Disentangling the Association Between Neurologic Deficits, Patient-Reported Impairments, and Quality of Life After Ischemic Stroke

Quality of Life in Patients with Excellent 3-Month Clinical Outcome after First-Ever Ischemic Stroke: A Time to Redefine Excellent Outcome?

INTRODUCTION

Ischemic stroke (IS) may have impact on long-term health-related quality of life (HRQoL) even in the patients with good clinical outcome, and tools mostly used for the assessment of outcome may underestimate or not reflect all relevant sequels after IS. We aimed to analyze HRQoL in the patients with excellent outcome after IS.

METHODS

We analyzed consecutive IS patients enrolled in the prospective FRAILTY study (ClinicalTrials.gov: NCT04839887) with excellent 3-month clinical outcome (score 0-1 in modified Rankin Scale [mRS]). Stroke Impact Scale (SIS) version 3.0 and Hospital Anxiety and Depression Scale (HADS) were used for the HRQoL, anxiety, and depression assessments, and subgroup comparisons were performed according to NIHSS score (0, ≥1), age (50<, ≥50 years), and sex.

RESULTS

In total, 158 patients (55.7% men, mean age 60.3 ± 13.4 years) were analyzed, and 72.2% of them had score 0 in mRS. The overall lowest median scores were found in the SIS domain "emotion," "strength," and "participation." Patients with NIHSS ≥1 had lower scores in all SIS domains except "emotions" and "mobility." Patients ≥50 years had lower score in "mobility" (p = 0.004) and females in domain of "social participation" (p = 0.044). No differences were found among all subgroups in HADS anxiety and depression. Age, NIHSS score, and depression were found negative predictors for the physical domains of HRQoL.

DISCUSSION/CONCLUSIONS

Despite excellent 3-month clinical outcome after IS, patients had affected substantially their HRQoL, especially those with NIHSS ≥1. Patients ≥50 years had more affected "mobility" and females "social participation."

Clinical Outcome Assessments in Encephalitis: A Systematic Review

BACKGROUND AND OBJECTIVES

Most patients with encephalitis experience persisting neurocognitive and neuropsychiatric sequelae in the years following this acute illness. Reported outcomes are often based on generic clinical outcome assessments that rarely capture the patient perspective. This may result in an underestimation of disease-specific sequelae. Disease-specific clinical outcome assessments can improve clinical relevance of reported outcomes and increase the power of research and trials. There are no patient-reported outcome measures (PROMs) developed or validated specifically for patients with encephalitis. The primary objective of this systematic literature review was to identify PROMs that have been developed for or validated in patients with encephalitis.

METHODS

We performed a systematic review of the literature published from inception until May 2023 in 3 large international databases (MEDLINE, EMBASE and Cochrane libraries). Eligible studies should have developed or validated a PROM in patients with encephalitis or encephalopathy. Methodologic quality was evaluated using the Consensus-based Standards for the selection of health status Measurement Instruments study design checklist for PROMs.

RESULTS

We identified no disease-specific PROMs developed or validated for patients with encephalitis. We identified one study on the development and validation of a disease-specific PROM for hepatic encephalopathy, although this disease course is substantially different to that of patients with encephalitis. The methodologic quality of the included study was generally rated as "doubtful." We identified 30 PROMs that have been applied in 46 studies on encephalitis or encephalopathy, although not validated in these populations. The most commonly applied PROMs for measuring Health-Related Quality of Life were the Medical Outcomes Study Short Form-36 and the Sickness Impact Profile. Emotional well-being was often assessed with the Beck Depression Inventory (BDI-II). Sporadically, PROMs were applied to address other aspects of outcome including daily functioning and sleep quality.

DISCUSSION

This systematic review confirms a critical gap in clinical outcome assessments in patients with encephalitis, failing to identify a validated measuring tool for detecting neurocognitive, functional, and health status. It is therefore essential to develop and/or validate disease-specific PROMs for the population with encephalitis to capture relevant information for patient management and clinical trials about the effects of disease that are at risk of being overlooked.

Psychometrics and validation of the EQ-5D-5L instrument in individuals with ischemic stroke in Lithuania

Background

Experiencing stroke is associated with deterioration in health-related quality of life (HRQL). One of the generic tools used for HRQL assessment is the EuroQol instrument of five dimensions and five levels (EQ-5D-5L), which has not yet been validated in Lithuania. This study aimed to evaluate validity, reliability, and factor structure of the EQ-5D-5L instrument in a sample of Lithuanian individuals at the end of the first week after experiencing ischemic stroke (IS).

Methods

The study had a cross-sectional design, including 134 individuals [61.9% men and 38.1% women; median (IQR) age was 66 years (59-73) years, in the final analysis]. Alongside the EQ-5D-5L, psychological distress was evaluated using the Hospital Anxiety and Depression Scale (HADS), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder Assessment-7 (GAD-7); neurological impairment with the National Institutes of Health Stroke Scale (NIHSS); and functional independence with the Barthel index (BI). Confirmatory factor analysis (CFA) was performed for validation of the factor structure.

Results

The internal consistency of the EQ-5D-5L instrument was 0.81. A significant ceiling effect (17.2%) of the descriptive part of the EQ-5D-5L was detected. The convergent validity of the EQ-5D-5L descriptive system was confirmed, with significant correlations with the other scales used, except for the visual analog scale. The two-factor ("physical" and "emotional") model was confirmed by CFA, with acceptable fit [root mean square error of approximation (RMSEA) = 0.045, RMSEA 90% CI = 0.000-0.145; comparative fit indices (CFI) = 0.996; non-normal fit index (NFI) = 0.983; Tucker-Lewis Index (TLI) = 0.936; χ2/df = 1.27)].

Conclusion

This study provides information on the psychometric properties of the EQ-5D-5L instrument in Lithuanian individuals, showing that the EQ-5D-5L descriptive system is a reliable and valid tool for HRQL assessment. The Lithuanian version of the descriptive part of the EQ-5D-5L instrument is best expressed as a two-factor model, estimating the physical and emotional dimensions of HRQL in individuals who have experienced IS.