 90-day mortality outcome was worse not only in OAC ICH but also in antiplatelet ICH, compared with patients with nonantithrombotic ICH. Antiplatelet ICH is common and is a serious condition with poor clinical outcome. Further studies are, therefore, warranted in determining the appropriate clinical management of these patients.

Differences in self-perceived general health, pain, and depression 1 to 5 years post-stroke related to work status at 1 year

Stroke is one of the most common diseases and has several potential consequences, such as psychological problems and pain. Return to work (RTW) after stroke in working-age individuals is incomplete. The present study aimed to investigate differences in self-perceived general health, pain, and depression between 1 and 5 years post-stroke related to RTW status. The study was nationwide, registry-based and the study population (n = 398) consisted of working-age people who had a stroke in 2011 and participated in 1-year and 5-year follow-up questionnaire surveys. Shift analyses with the Wilcoxon signed rank test and logistic regression were used. RTW within the first year post-stroke was associated with better self-perceived general health, less pain, and less depression both at 1 and 5 years post-stroke, compared with the no-RTW group. However, the RTW group had significant deterioration in general health and pain between 1 and 5 years, while the no-RTW group had no significant change. RTW was a significant predictor of lower odds of improvement in general health and pain between 1 and 5 years. This emphasizes the need for continued follow-up and support to ensure a balance between work and health for RTW individuals after stroke.

Reversal Treatment in Oral Anticoagulant-Related Intracerebral Hemorrhage-An Observational Study Based on the Swedish Stroke Register

Introduction: Intracerebral hemorrhage (ICH) is the most serious adverse effect of oral anticoagulant (OAC) treatment. The effect of OAC reversal therapy on outcome is uncertain. We compared 90-day survival and functional outcome in patients with OAC-ICH who received OAC reversal therapy with those who did not. Methods: Data from The Swedish Stroke Register (Riksstroke) for all registered cases of OAC-ICH during 2017 (572 patients) were used to obtain information on reversal (n = 369) and non-reversal (n = 203) treatment receiving patients. Univariate and multivariate Cox regression analysis stratified for level of consciousness (LOC) on admission, and adjustment for relevant baseline variables, was used to compare 90-day Hazard Ratios (HR) for mortality. Results: Sixty-five percent of patients received reversal treatment. These patients were younger, more often pre-stroke independent and alert at presentation. Withholding reversal treatment was associated with an increased death rate (HR = 1.47; 95% CI: 1.08-2.01) in a Cox regression model stratified for LOC and adjusted for baseline imbalances. Additional factors associated with an increased 90-day death rate were male sex (HR = 1.42; 95% CI: 1.06-1.92), age (HR = 1.05; 95% CI: 1.02-1.07), and intraventricular hemorrhage (HR = 2.41; CI: 1.77-3.29). Conclusion: In this large observational study 35% of patients with OAC-ICH did not receive reversal treatment. Patients receiving OAC-reversal treatment had an improved 90-day mortality outcome compared to those not receiving treatment. Mortality was strongly related to LOC. Further, and larger, studies are required to determine which patient groups may benefit from reversal therapy and in whom non-reversal is adequate.

Patterns in hospital readmissions after ischaemic stroke - An observational study from the Swedish stroke register (Riksstroke)

Introduction

While acute treatment and secondary prevention in stroke have undergone major improvements, hospital readmission after index stroke remains high. However, there are few reports on long-term readmission patterns.

Patients and methods

For this prospective observational study, data on demographics, functional status and living conditions were obtained from the Swedish Stroke Register (Riksstroke). Data on comorbidity and hospital readmissions up to five years post-index stroke were obtained from the Swedish National Patient Register. Patients were grouped based on number of readmissions: low (0–1) intermediate (2–4), high (5–9) or very high (≥10).

Results

Of the 10,092 patients included, 43.7% had been readmitted within 12 months and 74.0% within 5 years. There was an average of three readmissions per individual during the five-year interval. A small group of patients with a high-comorbidity burden accounted for the majority of readmissions: approximately 20% of patients accounted for 60% of readmissions, and 5% of patients accounted for 25%. Circulatory conditions were the most common cause followed by infectious disease, stroke, trauma and diseases of the nervous system other than stroke. The proportion of readmissions due to stroke decreased sharply in the first six months.

Conclusion

A small number of patients with a high degree of comorbidity accounted for the majority of hospital readmissions after index stroke. Our results highlight the need for further development of strategies to support high-risk comorbid stroke patients in the community setting. Further research describing characteristics and healthcare utilisation patterns in this group is warranted.

Drug trends and harm related to new psychoactive substances (NPS) in Sweden from 2010 to 2016: Experiences from the STRIDA project

Background

In the past decade, hundreds of new psychoactive substances (NPS) have been introduced as unclassified alternatives to the illicit drugs. The NPS represent a growing health concern by causing adverse effects and deaths but are usually undetectable by conventional drug tests. This report summarizes results and experiences from analytically confirmed drug-related acute intoxications in emergency departments (ED) and intensive care units (ICU) enrolled in the Swedish STRIDA project on NPS in 2010–2016.

Methods and findings

ED/ICU intoxications suspected to involve NPS were enrolled in the project, after initial contact with the Poisons Information Centre (PIC). Serum/plasma and urine samples, and sometimes drug products, were subjected to a comprehensive toxicological investigation, and the PIC retrieved information on associated clinical symptoms and treatment. Between January 2010-February 2016, 2626 cases were enrolled. The patients were aged 8–71 (mean 27, median 24) years and 74% were men. Most biological samples (81%) tested positive for one, or more (70%), psychoactive drugs, including 159 NPS, other novel or uncommon substances, classical recreational and illicit drugs, and prescription medications. When first detected, most NPS or other novel substances (75%) were not banned in Sweden, but they usually disappeared upon classification, which however often took a year or longer. Some NPS were found to be especially harmful and even fatal.

Conclusions

The STRIDA project provided a good overview of the current drug situation in Sweden and demonstrated a widespread use and rapid turnover of many different psychoactive substances. The accomplishment of the project can be attributed to several key factors (close collaboration between the PIC and laboratory to identify suspected poisonings, free analysis, continuous updating of analytical methods, evaluation of adverse effects, and sharing information) that are useful for future activities addressing the NPS problem. The results also illustrated how drug regulations can drive the NPS market.

Etiology, clinical presentation, outcome and the effect of initial management in immunocompromised patients with community acquired bacterial meningitis

OBJECTIVES

The aim was to analyze differences in clinical presentation, etiology, management, and outcome between immunocompromised and immunocompetent patients with acute bacterial meningitis (ABM).

METHODS

Data were extracted from 1056 adult ABM patients prospectively registered in the national Swedish quality register for ABM during 2008-2017. Primary endpoint was 30-day mortality and secondary endpoints 90-day mortality and unfavorable outcome.

RESULTS

An immunocompromised state was observed in 352 (33%) of the 1056 patients. Streptococcus pneumoniae dominated in both immunocompromised and immunocompetent patients (53% in both groups), whereas L monocytogenes occurred in 11% and 2%, respectively. The unadjusted odds ratio (OR) for 30-day mortality in immunocompromised compared to immunocompetent patients was 1.68 (95% confidence interval (CI): 1.07-2.63). Adjusted for age, sex, and mental status on admission the OR was 1.34 (CI: 0.82-2.21). Adjusted also for time to antibiotic treatment and corticosteroids the OR was 1.10 (CI: 0.59-2.05), and in patients without Listeria meningitis 0.98 (CI: 0.50-1.90). Although, the ORs were higher for 90-day mortality and unfavorable outcome the effects of adjustments were similar.

CONCLUSION

Mortality in immunocompromised patients with ABM is only moderately increased unless caused by Listeria. This difference is further reduced in patients given early antibiotic treatment and adjunctive corticosteroids.

FUNDING

This work was supported by Stockholm County Council.

Return to work after stroke: A Swedish nationwide registry-based study

OBJECTIVES

A substantial proportion of individuals with stroke are of working age. After stroke, it is important to return to work (RTW), both for the individual's satisfaction with life and economically for society. The current comprehensive, long-term study aimed at investigating in what time period the RTW continues after stroke and what factors could predict RTW.

MATERIALS AND METHODS

All individuals registered in the registry Riksstroke with stroke in Sweden at ages 18-58 years during 2011 were eligible for participation. RTW was based on sickness absence data from the Social Insurance Agency covering 1 year prestroke to 5 years post-stroke. Time to RTW was analyzed with Kaplan-Meier curves. Potential predictors of RTW were analyzed with Cox regression and logistic regression.

RESULTS

For RTW analyses, 1695 participants were included. Almost 50% RTW within 3 months, 70% within 1 year, and 80% within 2 years post-stroke. However, the RTW continued for several years, with a total of 85% RTW. Predictors of favorable time to RTW were male sex, ischemic stroke, and long university education compared with primary school education. Predictors of unfavorable times to RTW were higher stroke severity, defined by the level of consciousness, and older ages. Participants with self-expectations of RTW 1 year post-stroke had higher odds of RTW within 5 years.

CONCLUSIONS

The RTW continues for a longer time after stroke than previously known. Both self-expectations and demographical, socioeconomic, stroke-related factors were important predictors of RTW. This knowledge could assist healthcare professionals to individualize the rehabilitation post-stroke.

Application of NICE or SNC guidelines may reduce the need for computerized tomographies in patients with mild traumatic brain injury: a retrospective chart review and theoretical application of five guidelines

BACKGROUND

Traumatic brain injuries continue to be a significant cause of mortality and morbidity worldwide. Most traumatic brain injuries are classified as mild, with a low but not negligible risk of intracranial hemorrhage. To help physicians decide which patients might benefit from a computerized tomography (CT) of the head to rule out intracranial hemorrhage, several clinical decision rules have been developed and proven effective in reducing the amount of negative CTs, but they have not been compared against one another in the same cohort as to which one demonstrates the best performance.

METHODS

This study involved a retrospective review of the medical records of patients seeking care between January 1 and December 31, 2017 at Helsingborg Hospital, Sweden after head trauma. The Canadian CT Head Rule (CCHR), the New Orleans Criteria (NOC), the National Emergency X-Radiography Utilization Study II (NEXUS II), the National Institute of Health and Care Excellence (NICE) guideline and the Scandinavian Neurotrauma Committee (SNC) guideline were analyzed. A theoretical model for each guideline was constructed and applied to the cohort to yield a theoretical CT-rate for each guideline. Performance parameters were calculated and compared.

RESULTS

One thousand three hundred fifty-three patients were included; 825 (61%) CTs were performed, and 70 (5.2%) cases of intracranial hemorrhage were found. The CCHR and the NOC were applicable to a minority of the patients, while the NEXUS II, the NICE, and the SNC guidelines were applicable to the entire cohort. A theoretical application of the NICE and the SNC guidelines would have reduced the number of CT scans by 17 and 9% (P = < 0.0001), respectively, without missing patients with intracranial hemorrhages requiring neurosurgical intervention.

CONCLUSION

A broad application of either NICE or the SNC guidelines could potentially reduce the number of CT scans in patients suffering from mTBI in a Scandinavian setting, while the other guidelines seemed to increase the CT frequency. The sensitivity for intracranial hemorrhage was lower than in previous studies for all guidelines, but no fatality or need for neurosurgical intervention was missed by any guideline when they were applicable.

Meropenem versus Cefotaxime and Ampicillin as Empirical Antibiotic Treatment in Adult Bacterial Meningitis: a Quality Registry Study, 2008 to 2016

Cefotaxime, alone or with ampicillin, is frequently used in empirical treatment of acute bacterial meningitis (ABM). Meropenem is a less extensively investigated alternative. The aim of the study was to investigate the effects of empirical treatment with meropenem compared to cefotaxime plus ampicillin on outcome in ABM. The study was based on data from the Swedish quality register for ABM collected between January 2008 and December 2016. Propensity score matching was performed to adjust for baseline differences between the groups. Mortality within 30 days was the primary outcome. The treatment regimens of interest were administered to 623 patients; 328 were given cefotaxime plus ampicillin whereas 295 received meropenem. Using propensity score matching, the 30-day mortality rates were 3.2% in the cefotaxime plus ampicillin group and 3.6% in the meropenem group. For matched cases, the odds ratio (OR) for 30-day mortality for meropenem versus cefotaxime plus ampicillin was 1.15 (confidence interval [CI], 0.41 to 3.22; P = 0.79). The OR for 90-day mortality was 1.47 (CI, 0.62 to 3.52; P = 0.38) and for unfavorable outcome was 1.10 (CI, 0.75 to 1.63; P = 0.62). The findings of our study indicate that meropenem is an effective empirical treatment option for adults with community-acquired ABM. However, to spare carbapenems, guidelines should continue to recommend third-generation cephalosporins as an empirical treatment for the majority of patients with ABM.

Lumbar Puncture Performed Promptly or After Neuroimaging in Acute Bacterial Meningitis in Adults: A Prospective National Cohort Study Evaluating Different Guidelines

Background

Early treatment is pivotal for favorable outcome in acute bacterial meningitis (ABM). Lumbar puncture (LP) is the diagnostic key. The aim was to evaluate the effect on outcome of adherence to European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Infectious Diseases Society of America (IDSA), and Swedish guidelines regarding neuroimaging before LP.

Methods

The cohort comprised 815 adult ABM patients in Sweden registered prospectively between 2008 and 2015. Primary endpoint was in-hospital mortality and secondary endpoint was favorable outcome at 2-6 months of follow-up.

Results

Indications for neuroimaging before LP existed in 7%, 32%, and 65% according to Swedish, ESCMID, and IDSA guidelines, respectively. The adjusted odds ratio (aOR) was 0.48 (95% confidence interval [CI], .26-.89) for mortality and 1.52 (95% CI, 1.08-2.12) for favorable outcome if Swedish guidelines were followed. ESCMID guideline adherence resulted in aOR of 0.68 (95% CI, .38-1.23) for mortality and 1.05 (95% CI, .75-1.47) for favorable outcome. Following IDSA recommendations resulted in aOR of 1.09 (95% CI, .61-1.95) for mortality and 0.59 (95% CI, .42-.82) for favorable outcome. Performing prompt vs neuroimaging-preceded LP was associated with aOR of 0.38 (95% CI, .18-.77) for mortality and 2.11 (95% CI, 1.47-3.00) for favorable outcome. The beneficial effect of prompt LP was observed regardless of mental status and immunosuppression.

Conclusions

Adherence to Swedish guidelines in ABM is associated with decreased mortality and increased favorable outcome in contrast to adherence to ESCMID or IDSA recommendations. Our findings support that impaired mental status and immunocompromised state should not be considered indications for neuroimaging before LP in patients with suspected ABM.

Epidemiology of NPS Based Confirmed Overdose Cases: The STRIDA Project

The Swedish STRIDA project on new psychoactive substances (NPS) monitored the occurrence and health hazards of novel recreational drugs in Sweden through evaluation of analytically confirmed adverse events presenting in emergency departments and intensive care units. During a ~6-year period from 2010 to early 2016, about 2,600 cases of suspected NPS intoxications were included in the project. About 75% of patients were men and the total age range was 8-71 (median 24) years and 57% were 25 years or younger. A large number of NPS belonging to many different drug classes were identified in project samples of urine and blood (serum/plasma) submitted for free drug testing, including synthetic cannabinoid receptor agonists, stimulants, cathinones, hallucinogens, dissociative drugs, benzodiazepines, and opioids, and also in drug materials from the cases forwarded to the laboratory along with the biological samples. The STRIDA project has been shown to serve as an effective early warning system for NPS by collecting data on incidence, distribution, and adverse effects and has supported healthcare professionals in the knowledge and critical care of intoxications caused by a wide range of novel substances. The results of the STRIDA project have also illustrated how drug regulations can drive the NPS market.

A proposed amendment to the current guidelines for mild traumatic brain injury: reducing computerized tomographies while maintaining safety

PURPOSE

Head trauma is a common complaint in emergency departments. Identifying patients with serious injuries can be difficult and generates many computerized tomographies. Reducing the number of computerized tomographies decreases both cost and radiation exposure. The aim of this study was to evaluate whether the current Scandinavian Neurotrauma Committee guidelines could be revised in such a way that would enable hospitals to perform fewer computerized tomographies while maintaining the ability to identify all patients requiring neurological intervention.

METHODS

A retrospective study of the medical records of adult patients suffering a traumatic brain injury was performed. A total of 1671 patients over a period of 365 days were included, and 25 parameters were extracted. Multitrauma patients managed with ATLS™ were excluded. The Scandinavian Neurotrauma Committee guidelines were amended with the previously derived "low-risk proposal" and applied retrospectively to the cohort.

RESULTS

Incidence of intracranial hemorrhage was 5.6% (93/1671). Application of the current Scandinavian Neurotrauma Committee guidelines would have resulted in 860 computerized tomographies and would have missed 11 intracranial hemorrhages. The proposed amendment with the low-risk proposal would have resulted in 748 CT scans and would have missed 19 intracranial hemorrhages (a relative reduction of 13%). None of the missed intracranial hemorrhages required neurological intervention.

CONCLUSION

For patients with mild and moderate traumatic brain injuries, application of the Scandinavian Neurotrauma Committee guidelines amended with the low-risk proposal may result in a significant reduction of computerized tomographies without missing any patients in need of neurological intervention.

Prognosis for intracerebral hemorrhage during ongoing oral anticoagulant treatment

BACKGROUND

Intracerebral hemorrhage (ICH) is the most serious adverse effect of treatment with oral anticoagulants. Prognostic data after ICH associated with non-vitamin K antagonist oral anticoagulants (NOAC) compared to vitamin K antagonists (VKA) are sparse. We compared 90-day survival and functional outcome following NOAC-ICH versus VKA-ICH using data from the Swedish Stroke Register (Riksstroke).

METHODS

Using data from Riksstroke and the Swedish Causes of Death Register between 2012 and 2016, we compared all-cause 90-day mortality for patients with NOAC-ICH versus VKA-ICH using Kaplan-Meier survival analysis and Log-rank test. Cox regression, with adjustment for age, sex, previous stroke, and level of consciousness (LOC) on admission, was used to estimate hazard ratios (HR) for 90-day mortality. Estimated functional outcome at 90 days, based on the modified Rankin Scale (mRS), was compared between VKA- and NOAC-associated ICH using chi-squared test.

RESULTS

We included 2483 patients; 300 with NOAC-ICH and 2183 with VKA-ICH. In both groups, mean age was 79 years, and 58% were male. No significant difference between NOAC-ICH and VKA-ICH was found for all-cause 90-day mortality (44.3% NOAC-ICH versus 42.6% VKA-ICH; P = 0.54, HR = 0.93; 95% confidence interval (CI): 0.78-1.12) or 90-day estimated functional outcome (mRS 0-2:13.7% and 15.3%; mRS 3-5:27.3% and 28.9%, respectively (P = 0.52)). Factors predicting death were increased age (HR = 1.03; 95%CI: 1.02-1.04) and reduced LOC (drowsy: HR = 3.48; 95%CI: 2.86-4.23; comatose: HR = 12.27; 95%CI: 10.13-14.87).

CONCLUSION

In this large study on anticoagulant-associated ICH, we found no significant difference in mortality and functional outcome at 90 days between NOAC-ICH versus VKA-ICH.

Long-Term Survival and Function After Stroke: A Longitudinal Observational Study From the Swedish Stroke Register

Background and Purpose- Longitudinal long-term prognostic data after stroke based on large cohorts are sparse. We report recent survival and functional outcome data on ischemic stroke (IS) and intracerebral hemorrhage (ICH) for up to 5 years poststroke from the Swedish Stroke Register (Riksstroke). Methods- Beyond Riksstroke's regular follow-up surveys at 3 and 12 months, additional surveys were conducted in 2016 on 2 one-year cohorts with stroke 3 and 5 years earlier. Functional dependency was defined as modified Rankin Scale ≥3. Mortality data of the original cohorts were obtained from the Swedish Causes of Death Register. Multiple imputation was used to estimate functional status in nonresponders. Results- The study included 22 929 patients, 87.5% with IS and 12.5% with ICH. Loss to follow-up in the 4 surveys was 12.8% to 21.2%. Thirty-day mortality was higher for ICH than for IS (30.7% versus 11.1%; P<0.01), whereas for 30-day survivors, 5-year mortality did not differ significantly (P=0.858). Functional outcome was less favorable for ICH at all follow-up points. At 5 years, poor outcome (death or dependency) was 79% in ICH and 70.6% in IS (including imputed data; P<0.01). Favorable outcome was less common with increasing age and in patients with prestroke functional dependency. Conclusions- Despite advances in stroke care, long-term prognosis remains a cause for concern. At 5 years after stroke over 2 in 3 patients with IS, and over 3 in 4 patients with ICH, were dead or dependent. We present robust long-term prognostic data to serve as a reference for further development of healthcare and research in stroke.

Occurrence and time course of NPS benzodiazepines in Sweden - results from intoxication cases in the STRIDA project

CONTEXT

In recent years, many unclassified benzodiazepines (BZD) have appeared through online sale as new psychoactive substances (NPS). This study describes bioanalytical and clinical data related to intoxications involving NPS BZD ("designer BZD") in the Swedish STRIDA project.

STUDY DESIGN

Case series of consecutive patients with admitted or suspected intake of NPS presenting to hospitals all over Sweden for emergency treatment in 2012-2016.

PATIENTS AND METHOD

Urine samples collected in the STRIDA project were analyzed for 28 NPS BZD, using immunoassay and liquid chromatography-high-resolution mass spectrometry . Data of patient's age, gender, reported substance exposure, clinical signs, and treatment were obtained from medical and Poisons Information Center (PIC) records.

RESULTS

A total of fifteen different NPS BZD were analytically confirmed in 217 of 1913 (11%) cases involving patients (81% men) aged 15-66 (mean 28) years. The frequency of positive samples increased from 4% in 2012 to 19% in 2015. Etizolam (20 cases) was the first detected NPS BZD (January 2012), and it was followed by metizolam (four cases), estazolam (two), pyrazolam (33), flubromazepam (33), nifoxipam (five), diclazepam (four), meclonazepam (26), bromazepam (one), flubromazolam (92), deschloroetizolam (one), clonazolam (16), 3-hydroxyphenazepam (eight), ketazolam (one), and phenazepam (one). Most cases (89%) also involved other drugs. Use of NPS BZD was rarely (15%) reported during PIC consultation. In 24 patients exposed only to NPS BZD, CNS depression was the most prominent clinical sign, seven were observed in the intensive care unit, and they responded positively to flumazenil treatment.

CONCLUSIONS

An increasing use of NPS BZD in Sweden was detected in acute intoxication cases, sometimes leading to intensive care monitoring and support needs.

Acute Intoxications Involving α-Pyrrolidinobutiophenone (α-PBP): Results from the Swedish STRIDA Project

Introduction

Many new psychoactive substances (NPS) introduced as recreational drugs have been associated with severe intoxication and death.

Methods

Blood and/or urine samples were collected from intoxicated patients treated at Swedish hospitals that participated in the STRIDA project, a nationawide effort to address the growing problem of NPS. In patients undergoing evaluation for drug overdose, α-PBP was identified using liquid chromatography-mass spectrometry. Demographic and clinical data were collected during Poisons Information Centre consultations and retrieved from medical records.

Results

From April 2013 to November 2015, 43 patients tested positive for α-PBP. However, α-PBP was never specifically mentioned during consultation but only confirmed analytically. The α-PBP concentrations ranged 2.0–13,200 ng/mL in urine and 2.0–440 ng/mL in serum. The patients were aged 19–57 (mean 34) years, 81% were men, and 73% were known drug addicts. All cases except 1 also involved other NPS and/or classical drugs. MDPV, α-PVP, and other pyrovalerone analogues were the most common other NPS (31 cases; 72%). CNS depressants were detected in 28 cases (65%), with benzodiazepines (16 cases) being most frequent. Main clinical characteristics were agitation/anxiety (59%), tachycardia (54%), and hypertension (37%), and 14 patients (33%) required monitoring in the intensive care unit of which 8 were graded as severe intoxications. No fatalities were reported.

Conclusion

Patients with intoxication from α-PBP resembled those by NPS cathinones MDPV and α-PVP. As patients never specifically declared α-PBP intake and poly-drug intoxication was common, they may have been unaware of the actual substance taken.

Factors Influencing the Reliability of the Glasgow Coma Scale: A Systematic Review

BACKGROUND

The Glasgow Coma Scale (GCS) characterizes patients with diminished consciousness. In a recent systematic review, we found overall adequate reliability across different clinical settings, but reliability estimates varied considerably between studies, and methodological quality of studies was overall poor. Identifying and understanding factors that can affect its reliability is important, in order to promote high standards for clinical use of the GCS.

OBJECTIVE

The aim of this systematic review was to identify factors that influence reliability and to provide an evidence base for promoting consistent and reliable application of the GCS.

METHODS

A comprehensive literature search was undertaken in MEDLINE, EMBASE, and CINAHL from 1974 to July 2016. Studies assessing the reliability of the GCS in adults or describing any factor that influences reliability were included. Two reviewers independently screened citations, selected full texts, and undertook data extraction and critical appraisal. Methodological quality of studies was evaluated with the consensus-based standards for the selection of health measurement instruments checklist. Data were synthesized narratively and presented in tables.

RESULTS

Forty-one studies were included for analysis. Factors identified that may influence reliability are education and training, the level of consciousness, and type of stimuli used. Conflicting results were found for experience of the observer, the pathology causing the reduced consciousness, and intubation/sedation. No clear influence was found for the professional background of observers.

CONCLUSION

Reliability of the GCS is influenced by multiple factors and as such is context dependent. This review points to the potential for improvement from training and education and standardization of assessment methods, for which recommendations are presented.

Outcome of Trauma Patients Admitted to Emergency Department Based on Full Outline of Unresponsiveness Score

Introduction:

Full Outline of Unresponsiveness (FOUR) score is one of the existing scoring scales, which has been used for evaluating the level of consciousness in recent years.

Objective:

The present study has been done with the aim of evaluating the ability to predict the outcome of patients with head trauma based on FOUR score on admission to emergency department (ED).

Methods:

In the present prospective cross-sectional study, head trauma patients with any changes in alertness level presenting to ED were evaluated. FOUR score measurement was done on admission and 6 hours after that. The studied outcomes in the current study included discharge without sequel, discharge with neurologic sequel, brain death or death during 1 month after admission of the patients. To evaluate the correlation between FOUR score and the studied outcomes, area under the receiver operating characteristic (ROC) curve was used.

Results:

In the end, 52 patients with the mean age of 32.67 ± 15.20 years were evaluated (84.6% male). Traffic accident with the frequency of 39 (75.0%) patients was the most common mechanism of trauma among the studied patients and finally, after 1 month follow up it was determined that 13 (25%) patients were discharged without sequel and 31 (59.6%) died. Area under the ROC curve for prediction of the final outcome of death using FOUR score on admission and after 6 hours were 0.889 (95% confidence interval: 0.800 - 0.977) and 0.974 (95% confidence interval: 0.938 – 1.000), respectively. Best cutoff points for FOUR score were the scores 8 and 9 on admission of the patients, and the score 5, six hours after admission.

Conclusion:

Based on the findings of this study, it seems that FOUR score is applicable for prediction of probable death outcome in patients with head trauma presenting to ED.

Fever in the Emergency Department Predicts Survival of Patients With Severe Sepsis and Septic Shock Admitted to the ICU

OBJECTIVES

To study the prognostic value of fever in the emergency department in septic patients subsequently admitted to the ICU.

DESIGN

Observational cohort study from the Swedish national quality register for sepsis.

SETTING

Thirty ICU's in Sweden.

PATIENTS

Two thousand two hundred twenty-five adults who were admitted to an ICU within 24 hours of hospital arrival with a diagnosis of severe sepsis or septic shock were included.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Body temperature was measured and classified according to four categories (< 37°C, 37-38.29°C, 38.3-39.5°C, ≥ 39.5°C). The main outcome was in-hospital mortality. Odds ratios for mortality according to body temperature were estimated using multivariable logistic regression. Subgroup analyses were conducted according to age, sex, underlying comorbidity, and time to given antibiotics. Overall mortality was 25%. More than half of patients had a body temperature below 38.3°C. Mortality was inversely correlated with temperature and decreased, on average, more than 5% points per °C increase, from 50% in those with the lowest temperatures to 9% in those with the highest. Increased body temperature in survivors was also associated with shorter hospital stays. Patients with fever received better quality of care, but the inverse association between body temperature and mortality was robust and remained consistent after adjustment for quality of care measures and other factors that could have confounded the association. Among vital signs, body temperature was best at predicting mortality.

CONCLUSIONS

Contrary to common perceptions and current guidelines for care of critically ill septic patients, increased body temperature in the emergency department was strongly associated with lower mortality and shorter hospital stays in patients with severe sepsis or septic shock subsequently admitted to the ICU.

Comparing Time-Fixed Mortality Prediction Models and Their Effect on ICU Performance Metrics Using the Simplified Acute Physiology Score 3

OBJECTIVES

To examine ICU performance based on the Simplified Acute Physiology Score 3 using 30-day, 90-day, or 180-day mortality as outcome measures and compare results with 30-day mortality as reference.

DESIGN

Retrospective cohort study of ICU admissions from 2010 to 2014.

SETTING

Sixty-three Swedish ICUs that submitted data to the Swedish Intensive Care Registry.

PATIENTS

The development cohort was first admissions to ICU during 2011-2012 (n = 53,546), and the validation cohort was first admissions to ICU during 2013-2014 (n = 57,729).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Logistic regression was used to develop predictive models based on a first level recalibration of the original Simplified Acute Physiology Score 3 model but with 30-day, 90-day, or 180-day mortality as measures of outcome. Discrimination and calibration were excellent for the development dataset. Validation in the more recent 2013-2014 database showed good discrimination (C-statistic: 0.85, 0.84, and 0.83 for the 30-, 90-, and 180-d models, respectively), and good calibration (standardized mortality ratio: 0.99, 0.99, and 1.00; Hosmer-Lemeshow goodness of fit H-statistic: 66.4, 63.7, and 81.4 for the 30-, 90-, and 180-d models, respectively). There were modest changes in an ICU's standardized mortality ratio grouping (< 1.00, not significant, > 1.00) when follow-up was extended from 30 to 90 days and 180 days, respectively; about 11-13% of all ICUs.

CONCLUSIONS

The recalibrated Simplified Acute Physiology Score 3 hospital outcome prediction model performed well on long-term outcomes. Evaluation of ICU performance using standardized mortality ratio was only modestly sensitive to the follow-up time. Our results suggest that 30-day mortality may be a good benchmark of ICU performance. However, the duration of follow-up must balance between what is most relevant for patients, most affected by ICU care, least affected by administrative policies and practically feasible for caregivers.

Toxicity evaluation of α-pyrrolidinovalerophenone (α-PVP): results from intoxication cases within the STRIDA project

CONTEXT

An increasing number of new psychoactive substances (NPS) of different chemical classes have become available through marketing and sale over the Internet. This report from the Swedish STRIDA project presents the prevalence, laboratory results, and clinical features in a series of intoxications involving the stimulant NPS α-pyrrolidinovalerophenone (α-PVP), a potent dopamine re-uptake inhibitor, over a 4-year period.

STUDY DESIGN

Observational case series of consecutive patients with admitted or suspected intake of NPS presenting to hospitals in Sweden from 2012 to 2015.

PATIENTS AND METHODS

In the STRIDA project, blood and urine samples are collected from intoxicated patients with admitted or suspected intake of NPS or unknown drugs presenting to hospitals over the country. Analysis of NPS is performed by mass spectrometry multicomponent methods. Clinical data are collected when caregivers consult the Swedish Poisons Information Centre (PIC), and retrieved from medical records. The severity of poisoning is graded retrospectively using the Poisoning Severity Score (PSS). The inclusion criteria for this study included absence of other stimulants than α-PVP.

RESULTS

During the 4-year study period, 23 intoxications were originally coded as "α-PVP related" out of a total 3743 NPS-related inquiries (0.6%) at the PIC. The present study covered 42 analytically confirmed cases in which α-PVP was the only stimulant detected. The age range of patients was 20-58 (median 32) years, of which 79% were males. The α-PVP concentration in serum was 4.0-606 (median 64; n = 42) ng/mL and 2.0-41,294 (median 1782; n = 25) ng/mL in urine. There was no statistically significant association between the serum α-PVP concentration and urinary α-PVP/creatinine ratio in 25 cases, where both sets of data were available. In 14/42 (33%) cases, α-PVP was the only psychoactive substance identified. In the remaining cases, additional substances comprised opioids, benzodiazepines, and ethanol. The main clinical manifestations were tachycardia (80%), agitation (70%), hypertension (33%), hallucinations (20%), and delirium (18%). Classification of poisoning severity yielded 25 (60%) moderate (PSS 2), 7 (17%) severe (PSS 3), and 2 fatal cases (PSS 4).

CONCLUSIONS

In analytically confirmed α-PVP intoxication cases involving no other stimulant drugs, the urine and serum concentrations showed high variability. The clinical features were consistent with a severe sympathomimetic toxidrome. The results further demonstrated that α-PVP prevailed as a drug of abuse after being classified as a narcotic substance, and despite a high incidence of severe poisonings and fatalities. However, the low prevalence of α-PVP cases registered at the PIC suggested that many were unaware of the actual substance they had taken.

Associations between Ischemic Stroke Follow-Up, Socioeconomic Status, and Adherence to Secondary Preventive Drugs in Southern Sweden: Observations from the Swedish Stroke Register (Riksstroke)

Background: Currently, the knowledge that one has on adequate stroke follow-up practices is limited. We report associations between 90-day stroke follow-up, socio-economy and adherence to secondary prevention in southern Sweden. Methods: Data on 5,602 patients with ischemic stroke January 1, 2008-December 31, 2010, were obtained from Riksstroke and linked to official registers for information on education, birth country, doctor's follow-ups, and secondary prevention. Primary adherence at 4 months and persistence at 14 months post-stroke were calculated for warfarin, statins, antihypertensive, and antiplatelet drugs. Results: The 90-day follow-up rate was 75%. Patients not receiving a 90-day follow-up had lower age-adjusted OR of persistent drug use at 14 months for antihypertensive agents (OR = 0.74, 95% CI 0.60-0.91) and for antiplatelet drugs (OR = 0.72, 95% CI 0.60-0.87). Drug adherence rates 14 months post-stroke were 85% for antiplatelet drugs, 69% for warfarin, 88% for antihypertensive agents, and 76% for statins. One in three patients discontinued using one or more drug class within 14 months, and nonadherence was associated with activities of daily living dependency at 3 months (age-adjusted OR 0.63, 95% CI 0.57-0.69), but not with age, gender, or educational status. Conclusions: The use of secondary preventive drugs decreases over the first year after stroke and remains suboptimal. Specific reasons for nonadherence warrant further study.

Computed tomography and clinical outcome in patients with severe traumatic brain injury

OBJECTIVE

To study: (i) acute computed tomography (CT) characteristics and clinical outcome; (ii) clinical course and (iii) Corticosteroid Randomisation after Significant Head Injury acute calculator protocol (CRASH) model and clinical outcome in patients with severe traumatic brain injury (sTBI).

METHODS

Initial CT (CT_i) and CT 24 hours post-trauma (CT₂₄) were evaluated according to Marshall and Rotterdam classifications. Rancho Los Amigos Cognitive Scale-Revised (RLAS-R) and Glasgow Outcome Scale Extended (GOSE) were assessed at three months and one year post-trauma. The prognostic value of the CRASH model was evaluated.

RESULTS

Thirty-seven patients were included. Marshall CT_i and CT₂₄ were significantly correlated with RLAS-R at three months. Rotterdam CT₂₄ was significantly correlated with GOSE at three months. RLAS-R and the GOSE improved significantly from three months to one year. CRASH predicted unfavourable outcome at six months for 81% of patients with bad outcome and for 85% of patients with favourable outcome according to GOSE at one year.

CONCLUSION

Neither CT nor CRASH yielded clinically useful predictions of outcome at one year post-injury. The study showed encouragingly many instances of significant recovery in this population of sTBI. The combination of lack of reliable prognostic indicators and favourable outcomes supports the case for intensive acute management and rehabilitation as the default protocol in the cases of sTBI.

The Glasgow Coma Scale and evidence-informed practice: a critical review of where we are and where we need to be

AIMS AND OBJECTIVES

This paper aims to critically consider the evidence since the Glasgow Coma Scale was first launched, reflecting on how that evidence has shaped practice. It illustrates the lack of clarity and consensus about the use of the tool in practice and draws upon existing evidence to determine the route to clarity for an evidence-informed approach to practice.

BACKGROUND

The Glasgow Coma Scale has permeated and influenced practice for over 40 years, being well-established worldwide as the key tool for assessing level of consciousness. During this time, the tool has been scrutinised, evaluated, challenged and re-launched in a plethora of publications. This has led to an insight into the challenges, and to some extent the opportunities, in using the Glasgow Coma Scale in practice but has also resulted in a lack of clarity.

DESIGN

This is a discursive paper that invites readers to explore and arrive at a more comprehensive understanding of the Glasgow Coma Scale in practice and is based on searches of Scopus, Web of Knowledge, PubMed, Science Direct and CINAHL databases.

RESULTS

While the Glasgow Coma Scale has been rivalled by other tools in an attempt to improve upon it, a shift in practice to those tools has not occurred. The tool has withstood the test of time in this respect, indicating the need for further research into its use and a clear education strategy to standardise implementation in practice.

CONCLUSION

Further exploration is needed into the application of painful stimuli in using the Glasgow Coma Scale to assess level of consciousness. In addition, a robust educational strategy is necessary to maximise consistency in its use in practice.

RELEVANCE TO CLINICAL PRACTICE

The evidence illustrates inconsistency and confusion in the use of the Glasgow Coma Scale in practice; this has the potential to compromise care and clarity around the issues is therefore necessary.

Longitudinal changes in diffusion tensor imaging parameters of the corpus callosum between 6 and 12 months after diffuse axonal injury

BACKGROUND

Magnetic resonance diffusion tensor imaging (MR-DTI) is used increasingly to detect diffuse axonal injury (DAI) after traumatic brain injury (TBI).

PRIMARY OBJECTIVE

To investigate changes in the diffusion tensor imaging parameters of the corpus callosum 6 and 12 months after TBI, to optimize the timing of follow-up DTI investigations. A secondary goal was to study the relationship between DTI parameters and outcome.

RESEARCH DESIGN

Longitudinal prospective study.

METHODS AND PROCEDURES

MR-DTI was performed in 15 patients with suspected DAI, 6 and 12 months post-injury. Sixteen controls were also examined. Fractional anisotropy (FA) and diffusivity (trace) in the corpus callosum were analysed. The outcome measures were the extended Glasgow Outcome Scale and the Barrow Neurological Institute Screen for Higher Cerebral Functions, assessed at 6 and 12 months.

MAIN OUTCOMES AND RESULTS

FA decreased and trace increased at 6 and 12 months compared to controls. Trace continued to increase even further between 6 and 12 months, while FA remained unchanged. Patients with the worst outcomes had lower FA and higher trace compared to patients with better outcomes.

CONCLUSIONS

DTI parameters have not reached a stable level at 6 months after DAI, but continue to change, probably reflecting an incessant microstructural alteration of the white matter.

Serum Neurofilament Light Protein as a Marker for Diffuse Axonal Injury: Results from a Case Series Study

Diffuse axonal injury (DAI) is an important cause of morbidity in patients with traumatic brain injury (TBI). There is currently no simple and reliable technique for early identification of patients with DAI, or to prognosticate long-term outcome in this patient group. In the present study, we examined acute serum concentrations of neurofilament light (NFL) in nine patients with severe TBI and DAI using a novel ultrasensitive single molecule array (Simoa) assay. The relationships between the NFL concentrations and MRI in the acute stage as well as clinical outcome and magnetic resonance diffusion tensor imaging (MR-DTI) parameters at 12 months were analyzed. We found that the mean NFL concentrations among the patients displayed a 30-fold increase compared with controls, and that NFL completely discriminated between the patients and controls. We also found a relationship between serum NFL and MR-DTI parameters, with higher NFL concentrations in patients with higher trace (R² = 0.79) and lower fractional anisotropy (FA) (R ² = 0.83). These results suggest that serum NFL may be a valuable blood biomarker for TBI, reflecting the severity of DAI.

Atrial Fibrillation in Transient Ischemic Attack Versus Ischemic Stroke

Background and Purpose—

Compared with ischemic stroke (IS), the association of atrial fibrillation (AF) with transient ischemic attack (TIA) is less well established. We aimed to assess the proportion of AF in patients with TIA, and these patients’ characteristics and secondary preventive treatment in comparison to patients with IS.

Methods—

Hospital-based data on TIA and IS events, registered from July 2011 to June 2013, were obtained from the Swedish Stroke Register (Riksstroke). A time-based TIA definition (duration of symptoms <24 hours) was applied. AF was registered as present when previously known or diagnosed at the time of assessment.

Results—

AF was present in 2779 of 14 980 (18.6%) patients with TIA and 13 258 of 44 173 (30.0%) patients with IS. The proportion of AF increased with age, reaching 32.9% in TIA and 46.6% in IS patients ≥85 years. Both in TIA and IS, age, hypertension, a history of stroke, and TIA, and being a nonsmoker were associated with the presence of AF. In contrast to IS, AF was less common in female than in male patients with TIA. At discharge, 64.2% of TIA and 50.0% of IS patients with AF were treated with oral anticoagulants. Proportions of AF patients treated with oral anticoagulants decreased substantially with increasing age.

Conclusions—

AF is highly prevalent not only in IS but also in TIA patients, with proportions steeply increasing with age. In both TIA and IS, a substantial proportion of patients with AF were discharged without anticoagulant therapy.

Analytically Confirmed Intoxications Involving MDMB-CHMICA from the STRIDA Project

INTRODUCTION

About a decade ago, synthetic cannabinoids (SC) started to appear as recreational drugs on the new psychoactive substance (NPS) market. This report from the STRIDA project describes analytically confirmed intoxications involving MDMB-CHMICA (methyl-2-(1-(cyclohexylmethyl)-1H-indol-3-ylcarbonylamino)-3,3-dimethylbutanoate), a SC that was first detected in 2014.

STUDY DESIGN

This is an observational case series of patients from Sweden with suspected NPS exposure presenting in emergency departments and intensive care units. The results of retrospective serum and urine toxicological analysis were compared with clinical signs reported during consultation with the Poisons Information Centre and retrieved from medical records.

METHODS

Clinical and bioanalytical data in nine acute intoxications associated with MDMB-CHMICA during 2014-2015 are presented. The patients were aged 23-62 (median 34) years, and eight were men. MDMB-CHMICA (parent compound) was analytically confirmed in serum samples, using a liquid chromatography-high-resolution mass spectrometry multi-component method.

RESULTS

Of the nine MDMB-CHMICA-positive patients, eight had a Poisoning Severity Score (PSS) of 2 or 3, and five were monitored in the intensive care unit and all patients survived. Development of seizures and deep unconsciousness were common features. All cases except one also tested positive for other NPS and/or classical psychoactive compounds, hampering the possibility to establish a causal relationship between drug and toxic symptoms. MDMB-CHMICA was also identified in seven drug materials donated by the patients.

CONCLUSIONS

The association with severe adverse reactions in nine acute analytically confirmed intoxication cases involving MDMB-CHMICA is consistent with other reports of serious toxicity linked to this substance, suggesting that MDMB-CHMICA might be a particularly harmful SC.

Betamethasone and dexamethasone in adult community-acquired bacterial meningitis: a quality registry study from 1995 to 2014

Acute bacterial meningitis (ABM) is a highly lethal disease. Available data support the use of corticosteroids in high-income countries, but the effect on mortality is still controversial. The effects of corticosteroids on mortality and sequelae were evaluated in the national Swedish quality registry. In total, during 1995-2014 1746 adults with ABM were included, of whom 989 were treated with corticosteroids (betamethasone, n = 766; dexamethasone, n = 248; methylprednisolone, n = 2), 498 were not given corticosteroids and in 259 patients data for corticosteroids were missing. Fatal outcome was observed in 8.9% of the patients in the corticosteroid-treated group vs. 17.9% in the non-corticosteroid-treated group (p <0.001), resulting in an odds ratio (OR) of 0.57 with a 95% confidence interval (CI) of 0.40-0.81 adjusted for age, sex, mental status, and door-to-antibiotic time. In patients with meningitis caused by S. pneumoniae, mortality was 10.2% in the corticosteroid-treated group and 21.3% in the non-corticosteroid-treated group (p <0.001) with an adjusted OR of 0.50 (95% CI 0.31-0.80). In ABM patients with non-pneumococcal aetiology the adjusted OR was 0.71 (95% CI 0.40-1.26). Lower mortality was observed in the corticosteroid-treated group with impaired mental status, whereas no significant difference was found in patients with unaffected mental status. The adjusted ORs for betamethasone and dexamethasone were 0.49 (95% CI 0.28-0.84) and 0.61 (95% CI 0.37-1.01), respectively. Corticosteroid treatment decreases mortality in ABM and should be administered initially with antibiotics in adult ABM patients with impaired mental status regardless of presumed aetiology. Betamethasone seems to be at least as effective as dexamethasone.

Associations between care pathways and outcome 1 year after severe traumatic brain injury

OBJECTIVE

To assess associations between real-world care pathways for working-age patients in the first year after severe traumatic brain injury and outcomes at 1 year.

SETTING AND DESIGN

Prospective, observational study with recruitment from 6 neurosurgical centers in Sweden and Iceland. Follow-up to 1 year, independently of care pathways, by rehabilitation physicians and paramedical professionals.

PARTICIPANTS

Patients with severe traumatic brain injury, lowest (nonsedated) Glasgow Coma Scale score 3 to 8 during the first 24 hours and requiring neurosurgical intensive care, age 18 to 65 years, and alive 3 weeks after injury.

MAIN MEASURES

Length of stay in intensive care, time between intensive care discharge and rehabilitation admission, outcome at 1 year (Glasgow Outcome Scale Extended score), acute markers of injury severity, preexisting medical conditions, and post-acute complications. Logistic regression analyses were performed.

RESULTS

A multivariate model found variables significantly associated with outcome (odds ratio for good outcome [confidence interval], P value) to be as follows: length of stay in intensive care (0.92 [0.87-0.98], 0.014), time between intensive care discharge and admission to inpatient rehabilitation (0.97 [0.94-0.99], 0.017), and post-acute complications (0.058 [0.006-0.60], 0.017).

CONCLUSIONS

Delays in rehabilitation admission were negatively associated with outcome. Measures to ensure timely rehabilitation admission may improve outcome. Further research is needed to evaluate possible causation.