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Berehan HB, Dessie ZG, Tesfaw LM. Exploring functional abilities and competing risks among stroke patients: a longitudinal and survival analysis study at Felege Hiwot Referral Hospital, Ethiopia. BMJ Open 2024; 14:e073384. [PMID: 38697761 DOI: 10.1136/bmjopen-2023-073384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2024] Open
Abstract
OBJECTIVES This study aimed to evaluate competing risks and functional ability measures among patients who had a stroke. DESIGN A joint model comprising two related submodels was applied: a cause-specific hazard submodel for competing drop-out and stroke-related death risks, and a partial proportional odd submodel for longitudinal functional ability. SETTING Felege Hiwot Referral Hospital, Ethiopia. PARTICIPANTS The study included 400 patients who had a stroke from the medical ward outpatient stroke unit at Felege Hiwot Referral Hospital, who were treated from September 2018 to August 2021. RESULTS Among the 400 patients who had a stroke, 146 (36.5%) died and 88 (22%) dropped out. At baseline, 14% of patients had no symptoms and/or disability while 24% had slight disability, and 25% had severe disability. Most patients (37.04%) exhibited moderate functional ability. The presence of diabetes increased the cause-specific hazard of death by 3.95 times (95% CI 2.16 to 7.24) but decreased the cause-specific hazard of drop-out by 95% (aHR 0.05; 95% CI 0.01 to 0.46) compared with non-diabetic patients who had a stroke. CONCLUSION A substantial proportion of patients who had a stroke experienced mortality and drop-out during the study period, highlighting the importance of considering competing risks in stroke research. Age, diabetes, white cell count and stroke complications were significant covariates affecting both longitudinal and survival submodels. Compared with stand-alone models, the joint competing risk modelling technique offers comprehensive insights into the disease's transition pattern.
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Affiliation(s)
| | - Zelalem G Dessie
- School of Mathematics, Statistics and Computer Science, University of KwaZulu-Natal, Durban, South Africa
- Department of Statistics, Bahir Dar University, Bahir Dar, Ethiopia
| | - Lijalem Melie Tesfaw
- Department of Statistics, Bahir Dar University, Bahir Dar, Ethiopia
- Epidemiology and Biostatistics Division, The University of Queensland, Brisbane, Queensland, Australia
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Shaw L, Briscoe S, Nunns MP, Lawal HM, Melendez-Torres GJ, Turner M, Garside R, Thompson Coon J. What is the quantity, quality and type of systematic review evidence available to inform the optimal prescribing of statins and antihypertensives? A systematic umbrella review and evidence and gap map. BMJ Open 2024; 14:e072502. [PMID: 38401904 PMCID: PMC10895245 DOI: 10.1136/bmjopen-2023-072502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 01/31/2024] [Indexed: 02/26/2024] Open
Abstract
OBJECTIVES We aimed to map the systematic review evidence available to inform the optimal prescribing of statins and antihypertensive medication. DESIGN Systematic umbrella review and evidence and gap map (EGM). DATA SOURCES Eight bibliographic databases (Cochrane Database of Systematic Reviews, CINAHL, EMBASE, Health Management Information Consortium, MEDLINE ALL, PsycINFO, Conference Proceedings Citation Index-Science and Science Citation Index) were searched from 2010 to 11 August 2020. Update searches conducted in MEDLINE ALL 2 August 2022. We searched relevant websites and conducted backwards citation chasing. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We sought systematic reviews of quantitative or qualitative research where adults 16 years+ were currently receiving, or being considered for, a prescription of statin or antihypertensive medication. Eligibility criteria were applied to the title and abstract and full text of each article independently by two reviewers. DATA EXTRACTION AND SYNTHESIS Quality appraisal was completed by one reviewer and checked by a second. Review characteristics were tabulated and incorporated into an EGM based on a patient care pathway. Patients with lived experience provided feedback on our research questions and EGM. RESULTS Eighty reviews were included within the EGM. The highest quantity of evidence focused on evaluating interventions to promote patient adherence to antihypertensive medication. Key gaps included a lack of reviews synthesising evidence on experiences of specific interventions to promote patient adherence or improve prescribing practice. The evidence was predominantly of low quality, limiting confidence in the findings from individual reviews. CONCLUSIONS This EGM provides an interactive, accessible format for policy developers, service commissioners and clinicians to view the systematic review evidence available relevant to optimising the prescribing of statin and antihypertensive medication. To address the paucity of high-quality research, future reviews should be conducted and reported according to existing guidelines and address the evidence gaps identified above.
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Affiliation(s)
- Liz Shaw
- Exeter Policy Research Programme Evidence Review Facility, Faculty of Health and Life Sciences, St Luke's Campus, University of Exeter, EX1 2LU, Exeter, UK
| | - Simon Briscoe
- Exeter Policy Research Programme Evidence Review Facility, Faculty of Health and Life Sciences, St Luke's Campus, University of Exeter, EX1 2LU, Exeter, UK
| | - Michael P Nunns
- Exeter Policy Research Programme Evidence Review Facility, Faculty of Health and Life Sciences, St Luke's Campus, University of Exeter, EX1 2LU, Exeter, UK
| | - Hassanat Mojirola Lawal
- Exeter Policy Research Programme Evidence Review Facility, Faculty of Health and Life Sciences, St Luke's Campus, University of Exeter, EX1 2LU, Exeter, UK
| | - G J Melendez-Torres
- Exeter Policy Research Programme Evidence Review Facility, Faculty of Health and Life Sciences, St Luke's Campus, University of Exeter, EX1 2LU, Exeter, UK
| | - Malcolm Turner
- Exeter Policy Research Programme Evidence Review Facility, Faculty of Health and Life Sciences, St Luke's Campus, University of Exeter, EX1 2LU, Exeter, UK
- NIHR ARC South West Peninsula Patient and Public Engagement Group, University of Exeter, Exeter, UK
| | - Ruth Garside
- Exeter Policy Research Programme Evidence Review Facility, Faculty of Health and Life Sciences, St Luke's Campus, University of Exeter, EX1 2LU, Exeter, UK
- European Centre for Environment and Health, University of Exeter, Exeter, UK
| | - Jo Thompson Coon
- Exeter Policy Research Programme Evidence Review Facility, Faculty of Health and Life Sciences, St Luke's Campus, University of Exeter, EX1 2LU, Exeter, UK
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Li G, Sun Y, Liu T, Yang P, Peng Y, Chen W, Zhang L, Chu J, Kuai D, Wang Z, Wu W, Xu Y, Zhou B, Geng Y, Yin C, Li J, Wang M, Peng X, Xiao Y, Li M, Zhang X, Liu P, Wang N, Zhang Y. Predictive factors of poor outcome and mortality among anterior ischaemic stroke patients despite successful recanalisation in China: a secondary analysis of the CAPTURE trial. BMJ Open 2023; 13:e078917. [PMID: 38070920 PMCID: PMC10729217 DOI: 10.1136/bmjopen-2023-078917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/02/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVES This work aimed to analyse the risk factors for poor outcomes and mortality among patients with anterior large vessel occlusion (LVO) ischaemic stroke, despite successful recanalisation. SETTING AND PARTICIPANTS This study conducted a secondary analysis among patients who underwent successful recanalisation in the CAPTURE trial. The trial took place between March 2018 and September 2020 at 21 sites in China. The CAPTURE trial enrolled patients who had an acute ischaemic stroke aged 18-80 years with LVO in anterior circulation. INTERVENTIONS Thrombectomy was immediately performed using Neurohawk or the Solitaire FR after randomisation in CAPTURE trial. Rescue treatment was available for patients with severe residual stenosis caused by atherosclerosis. PRIMARY AND SECONDARY OUTCOME MEASURES The primary goal was to predict poor 90-day survival or mortality within 90 days post-thrombectomy. Univariate analysis, using the χ2 test or Fisher's exact test, was conducted for each selected factor. Subsequently, a multivariable analysis was performed on significant factors (p≤0.10) identified through univariate analysis using the backward selection logistic regression approach. RESULTS Among the 207 recruited patients, 79 (38.2%) exhibited poor clinical outcomes, and 26 (12.6%) died within 90 days post-thrombectomy. Multivariate analysis revealed that the following factors were significantly associated with poor 90-day survival: age ≥67 years, internal carotid artery (ICA) occlusion (compared with middle cerebral artery (MCA) occlusion), initial National Institutes of Health Stroke Scale (NIHSS) score ≥17 and final modified Thrombolysis in Cerebral Infarction (mTICI) score 2b (compared with mTICI 3). Additionally, the following factors were significantly associated with mortality 90 days post-thrombectomy: initial NIHSS score ≥17, ICA occlusion (compared with MCA occlusion) and recanalisation with more than one pass. CONCLUSIONS Age, NIHSS score, occlusion site, mTICI score and the number of passes can be independently used to predict poor 90-day survival or mortality within 90 days post-thrombectomy. TRIAL REGISTRATION NUMBER NCT04995757.
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Affiliation(s)
- Guangwen Li
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yujie Sun
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Tonghui Liu
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Pengfei Yang
- Neurovascular Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Ya Peng
- Department of Neurosurgery, Changzhou First People's Hospital, Changzhou, Jiangsu, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Hospital Affiliated to Fujian Medical University, Zhangzhou, China
| | - Liyong Zhang
- Department of Neurosurgery, Liaocheng People's Hospital Brain Hospital, Liaocheng, Shandong, China
| | - Jianfeng Chu
- Department of Neurology, The First People's Hospital of Jining City, Jining, China
| | - Dong Kuai
- Department of Neurosurgery, Shanxi Provincial Cardiovascular Hospital, Taiyuan, China
| | - Zibo Wang
- Department of Neurointervention, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Wei Wu
- Department of Neurology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Yun Xu
- Department of Neurology, Nanjing Gulou Hospital, Nanjing, China
| | - Bin Zhou
- Department of Neurointervention, Cerebrovascular Disease Center, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, China
| | - Yu Geng
- Department of Neurology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, China
| | - Congguo Yin
- Department of Neurology, Hangzhou First People's Hospital, Hangzhou, Zhejiang, China
| | - Jiang Li
- Department of Neurosurgery, The Second Affiliated Hospital of Air Force Military Medical University, Xi'an, China
| | - Ming Wang
- Department of Neurointervention, Nanyang Second People's Hospital, Nanyang, China
| | - Xiaoxiang Peng
- Department of Neurology, The Third People's Hospital of Hubei Province, Wuhan, China
| | - Yaping Xiao
- Department of Neurology, Shanghai Oriental Hospital, Shanghai, China
| | - Minghua Li
- Institute of Diagnostic and Interventional Neuroradiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xianjun Zhang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Peng Liu
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Naidong Wang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yong Zhang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
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Sun Y, Luo J, Gong H, Xu R, Zhang X, Yang B, Ma Y, Wang T, Jiao L. Comparison of drug-coated balloon angioplasty versus standard medical therapy on recurrent stroke and mortality rates among patients with symptomatic intracranial atherosclerotic stenosis: protocol for a systematic review and meta-analysis. BMJ Open 2023; 13:e078040. [PMID: 38016792 PMCID: PMC10685973 DOI: 10.1136/bmjopen-2023-078040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 11/09/2023] [Indexed: 11/30/2023] Open
Abstract
INTRODUCTION Stroke remains the second leading cause of death worldwide, a common cause of which is intracranial atherosclerotic stenosis (ICAS). Medical treatment is recommended as first-line therapy for treating ICAS, but the recurrence rate remains high. Drug-coated balloon (DCB) angioplasty has been designed to lower the risk of recurrent stenosis, holding therapeutic promise in the treatment of ICAS. However, the benefits of DCB require further evaluation. METHODS AND ANALYSIS The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols was followed to develop this protocol. We will systematically search online databases including Cochrane Central Register of Controlled Trials, PubMed, Web of Science, EMBASE, China Biological Medicine Database, ClinicalTrials.gov and WHO ICTRP from 1 January 2011 to the date of search. This will be supplemented by a manual search of unpublished and ongoing trials to manually select articles for inclusion. Inclusion criteria are randomised or quasi-randomised clinical trials and observational studies that investigated DCB or medical treatment for patients with a symptomatic ICAS of 50%-99%. The primary outcome is short-term composite safety including death of any cause, or non-fatal stroke. Secondary outcomes include long-term death or stroke, restenosis, neurological rehabilitation, quality of life and other complications. The available data will be analysed using meta-analysis, if appropriate. The evaluation of heterogeneity and biases will be guided by the Cochrane Handbook for Systematic Reviews of Interventions. ETHICS AND DISSEMINATION This systematic review does not require ethical approval as all available data from eligible studies will be anonymous with no concerns regarding privacy. Our findings will be disseminated through international conferences and peer-reviewed publications. Additional data from the study are available on request to corresponding authors via email. PROSPERO REGISTRATION NUMBER CRD42022341607.
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Affiliation(s)
- Yixin Sun
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- Peking University First Hospital, Beijing, China
- Health Science Center, Peking University, Beijing, China
| | - Jichang Luo
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Haozhi Gong
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Ran Xu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Xiao Zhang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Bin Yang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Yan Ma
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
- National Center for Neurological Disorders, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
- National Center for Neurological Disorders, Beijing, China
- Department of Interventional Neuroradiology, Xuanwu Hospital Capital Medical University, Beijing, China
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Salazar-Cifuentes P, Contreras T, Hernández E, Leiva-Abarca E, Castro-Flores P, San Juan D, Araneda R, Ebner-Karestinos D. Evaluation of ALBA device for upper extremity motor function in adults with subacute and chronic acquired brain injury: a randomised controlled trial protocol in a tertiary clinic of the metropolitan region of Chile. BMJ Open 2023; 13:e076774. [PMID: 37993168 PMCID: PMC10668162 DOI: 10.1136/bmjopen-2023-076774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/30/2023] [Indexed: 11/24/2023] Open
Abstract
INTRODUCTION Stroke is a significant worldwide cause of death and a prevalent contributor to long-term disability among adults. Survivors commonly encounter a wide array of motor, sensory and cognitive impairments. Rehabilitation interventions, mainly targeting the upper extremities, include a wide array of components, although the evidence indicates that the intensity of practice and task-specific training play crucial roles in facilitating effective results. Assisted therapy with electronic devices designed for the affected upper extremity could be employed to enable partial or total control of this limb, while simultaneously incorporating the aforementioned characteristics in the rehabilitation process. METHODS AND ANALYSIS 32 adults who had a subacute or chronic stroke, aged over 18 years old, will be included for this randomised controlled trial aiming to determine the non-inferiority effect of the inclusion of a robotic device (ALBA) to regular treatment against only regular rehabilitation. Participants will be assessed before and after 4 weeks of intervention and at 3 months of follow-up. The primary outcome will be the Fugl-Meyer assessment for upper extremities; secondary outcomes will include the questionnaires Functional Independence Measure, Medical Outcomes Study 36-item Short-Form Health Survey as well as the System Usability Scale. ETHICS AND DISSEMINATION Full ethical approval was obtained for this study from the scientific and ethical review board Servicio de Salud Metropolitano Oriente of Santiago (approval number: SSMOriente030522), and the recommendations of the Chilean law no 20120 of 7 September 2006, concerning scientific research in the human being, its genome and human cloning, will be followed. Ahead of inclusion, potential participants will read and sign a written informed consent form. Future findings will be presented and published in conferences and peer-reviewed journals. TRIAL REGISTRATION NUMBER International ClinicalTrials.gov Registry (NCT05824416; https://clinicaltrials.gov/ct2/show/NCT05824416?term=uMOV&draw=2&rank=1).
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Affiliation(s)
| | | | | | | | | | | | - Rodrigo Araneda
- Exercise and Rehabilitation Science Institute, School of Physical Therapy, Faculty of Rehabilitation Science, Universidad Andres Bello, Santiago, Chile
| | - Daniela Ebner-Karestinos
- Exercise and Rehabilitation Science Institute, School of Physical Therapy, Faculty of Rehabilitation Science, Universidad Andres Bello, Santiago, Chile
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Jones SP, Injety RJ, Pandian JD, Ratra S, Sylaja PN, Babu V, Srivastava MP, Sharma S, Sharma S, Webster J, Koirala A, Kaushal P, Kulkarni GB, Dixit A, Sharma A, Prajapati J, Weldon JC, Kuroski JA, Watkins CL, Lightbody CE. Healthcare professionals' perspectives of the provision of, and challenges for, eating, drinking and psychological support post stroke: findings from semistructured interviews across India. BMJ Open 2023; 13:e069150. [PMID: 37880173 PMCID: PMC10603406 DOI: 10.1136/bmjopen-2022-069150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 09/21/2023] [Indexed: 10/27/2023] Open
Abstract
AIM This qualitative study explores with health professionals the provision of, and challenges for, postdischarge stroke care, focussing on eating, drinking and psychological support across India. DESIGN Qualitative semistructured interviews. SETTING Seven geographically diverse hospitals taking part in a Global Health Research Programme on Improving Stroke Care in India. PARTICIPANTS A purposive sample of healthcare professionals with current experience of working with patients who had a stroke. RESULTS Interviews with 66 healthcare professionals (23 nurses (14 staff nurses; 7 senior nurse officers; 1 intensive care unit nurse; 1 palliative care nurse)); 16 doctors (10 neurologists; 6 physicians); 10 physiotherapists; 5 speech and language therapists; 4 occupational therapists; 4 dieticians; 2 psychiatrists; and 2 social workers resulted in three main themes: integrated inpatient discharge care planning processes; postdischarge patient and caregiver role and challenges; patient and caregiver engagement post discharge. CONCLUSIONS Discharge planning was integrated and customised, although resources were limited in some sites. Task shifting compensated for a lack of specialists but was limited by staff education and training. Caregivers faced challenges in accessing and providing postdischarge care. Postdischarge care was mainly hospital based, supported by teleservices, especially for rural populations. Further research is needed to understand postdischarge care provision and the needs of stroke survivors and their caregivers.
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Affiliation(s)
- Stephanie P Jones
- School of Nursing and Midwifery, University of Central Lancashire, Preston, UK
| | - Ranjit J Injety
- Department of Neurology, Christian Medical College and Hospital Ludhiana, Ludhiana, Punjab, India
| | - Jeyaraj D Pandian
- Department of Neurology, Christian Medical College and Hospital Ludhiana, Ludhiana, Punjab, India
| | - Sanjali Ratra
- Department of Neurology, Christian Medical College and Hospital Ludhiana, Ludhiana, Punjab, India
| | - P N Sylaja
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Veena Babu
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Mv Padma Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Sakshi Sharma
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Sudhir Sharma
- Department of Neurology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - Jemin Webster
- Department of Medicine, Baptist Christian Hospital Tezpur, Tezpur, Assam, India
| | - Amrit Koirala
- Department of Medicine, Baptist Christian Hospital Tezpur, Tezpur, Assam, India
| | - Pawna Kaushal
- Department of Neurology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - Girish Baburao Kulkarni
- Department of Neurology, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India
| | - Anand Dixit
- Department of Neurology, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, India
| | - Arvind Sharma
- Department of Neurology, Zydus Research Center, Ahmedabad, Gujarat, India
| | - Jagruti Prajapati
- Department of Neurology, Zydus Research Center, Ahmedabad, Gujarat, India
| | - Jo Catherine Weldon
- School of Nursing and Midwifery, University of Central Lancashire, Preston, UK
| | - Jennifer A Kuroski
- School of Nursing and Midwifery, University of Central Lancashire, Preston, UK
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Moshi B, Yongolo N, Biswaro SM, Maro H, Linus S, Siebert S, Nkenguye W, McIntosh E, Shirima F, Njau RE, Andongolile AA, Mwanswila MJ, Halliday JEB, Krauth S, Kilonzo K, Walker RW, Temu GA, Mmbaga BT. Trends of frequency, mortality and risk factors among patients admitted with stroke from 2017 to 2019 to the medical ward at Kilimanjaro Christian Medical Centre hospital: a retrospective observational study. BMJ Open 2023; 13:e071918. [PMID: 37524544 PMCID: PMC10391824 DOI: 10.1136/bmjopen-2023-071918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023] Open
Abstract
OBJECTIVE The burden of stroke has increased in recent years worldwide, particularly in low-income and middle-income countries. In this study we aim to determine the number of stroke admissions, and associated comorbidities, at a referral hospital in Northern Tanzania. DESIGN This was a retrospective observational study. SETTING The study was conducted at a tertiary referral hospital, Kilimanjaro Christian Medical Centre (KCMC), in the orthern zone of Tanzania. PARTICIPANTS The study included adults aged 18 years and above, who were admitted to the medical wards from 2017 to 2019. OUTCOME The primary outcome was the proportion of patients who had a stroke admitted in the medical ward at KCMC and the secondary outcome was clinical outcome such as mortality. METHODS We conducted a retrospective audit of medical records from 2017 to 2019 for adult patients admitted to the medical ward at KCMC. Data extracted included demographic characteristics, previous history of stroke and outcome of the admission. Factors associated with stroke were investigated using logistic regression. RESULTS Among 7976 patients admitted between 2017 and 2019, 972 (12.2%) were patients who had a stroke. Trends show an increase in patients admitted with stroke over the 3 years with 222, 292 and 458 in 2017, 2018 and 2019, respectively. Of the patients who had a stroke, 568 (58.4%) had hypertension while 167 (17.2%) had diabetes mellitus. The proportion of admitted stroke patients aged 18-45 years, increased from 2017 (n=28, 3.4%) to 2019 (n=40, 4.3%). The in-hospital mortality related to stroke was 229 (23.6%) among 972 patients who had a stroke and female patients had 50% higher odds of death as compared with male patients (OR:1.5; CI 1.30 to 1.80). CONCLUSION The burden of stroke on individuals and health services is increasing over time, which reflects a lack of awareness on the cause of stroke and effective preventive measures. Prioritising interventions directed towards the reduction of non-communicable diseases and associated complications, such as stroke, is urgently needed.
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Affiliation(s)
- Baraka Moshi
- Epidemiology and Applied Biostatistics, Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania
- Department of Clinical research, Kilimanjaro Clinical Research Institute, Moshi, United Republic of Tanzania
| | - Nateiya Yongolo
- Department of Clinical research, Kilimanjaro Clinical Research Institute, Moshi, United Republic of Tanzania
- Depatment of Epidemiology and Applied Biostatistics and Depatment of Internal Medicine, Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania
| | - Sanjura Mandela Biswaro
- Department of Clinical research, Kilimanjaro Clinical Research Institute, Moshi, United Republic of Tanzania
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania
| | - Hans Maro
- Depatment of Epidemiology and Applied Biostatistics and Depatment of Internal Medicine, Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania
- Department of Epidemiology, Tanzania Health Promotion Support (THPS), Moshi, United Republic of Tanzania
| | - Sakanda Linus
- Department of Clinical research, Kilimanjaro Clinical Research Institute, Moshi, United Republic of Tanzania
- Depatment of Epidemiology and Applied Biostatistics and Depatment of Internal Medicine, Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania
| | - Stefan Siebert
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
- Depatment of Inflammation Medicine and Rheumatology, Health Economics and Health Technology Assessment (HEHTA), University of Glasgow Institute of Health and Wellbeing, Glasgow, UK
| | - William Nkenguye
- Depatment of Epidemiology and Applied Biostatistics and Depatment of Internal Medicine, Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania
| | - Emma McIntosh
- Depatment of Inflammation Medicine and Rheumatology, Health Economics and Health Technology Assessment (HEHTA), University of Glasgow Institute of Health and Wellbeing, Glasgow, UK
| | - Febronia Shirima
- Department of Clinical research, Kilimanjaro Clinical Research Institute, Moshi, United Republic of Tanzania
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania
| | - Rosalia E Njau
- Department of Clinical research, Kilimanjaro Clinical Research Institute, Moshi, United Republic of Tanzania
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania
| | - Alice A Andongolile
- Department of Clinical research, Kilimanjaro Clinical Research Institute, Moshi, United Republic of Tanzania
- Depatment of Epidemiology and Applied Biostatistics and Depatment of Internal Medicine, Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania
| | - Manasseh Joel Mwanswila
- Department of Clinical research, Kilimanjaro Clinical Research Institute, Moshi, United Republic of Tanzania
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania
| | - Jo E B Halliday
- School of Biodiversity, One Health and Veterinary Medicine, University of Glasgow, Glasgow, London, UK
| | - Stefanie Krauth
- Depatment of Inflammation Medicine and Rheumatology, Health Economics and Health Technology Assessment (HEHTA), University of Glasgow Institute of Health and Wellbeing, Glasgow, UK
- School of Biodiversity, One Health and Veterinary Medicine, University of Glasgow, Glasgow, London, UK
| | - Kajiru Kilonzo
- Depatment of Epidemiology and Applied Biostatistics and Depatment of Internal Medicine, Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania
| | - Richard William Walker
- Depatment of One health and Veterinary Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Gloria August Temu
- Depatment of Epidemiology and Applied Biostatistics and Depatment of Internal Medicine, Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania
| | - Blandina T Mmbaga
- Department of Clinical research, Kilimanjaro Clinical Research Institute, Moshi, United Republic of Tanzania
- Depatment of Epidemiology and Applied Biostatistics and Depatment of Internal Medicine, Kilimanjaro Christian Medical University College, Moshi, United Republic of Tanzania
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Morsi RZ, Zhang Y, Carrión-Penagos J, Desai H, Tannous E, Kothari S, Khamis AM, Darzi AJ, Tarabichi A, Bastin R, Hneiny L, Thind S, Coleman E, Brorson JR, Mendelson S, Mansour A, Prabhakaran S, Kass-Hout T. Endovascular thrombectomy with or without thrombolysis bridging in patients with acute ischaemic stroke: protocol for a systematic review, meta-analysis of randomised trials and cost-effectiveness analysis. BMJ Open 2023; 13:e064322. [PMID: 37308271 DOI: 10.1136/bmjopen-2022-064322] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023] Open
Abstract
INTRODUCTION Current published guidelines and meta-analyses comparing endovascular thrombectomy (EVT) alone versus EVT with bridging intravenous thrombolysis (IVT) suggest that EVT alone is non-inferior to EVT with bridging thrombolysis in achieving favourable functional outcome. Because of this controversy, we aimed to systematically update the evidence and meta-analyse data from randomised trials comparing EVT alone versus EVT with bridging thrombolysis, and performed an economic evaluation comparing both strategies. METHODS AND ANALYSIS We will conduct a systematic review of randomised controlled trials comparing EVT with or without bridging thrombolysis in patients presenting with large vessel occlusions. We will identify eligible studies by systematically searching the following databases from inception without any language restrictions: MEDLINE (through Ovid), Embase and the Cochrane Library. The following criteria will be used to assess eligibility for inclusion: (1) adult patients ≥18 years old; (2) randomised patients to EVT alone or to EVT with IVT; and (3) measured outcomes, including functional outcomes, at least 90 days after randomisation. Pairs of reviewers will independently screen the identified articles, extract information and assess the risk of bias of eligible studies. We will use the Cochrane Risk-of-Bias tool to evaluate risk of bias. We will also use the Grading of Recommendations, Assessment, Development and Evaluation approach to assess the certainty in evidence for each outcome. We will then perform an economic evaluation based on the extracted data. ETHICS AND DISSEMINATION This systematic review will not require a research ethics approval because no confidential patient data will be used. We will disseminate our findings by publishing the results in a peer-reviewed journal and via presentation at conferences. PROSPERO REGISTRATION NUMBER CRD42022315608.
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Affiliation(s)
- Rami Z Morsi
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Harsh Desai
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Elie Tannous
- Department of Pathology, Albany Medical Center, Albany, New York, USA
| | - Sachin Kothari
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Assem M Khamis
- Wolfson Palliative Care Research Centre, Hull York Medical School, Hull, UK
| | - Andrea J Darzi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ammar Tarabichi
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Reena Bastin
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Layal Hneiny
- Wegner Health Sciences Information Center, University of South Dakota, Sioux Falls, South Dakota, USA
| | - Sonam Thind
- Section of Neurosurgery, Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Elisheva Coleman
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - James R Brorson
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Scott Mendelson
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Ali Mansour
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Tareq Kass-Hout
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
- Section of Neurosurgery, Department of Surgery, University of Chicago, Chicago, Illinois, USA
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Kengne Talla P, Thomas A, Ataman R, Auger C, McKerral M, Wittich W, Poncet F, Ahmed S. Evaluating the implementation of the Mayo-Portland Adaptability Inventory-4 (MPAI-4) in three rehabilitation settings in Quebec: a mixed-methods study protocol. BMJ Open 2023; 13:e068866. [PMID: 37221032 DOI: 10.1136/bmjopen-2022-068866] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
INTRODUCTION Stroke is a leading cause of morbidity and mortality worldwide, placing an immense burden on patients and the health system. Timely access to rehabilitation services can improve stroke survivors' quality of life. The use of standardised outcome measures is endorsed for optimising patient rehabilitation outcomes and improving clinical decision-making. This project results from a provincially mandated recommendation to use the fourth version of the Mayo-Portland Adaptability Inventory (MPAI-4) to measure changes in social participation of stroke survivors and to maintain commitment to evidence-informed practices in stroke care. This protocol outlines the implementation process of the MPAI-4 for three rehabilitation centres. The objectives are to: (a) describe the context of MPAI-4 implementation; (b) determine clinical teams' readiness for change; (c) identify barriers and enablers to implementing the MPAI-4 and match the implementation strategies; (d) evaluate the MPAI-4 implementation outcomes including the degree of integration of the MPAI-4 into clinical practice and (e) explore participants' experiences using the MPAI-4. METHODS AND ANALYSIS We will use a multiple case study design within an integrated knowledge translation (iKT) approach with active engagement from key informants. Each case is a rehabilitation centre implementing MPAI-4. We will collect data from clinicians and programme managers using mixed methods guided by several theoretical frameworks. Data sources include surveys, focus groups and patient charts. We will conduct descriptive, correlational and content analyses. Ultimately, we will analyse, integrate data from qualitative and quantitative components and report them within and across participating sites. Results will provide insights about iKT within stroke rehabilitation settings that could be applied to future research projects. ETHICS AND DISSEMINATION The project received Institutional Review Board approval from the Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal. We will disseminate results in peer-reviewed publications and at local, national and international scientific conferences.
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Affiliation(s)
- Pascaline Kengne Talla
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Quebec, Canada
- Centre de recherche interdisciplinaire en readaptation du Montreal metropolitain, Montreal, Quebec, Canada
- Lethbridge-Layton-Mackay Rehabilitation Centre, Centre Intégré Universitaire de Santé et de Services Sociaux (CIUSSS) du Centre Ouest-de-l'Ile-de-Montréal, Montreal, Quebec, Canada
| | - Aliki Thomas
- Centre de recherche interdisciplinaire en readaptation du Montreal metropolitain, Montreal, Quebec, Canada
- School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada
- Faculty of Education, McGill University, Montreal, Quebec, Canada
- Integrated Health and Social Services Centre of Laval (CISSS de Laval), Laval, Quebec, Canada
| | - Rebecca Ataman
- Centre de recherche interdisciplinaire en readaptation du Montreal metropolitain, Montreal, Quebec, Canada
- Lethbridge-Layton-Mackay Rehabilitation Centre, Centre Intégré Universitaire de Santé et de Services Sociaux (CIUSSS) du Centre Ouest-de-l'Ile-de-Montréal, Montreal, Quebec, Canada
- School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada
| | - Claudine Auger
- Centre de recherche interdisciplinaire en readaptation du Montreal metropolitain, Montreal, Quebec, Canada
- École de la réadaptation, Faculte de Medecine, Université de Montreal, Montreal, Quebec, Canada
- Integrated University Health and Social Services Centre for South-Central Montreal (Institut Universitaire sur la Réadaptation en Déficience Physique de Montréal, CIUSSS du Centre-Sud-de-l'Île-de-Montréal), Montreal, Quebec, Canada
| | - Michelle McKerral
- Centre de recherche interdisciplinaire en readaptation du Montreal metropolitain, Montreal, Quebec, Canada
- Integrated University Health and Social Services Centre for South-Central Montreal (Institut Universitaire sur la Réadaptation en Déficience Physique de Montréal, CIUSSS du Centre-Sud-de-l'Île-de-Montréal), Montreal, Quebec, Canada
- Department of Psychology, Université de Montréal, Montreal, Quebec, Canada
| | - Walter Wittich
- Centre de recherche interdisciplinaire en readaptation du Montreal metropolitain, Montreal, Quebec, Canada
- School of Optometry, Université de Montreal, Montreal, Quebec, Canada
- Institut Nazareth et Louis-Braille, Integrated Health and Social Services Centre of Montérégie-Centre (CISSS de la Montérégie-Centre), Montérégie, Quebec, Canada
| | - Frédérique Poncet
- Centre de recherche interdisciplinaire en readaptation du Montreal metropolitain, Montreal, Quebec, Canada
- Lethbridge-Layton-Mackay Rehabilitation Centre, Centre Intégré Universitaire de Santé et de Services Sociaux (CIUSSS) du Centre Ouest-de-l'Ile-de-Montréal, Montreal, Quebec, Canada
- School of Optometry, Université de Montreal, Montreal, Quebec, Canada
| | - Sara Ahmed
- Centre de recherche interdisciplinaire en readaptation du Montreal metropolitain, Montreal, Quebec, Canada
- Lethbridge-Layton-Mackay Rehabilitation Centre, Centre Intégré Universitaire de Santé et de Services Sociaux (CIUSSS) du Centre Ouest-de-l'Ile-de-Montréal, Montreal, Quebec, Canada
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Wang G, Qiao L, Tang Z, Zhou S, Min J, Li M. Association between bilirubin levels and risk of stroke: a systematic review and meta-analysis. BMJ Open 2023; 13:e064433. [PMID: 37164466 PMCID: PMC10174027 DOI: 10.1136/bmjopen-2022-064433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2023] Open
Abstract
OBJECTIVE To evaluate the association between bilirubin levels and stroke risk. DESIGN Systematic review and meta-analysis, reported in accordance with Meta-analysis Of Observational Studies in Epidemiology guidelines. DATA SOURCES The PubMed, Embase, Cochrane Central Register of Controlled Trials and China National Knowledge Infrastructure Databases were searched from inception up to 27 February 2022. ELIGIBILITY CRITERIA Cohort studies assessing the dose-response relationship between bilirubin levels and risk of stroke were eligible for inclusion. There were no language restrictions. DATA EXTRACTION AND SYNTHESIS All data from eligible studies were collected and assessed by two independent investigators. We generated pooled relative risks (RRs) with 95% CIs. We used a restricted cubic spline model for the dose-response analyses. Subsequent subgroup analyses were conducted according to stroke outcomes, follow-up duration, geographical area and size of the cohort. RESULTS Nine articles including results from 11 cohort studies with 7835 cases of stroke and 263 596 participants met the inclusion criteria. The summarised RR of stroke comparing the highest and lowest bilirubin level was 0.85 (95% CI 0.72 to 0.99). The dose-response analysis indicated that a 15 µmol/L increment of bilirubin level was associated with an 18% lower risk of stroke (RR=0.82, 95% CI 0.67 to 0.99). For ischaemic stroke, the RR was 0.76 (95% CI 0.58 to 0.99). Significant publication bias was not detected. CONCLUSIONS Elevated bilirubin levels were associated with a decreased risk of stroke among adults. PROSPERO REGISTRATION NUMBER CRD42017071497.
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Affiliation(s)
- Gege Wang
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Luyao Qiao
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Zhenyu Tang
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Siqi Zhou
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jun Min
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Min Li
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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Askim T, Hokstad A, Bergh E, Døhl Ø, Ellekjær H, Ihle-Hansen H, Indredavik B, Leer ASM, Lydersen S, Saltvedt I, Seljeseth Y, Thommessen B. Multimodal individualised intervention to prevent functional decline after stroke: protocol of a randomised controlled trial on long-term follow-up after stroke (LAST-long). BMJ Open 2023; 13:e069656. [PMID: 37164457 PMCID: PMC10173970 DOI: 10.1136/bmjopen-2022-069656] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2023] Open
Abstract
INTRODUCTION Multimodal interventions have emerged as new approaches to provide more targeted intervention to reduce functional decline after stroke. Still, the evidence is contradictory. The main objective of the Life After Stroke (LAST)-long trial is to investigate if monthly meetings with a stroke coordinator who offers a multimodal approach to long-term follow-up can prevent functional decline after stroke. METHODS AND ANALYSIS LAST-long is a pragmatic single-blinded, parallel-group randomised controlled trial recruiting participants living in six different municipalities, admitted to four hospitals in Norway. The patients are screened for inclusion and recruited into the trial 3 months after stroke. A total of 300 patients fulfilling the inclusion criteria will be randomised to an intervention group receiving monthly follow-up by a community-based stroke coordinator who identifies the participants' individual risk profile and sets up an action plan based on individual goals, or to a control group receiving standard care. All participants undergo blinded assessments at 6-month, 12-month and 18-month follow-up. Modified Rankin Scale at 18 months is primary outcome. Secondary outcomes are results of blood tests, blood pressure, adherence to secondary prophylaxis, measures of activities of daily living, cognitive function, physical function, physical activity, patient reported outcome measures, caregiver's burden, the use and costs of health services, safety measures and measures of adherence to the intervention. Mixed models will be used to evaluate differences between the intervention and control group for all endpoints across the four time points, with treatment group, time as categorical covariates and their interaction as fixed effects, and patient as random effect. ETHICS AND DISSEMINATION This trial was approved by the Regional Committee of Medical and Health Research Ethics, REC no. 2018/1809. The main results will be published in international peer-reviewed open access scientific journals and to policy-makers and end users in relevant channels. TRIAL REGISTRATION NUMBER ClincalTrials.gov Identifier: NCT03859063, registered on 1 March 2019.
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Affiliation(s)
- Torunn Askim
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Anne Hokstad
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Elin Bergh
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurology, Akershus University Hospital, Lorenskog, Norway
| | - Øystein Døhl
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
- Department of Finance, Trondheim Municipality, Trondheim, Norway
| | - Hanne Ellekjær
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
- Department of Stroke, Clinic of Medicine, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | | | - Bent Indredavik
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
- Department of Stroke, Clinic of Medicine, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Anne Silja Mäkitalo Leer
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
- Department of Health and Social Services, Trondheim Municipality, Trondheim, Norway
| | - Stian Lydersen
- Department of Mental Health, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Ingvild Saltvedt
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
- Department of Geriatric Medicine, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Yngve Seljeseth
- Department of Medicine, Ålesund Hospital, Helse More og Romsdal HF, Ålesund, Norway
| | - Bente Thommessen
- Department of Neurology, Akershus University Hospital, Lorenskog, Norway
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12
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Almubayyidh M, Alghamdi I, Parry-Jones AR, Jenkins D. Clinical features and novel technologies for prehospital detection of intracerebral haemorrhage: a scoping review protocol. BMJ Open 2023; 13:e070228. [PMID: 37137559 PMCID: PMC10163533 DOI: 10.1136/bmjopen-2022-070228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Abstract
INTRODUCTION The detection of intracerebral haemorrhage (ICH) in the prehospital setting without conventional imaging technology might allow early treatment to reduce haematoma expansion and improve patient outcomes. Although ICH and ischaemic stroke share many clinical features, some may help in distinguishing ICH from other suspected stroke patients. In combination with clinical features, novel technologies may improve diagnosis further. This scoping review aims to first identify the early, distinguishing clinical features of ICH and then identify novel portable technologies that may enhance differentiation of ICH from other suspected strokes. Where appropriate and feasible, meta-analyses will be performed. METHODS The scoping review will follow the recommendations of the Joanna Briggs Institute Methodology for Scoping Reviews as well as the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. A systematic search will be conducted using MEDLINE (Ovid), EMBASE (Ovid) and CENTRAL (Ovid). EndNote reference management software will be used to remove duplicate entries. Two independent reviewers will screen titles, abstracts and full-text reports according to prespecified eligibility criteria using the Rayyan Qatar Computing Research Institute software. One reviewer will screen all titles, abstracts and full-text reports of potentially eligible studies, while the other reviewer will independently screen at least 20% of all titles, abstracts and full-text reports. Conflicts will be resolved through discussion or by consulting a third reviewer. Results will be tabulated in accordance with the scoping review's objectives along with a narrative discussion. ETHICS AND DISSEMINATION Ethical approval is not required for this review, as it will only include published literature. The results will be published in an open-access, peer-reviewed journal, presented at scientific conferences and form part of a PhD thesis. We expect the findings to contribute to future research into the early detection of ICH in suspected stroke patients.
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Affiliation(s)
- Mohammed Almubayyidh
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
- Department of Aviation and Marine, Prince Sultan Bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia
| | - Ibrahim Alghamdi
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
- Department of Emergency Medical Services, College of Applied Medical Sciences, Khamis Mushait Campus, King Khalid University, Abha, Saudi Arabia
| | - Adrian Robert Parry-Jones
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
- Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - David Jenkins
- Division of Informatics, Imaging and Data Science, The University of Manchester, Manchester, UK
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Vestergaard SB, Damsbo AG, Blauenfeldt RA, Johnsen SP, Andersen G, Mortensen JK. Impact of prestroke physical activity and citalopram treatment on poststroke depressive symptoms: a secondary analysis of data from the TALOS randomised controlled trial in Denmark. BMJ Open 2023; 13:e070822. [PMID: 36997260 PMCID: PMC10069592 DOI: 10.1136/bmjopen-2022-070822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
Abstract
OBJECTIVES To investigate the association between prestroke physical activity and depressive symptoms up to 6 months after stroke and examine if citalopram treatment modified the association. DESIGN A secondary analysis of data from the multicentre randomised controlled trial The Efficacy of Citalopram Treatment in Acute Ischemic Stroke (TALOS). SETTING AND PARTICIPANTS TALOS was conducted at multiple stroke centres in Denmark from 2013 to 2016. It enrolled 642 non-depressed patients with first-ever acute ischaemic stroke. Patients were eligible for this study if a prestroke physical activity level was assessed by the Physical Activity Scale for the Elderly (PASE). INTERVENTIONS All patients were randomised to citalopram or placebo for 6 months. OUTCOMES Depressive symptoms 1 and 6 months after stroke measured on the Major Depression Inventory (MDI) ranging from 0 to 50. RESULTS A total of 625 patients were included. Median (IQR) age was 69 (60-77) years, 410 (65.6%) were men, 309 (49.4 %) received citalopram and median (IQR) prestroke PASE score was 132.5 (76-197). Higher prestroke PASE quartile, compared with the lowest PASE quartile, was associated with fewer depressive symptoms both after 1 month (mean difference third quartile -2.3 (-4.2, -0.5), p=0.013, mean difference fourth quartile -2.4 (-4.3, -0.5), p=0.015) and 6 months after stroke (mean difference third quartile -3.3 (-5.5, -1.2), p=0.002, mean difference fourth quartile -2.8 (-5.2, -0.3), p=0.027). There was no interaction between citalopram treatment and prestroke PASE score on poststroke MDI scores (p=0.86). CONCLUSIONS A higher prestroke physical activity level was associated with fewer depressive symptoms 1 and 6 months after stroke. Citalopram treatment did not seem to modify this association. TRIAL REGISTRATION NUMBERS NCT01937182 (ClinicalTrials.gov) and 2013-002253-30 (EUDRACT).
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Affiliation(s)
- Sigrid Breinholt Vestergaard
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Andreas Gammelgaard Damsbo
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Rolf Ankerlund Blauenfeldt
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Grethe Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Janne Kaergaard Mortensen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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14
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Zhang SY, Dewar B, Fahed R, Shamy M, Shorr R, Dowlatshahi D. Prevalence of spontaneous recanalisation of complete internal carotid occlusion: protocol for a systematic scoping review. BMJ Open 2023; 13:e067773. [PMID: 36889831 PMCID: PMC10008469 DOI: 10.1136/bmjopen-2022-067773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023] Open
Abstract
INTRODUCTION Although previously thought to be a rare occurrence, spontaneous recanalisation is not uncommon, with a growing number of reports describing this phenomenon. However, the frequency, time course and mechanism of spontaneous recanalisation remain unknown. A better characterisation of these events is essential to ensuring adequate identification and proper future trial design for treatment. OBJECTIVE To describe the current body of literature around spontaneous recanalisation following internal carotid occlusion. METHODS AND ANALYSIS With the assistance of an information specialist, we will search MEDLINE, Embase, Cochrane Central Register for Controlled Trials and Web of Science for studies of adults with spontaneous recanalisation or transient occlusion of the internal carotid artery. Two reviewers will independently collect data on included studies pertaining to publication data, study population information, timepoints of initial presentation, recanalisation and subsequent follow-up. ETHICS AND DISSEMINATION Primary data will not be collected; therefore, formal ethics is not required. The findings of this study will be disseminated through peer-reviewed publications and presentations at academic conferences.
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Affiliation(s)
- Sarah Y Zhang
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Québec, Canada
| | - Brian Dewar
- Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Robert Fahed
- Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Michel Shamy
- Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Risa Shorr
- Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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15
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Wong JZW, Park PSW, Frost T, Stephens K, Newk-Fon Hey Tow FK, Garcia PG, Senanayake C, Choi PMC. Using body cameras to quantify the duration of a Code Stroke and identify workflow issues: a continuous observation workflow time study. BMJ Open 2023; 13:e067816. [PMID: 36697041 PMCID: PMC9884893 DOI: 10.1136/bmjopen-2022-067816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE 'Code Stroke' (Code) is used in health services to streamline hyperacute assessment and treatment delivery for patients with ischaemic stroke. However, there are few studies that detail the time spent on individual components performed during a Code. We sought to quantify the time taken for each process during a Code and investigate associations with modifiable and non-modifiable factors. DESIGN Continuous observation workflow time study. SETTING AND PARTICIPANTS Recordings of 100 Codes were performed at a high-volume primary stroke centre in Melbourne, Australia, between January and June 2020 using a body camera worn by a member of the stroke team. MAIN OUTCOME MEASURES The main measures included the overall duration of Codes and the individual processes within the Code workflow. Associations between variables of interest and process times were explored using linear regression models. RESULTS 100 Codes were captured, representing 19.2% of all Codes over the 6 months. The median duration of a complete Code was 54.2 min (IQR 39.1-74.7). Administrative work performed after treatment is completed (median 21.0 min (IQR 9.8-31.4)); multimodal CT imaging (median 13.0 min (IQR 11.5-15.7)), and time between decision and thrombolysis administration (median 8.1 min (IQR 6.1-10.8)) were the longest components of a Code. Tenecteplase was able to be prepared faster than alteplase (median 1.8 vs 4.9 min, p=0.02). The presence of a second junior doctor was associated with shorter administrative work time (median 10.3 vs 25.1 min, p<0.01). No specific modifiable factors were found to be associated with shorter overall Code duration. CONCLUSIONS Codes are time intensive. Time spent on decision-making was a relatively small component of the overall Code duration. Data from body cameras can provide granular data on all aspects of Code workflow to inform potential areas for improvement at individual centres.
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Affiliation(s)
- Joseph Zhi Wen Wong
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
- Departments of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Peter Si Woo Park
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Tanya Frost
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Karen Stephens
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
| | | | - Pamela Gayle Garcia
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Channa Senanayake
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Philip M C Choi
- Department of Neurosciences, Eastern Health, Box Hill Hospital, Box Hill, Victoria, Australia
- Eastern Health Clinical School, Monash University Faculty of Medicine, Nursing and Health Sciences, Clayton, Victoria, Australia
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Pedlow K, McDonough S, Klempel N, Hylands J, Hughes N, Campbell Z, Eng JJ, Stephenson A, Kennedy N. PREP Plus combined postrehabilitation programme to support upper limb recovery in community-dwelling stroke survivors: protocol for a mixed-methods, cluster-assigned feasibility study. BMJ Open 2023; 13:e069016. [PMID: 36669847 PMCID: PMC9872469 DOI: 10.1136/bmjopen-2022-069016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 11/03/2022] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Poor recovery of the upper limb following a stroke has been recognised as a significant problem in the UK. Although there is good evidence that early, intense rehabilitation can lead to upper limb recovery, often this is not maintained, with less than 50% of people regaining the ability to use their upper limb for independent function at 6 months. Upper limb recovery potential is reported for many years poststroke, yet current long-term provision is insufficient. METHODS AND ANALYSIS 60 participants will be recruited into this feasibility study, with 30 allocated to a Post Rehabilitation Enablement Programme (PREP) alone and 30 allocated to a combined programme, PREP Plus, consisting of PREP and the Graded Repetitive Arm Supplementary Programme (GRASP). We will aim to complete four iterative waves. Within each wave, the intervention design will be refined, based on participant feedback. Within each wave, there will be one cluster unit (one intervention group ;PREP Plus) and one control group ;PREP alone)). A total of five PREP sites within Northern Ireland Health and Social Care Trusts will be used for this study. PREP Plus will have a home exercise component along with exercises logs and a behaviour contract. Qualitative and quantitative measures will evaluate the acceptability and feasibility to determine how feasible it is to embed the intervention into practice, as well as to determine the feasibility of a larger, mixed-methods, randomised controlled trial to assess intervention efficacy. Clinical endpoints will also be explored. ETHICS AND DISSEMINATION This study has been approved by the Health and Social Care Research Ethics Committee A, IRAS project ID (278620). Participants will provide informed consent prior to participating in the study. Information outlining the purpose of the study, what data will be collected and how the data will be managed will be provided. Results will be published in peer-reviewed journals and any published data will be available on the university data repository. The project management group will advise on different avenues for dissemination to ensure it reaches appropriate audiences. TRIAL REGISTRATION NUMBER NCT05090163.
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Affiliation(s)
- Katy Pedlow
- School of Health Sciences, Ulster University, Londonderry, UK
| | | | - Natalie Klempel
- School of Health Sciences, Ulster University, Londonderry, UK
| | - Jenny Hylands
- School of Health Sciences, Ulster University, Londonderry, UK
| | | | - Zoe Campbell
- Northern Ireland Chest Heart and Stroke, Belfast, UK
| | - Janice J Eng
- Physical Therapy, University of British Columbia, Vancouver, Columbia, Canada
| | | | - Niamh Kennedy
- School of Psychology, Ulster University, Coleraine, UK
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Nambiar V, Raj M, Vasudevan D, Bhaskaran R, Sudevan R. One-year mortality after acute stroke: a prospective cohort study from a comprehensive stroke care centre, Kerala, India. BMJ Open 2022; 12:e061258. [PMID: 36442894 PMCID: PMC9710353 DOI: 10.1136/bmjopen-2022-061258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES The primary objective was to report the 1-year all-cause mortality among patients with stroke. The secondary objectives were (1) to report the mortality stratified by type of stroke and sex and (2) to report predictors of 1-year mortality among patients with stroke. DESIGN A prospective cohort study. SETTING Institutional-stroke care unit of a tertiary care hospital PARTICIPANTS: Patients who were treated in the study institution during 2016-2020 for acute stroke and were followed up for a period of 1 year after stroke in the same institution. MAIN OUTCOME MEASURES The main outcome measures were the mortality proportion of any stroke and first ever stroke cohorts at select time points, including in-hospital stay, along with 2 weeks, 2 months, 6 months and 1 year after index stroke. The secondary outcomes were (1) mortality proportions stratified by sex and type of stroke and (2) predictors of 1-year mortality for any stroke and first ever stroke. RESULTS We recruited a total of 1336 patients. The mean age of participants was 61.6 years (13.5 years). The mortality figures for 2 weeks, 2 months, 6 months and 12 months after discharge were 79 (5.9%), 88 (6.7%), 101 (7.6%) and 114 (8.5%), respectively, in the full cohort. The in-hospital mortality was 45 (3.4%). The adjusted analysis revealed 3 predictors for 1-year mortality after first ever stroke-age, pre-treatment National Institutes of Health Stroke Scale (NIHSS) score and Modified Rankin Scale (mRS) score at baseline. The same for the full cohort had only two predictors-age and pre-treatment NIHSS score. CONCLUSION Mortality of stroke at 1-year follow-up in the study population is low in comparison to several studies published earlier. The predictors of 1-year mortality after stroke included age, NIHSS score at baseline and mRS score at baseline.
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Affiliation(s)
- Vivek Nambiar
- Division of Stroke, Department of Neurology, Amrita Institute of Medical Sciences and Research Centre, Cochin, India
| | - Manu Raj
- Department of Pediatrics and Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre, Cochin, India
| | - Damodaran Vasudevan
- Department of Health Sciences Research, Amrita Institute of Medical Sciences and Research Centre, Cochin, India
| | - Renjitha Bhaskaran
- Department of Biostatistics, Amrita Institute of Medical Sciences, Cochin, India
| | - Remya Sudevan
- Department of Health Sciences Research, Amrita Institute of Medical Sciences, Amrita viswa vidyapeetham, Cochin, India
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Singh H, Nelson MLA, Martyniuk J, Colquhoun H, Munce S, Cameron JI, Kokorelias KM, Pakkal O, Kuluski K. Scoping review protocol of the use of codesign methods in stroke intervention development. BMJ Open 2022; 12:e065150. [PMID: 36410803 PMCID: PMC9680189 DOI: 10.1136/bmjopen-2022-065150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Codesign is an emerging research method to enhance intervention development by actively engaging non-researchers (eg, people who have had a stroke, caregivers and clinicians) in research. The involvement of non-researchers in research is becoming increasingly popular within health studies as it may produce more relevant and effective findings. The stroke population commonly exhibits challenges such as aphasia and cognitive changes that may limit their participation in codesign. However, the use of codesign within the stroke literature has not been comprehensively reviewed. This scoping review will determine: (1) what is the extent, range and nature of stroke research that has used codesign methods? (2) What codesign methods have been used to develop stroke interventions? (3) What considerations for codesigning interventions with people who have stroke are not captured in the findings? METHODS AND ANALYSIS This is a protocol for a scoping review to identify the literature relating to stroke, and codesign will be conducted on OVID Medline, OVID Embase, OVID PsychINFO, EBSCO CINAHL, the Cochrane Library, Scopus, PEDro-Physiotherapy Evidence Database and Global Index Medicus. Studies of any design and publication date will be included. Title and abstract and full-text review will be conducted independently by two reviewers. Data will be extracted, collated and then summarised descriptively using quantitative (eg, numerical descriptions) and qualitative (eg, textual descriptions) methods. Numerical summaries will map the extent (eg, number of studies), range (eg, types of studies) and nature (eg, types of interventions developed) of the literature on this topic. A thematic analysis will provide insights into the codesign methods (eg, activities, non-researchers), including heterogeneity across and within studies. ETHICS AND DISSEMINATION This review protocol does not require ethics approval as data has not been collected/analysed. The findings will highlight opportunities and recommendations to inform future codesign research in stroke and other populations who exhibit similar challenges/disabilities, and they will be disseminated via publications, presentations and stakeholder meetings. TRIAL REGISTRATION NUMBERREGISTRATION Open Science Framework: 10.17605/OSF.IO/NSD2W.
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Affiliation(s)
- Hardeep Singh
- Department of Occupational Science & Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- KITE, Toronto Rehabilitation Institute, Toronto, Ontario, Canada
- Rehabilitation Science Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Michelle LA Nelson
- Bridgepoint Collaboratory for Research and Innovation, Sinai Health System, Lunenfeld-Tanenbaum Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Julia Martyniuk
- Gerstein Science Information Centre, University of Toronto, Toronto, Ontario, Canada
| | - Heather Colquhoun
- Department of Occupational Science & Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Rehabilitation Science Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sarah Munce
- Department of Occupational Science & Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- KITE, Toronto Rehabilitation Institute, Toronto, Ontario, Canada
- Rehabilitation Science Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jill I Cameron
- Department of Occupational Science & Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Rehabilitation Science Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Kristina Marie Kokorelias
- Geriatric Medicine, Department of Medicine, Sinai Health System/University Health Network, Toronto, ON, Canada
| | - Oya Pakkal
- Bridgepoint Collaboratory for Research and Innovation, Sinai Health System, Lunenfeld-Tanenbaum Research Institute, Toronto, Ontario, Canada
| | - Kerry Kuluski
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
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Coors M, Flemming R, Schüttig W, Hubert GJ, Hubert ND, Sundmacher L. Health economic evaluation of the 'Flying Intervention Team' as a novel stroke care concept for rural areas: study protocol of the TEMPiS-GÖA study. BMJ Open 2022; 12:e060533. [PMID: 36127094 PMCID: PMC9490577 DOI: 10.1136/bmjopen-2021-060533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 08/31/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Providing comprehensive stroke care poses major organisational and financial challenges to the German healthcare system. The quasi-randomised TEMPiS-Flying Intervention Team (TEMPiS-FIT) study aims to close the gap in the treatment of patients who had ischaemic stroke in rural areas of Southeast Bavaria by flying a team of interventionalists via helicopter directly to patients in the regional TEMPiS hospitals instead of transporting the patients to the next comprehensive stroke centre. The objective of the present paper is to describe the methods for the economic evaluation (TEMPiS-Gesundheitsökonomische Analyse (TEMPiS-GÖA)) alongside the TEMPiS-FIT study to determine whether the new form of care is cost-effective compared with standard care. METHODS AND ANALYSIS The within-trial cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) will be performed from a statutory health insurance perspective as well as from a societal perspective over the time horizon of 12 months after the patients' hospital discharge. Direct costs from outpatient and inpatient care are collected from routine data of the participating health insurance funds, while medical and non-medical costs from a patient's perspective are retrieved from primary data collected during the TEMPiS-FIT study and follow-up questionnaires. Results will be presented as incremental cost-effectiveness ratio and incremental cost-utility ratio quantifying the incremental costs and health benefits compared with standard care practice. The outcome of the CEA will be measured in costs per minute reduction in mean process time to thrombectomy. The outcome of the CUA will be presented as costs per quality-adjusted life year gained. ETHICS AND DISSEMINATION Ethical approval for the TEMPiS-FIT study was granted by the Bavarian State Medical Association Ethics Committee (# 17056). Results will be disseminated via reports, presentations of the results in publications and at conferences and on the TEMPiS website. TRIAL REGISTRATION NUMBER German Clinical Trials Register DRKS00023885. Registered on 2 July 2021 - retrospectively registered.
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Affiliation(s)
- Marie Coors
- Department of Health Economics, Technical University of Munich, Munich, Germany
| | - Ronja Flemming
- Department of Health Economics, Technical University of Munich, Munich, Germany
| | - Wiebke Schüttig
- Department of Health Economics, Technical University of Munich, Munich, Germany
| | - Gordian Jan Hubert
- Department of Neurology, TEMPiS Telemedical Stroke Centre, München Klinik Harlaching, Munich, Germany
| | - Nikolai Dominik Hubert
- Department of Neurology, TEMPiS Telemedical Stroke Centre, München Klinik Harlaching, Munich, Germany
| | - Leonie Sundmacher
- Department of Health Economics, Technical University of Munich, Munich, Germany
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Fulton S, Janssen H, Salih S, James A, Elphinston RA. Feasibility and acceptability of a mobile model of environmental enrichment for patients with mixed medical conditions receiving inpatient rehabilitation: a mixed methods study. BMJ Open 2022; 12:e061212. [PMID: 36115676 PMCID: PMC9486324 DOI: 10.1136/bmjopen-2022-061212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To investigate the feasibility and acceptability of a mobile model of environmental enrichment (EE), a paradigm that promotes activity engagement after stroke, in patients with mixed medical conditions receiving inpatient rehabilitation. DESIGN A mixed methods study design was used. An online qualitative survey assessed staff perspectives of acceptability of the mobile EE model including perceived barriers and enablers pre-implementation and post implementation. An A-B quasi-experimental case study of patient activity levels over a 2-week observational period provided feasibility data. This included recruitment and retention rates, completion of scheduled patient activity observations and validated baseline questionnaires, and number of adverse events. SETTING A 30-bed mixed medical ward in a public hospital that services Brisbane's southern bayside suburbs. The rehabilitation programme operates with patients co-located throughout the medical/surgical wards. PARTICIPANTS Nursing and allied health professionals working across the rehabilitation programme completed pre-implementation (n=19) and post implementation (n=16) qualitative questions. Patients admitted to the ward and who received the inpatient rehabilitation programme from June to November 2016 were also recruited. INTERVENTIONS The mobile EE intervention included activities to primarily promote social and cognitive stimulation (eg, puzzles, board games) delivered by hospital volunteers and was designed to be moved throughout the wards. RESULTS Four themes emerged from staff reports, suggesting that the role of patient, staff and intervention characteristics, and the ward environment were important barriers and enablers to implementation. Of the 12 eligible patients, six consented to the study, and five completed the intervention. All patients completed the baseline measures. No adverse events were reported. CONCLUSIONS As interest grows in human EE models, it will be important to tailor EE interventions to the unique demands of hospital rehabilitation services. A mobile EE model delivered in a small, mixed rehabilitation ward appears feasible and acceptable to study in a larger controlled feasibility trial.
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Affiliation(s)
- Sarah Fulton
- Speech Pathology Department, Redland Hospital, Metro South Hospital and Health Service, Brisbane, Queensland, Australia
| | - Heidi Janssen
- Hunter Stroke Service and Community and Aged Care Services, Community Stroke Team, Hunter New England Local Health District and Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Salih Salih
- Rehabilitation Unit, Redland Hospital, Metro South Hospital and Health Service, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Alecia James
- Speech Pathology Department, Redland Hospital, Metro South Hospital and Health Service, Brisbane, Queensland, Australia
| | - Rachel A Elphinston
- RECOVER Injury Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Centre for Functioning and Health Research, Metro South Hospital and Health Service, Brisbane, Queensland, Australia
- National Health and Medical Research Council Centre of Research Excellence - Better Health Outcomes for Compensable Injury, The University of Queensland, Brisbane, Queensland, Australia
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21
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Williams K, Modi RN, Dymond A, Hoare S, Powell A, Burt J, Edwards D, Lund J, Johnson R, Lobban T, Lown M, Sweeting MJ, Thom H, Kaptoge S, Fusco F, Morris S, Lip G, Armstrong N, Cowie MR, Fitzmaurice DA, Freedman B, Griffin SJ, Sutton S, Hobbs FR, McManus RJ, Mant J, Safer Authorship Group T. Cluster randomised controlled trial of screening for atrial fibrillation in people aged 70 years and over to reduce stroke: protocol for the pilot study for the SAFER trial. BMJ Open 2022; 12:e065066. [PMID: 36691194 PMCID: PMC9472173 DOI: 10.1136/bmjopen-2022-065066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 08/16/2022] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) is a common arrhythmia associated with 30% of strokes, as well as other cardiovascular disease, dementia and death. AF meets many criteria for screening, but there is limited evidence that AF screening reduces stroke. Consequently, no countries recommend national screening programmes for AF. The Screening for Atrial Fibrillation with ECG to Reduce stroke (SAFER) trial aims to determine whether screening for AF is effective at reducing risk of stroke. The aim of the pilot study is to assess feasibility of the main trial and inform implementation of screening and trial procedures. METHODS AND ANALYSIS SAFER is planned to be a pragmatic randomised controlled trial (RCT) of over 100 000 participants aged 70 years and over, not on long-term anticoagulation therapy at baseline, with an average follow-up of 5 years. Participants are asked to record four traces every day for 3 weeks on a hand-held single-lead ECG device. Cardiologists remotely confirm episodes of AF identified by the device algorithm, and general practitioners follow-up with anticoagulation as appropriate. The pilot study is a cluster RCT in 36 UK general practices, randomised 2:1 control to intervention, recruiting approximately 12 600 participants. Pilot study outcomes include AF detection rate, anticoagulation uptake and other parameters to incorporate into sample size calculations for the main trial. Questionnaires sent to a sample of participants will assess impact of screening on psychological health. Process evaluation and qualitative studies will underpin implementation of screening during the main trial. An economic evaluation using the pilot data will confirm whether it is plausible that screening might be cost-effective. ETHICS AND DISSEMINATION The London-Central Research Ethics Committee (19/LO/1597) and Confidentiality Advisory Group (19/CAG/0226) provided ethical approval. Dissemination will be via publications, patient-friendly summaries, reports and engagement with the UK National Screening Committee. TRIAL REGISTRATION NUMBER ISRCTN72104369.
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Affiliation(s)
- Kate Williams
- Strangeways Research Laboratory, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Rakesh Narendra Modi
- Strangeways Research Laboratory, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Andrew Dymond
- Strangeways Research Laboratory, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sarah Hoare
- THIS (The Healthcare Improvement Studies) Institute, University of Cambridge, Cambridge, UK
| | - Alison Powell
- THIS (The Healthcare Improvement Studies) Institute, University of Cambridge, Cambridge, UK
| | - Jenni Burt
- THIS (The Healthcare Improvement Studies) Institute, University of Cambridge, Cambridge, UK
| | - Duncan Edwards
- Strangeways Research Laboratory, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jenny Lund
- Strangeways Research Laboratory, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Rachel Johnson
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Mark Lown
- Primary Care Population Sciences and Medical Education, University of Southampton School, Southampton, UK
| | - Michael J Sweeting
- Department of Health Sciences, George Davies Centre, University of Leicester, Leicester, UK
| | - H Thom
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Stephen Kaptoge
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Francesco Fusco
- Strangeways Research Laboratory, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephen Morris
- Strangeways Research Laboratory, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Gregory Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Natalie Armstrong
- Department of Health Sciences, George Davies Centre, University of Leicester, Leicester, UK
| | - Martin R Cowie
- Guy's & St Thomas' NHS Foundation Trust, Royal Brompton Hospital, London, UK
- Faculty of Life Sciences and Medicine, Kings College London, London, UK
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, UK
| | - David A Fitzmaurice
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Ben Freedman
- Heart research Institute, Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Simon J Griffin
- Strangeways Research Laboratory, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- MRC Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Stephen Sutton
- Strangeways Research Laboratory, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jonathan Mant
- Strangeways Research Laboratory, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - The Safer Authorship Group
- Strangeways Research Laboratory, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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He Q, Wang J, Ma L, Li H, Tao C, You C. Safety of surgical Treatment In severe primary Pontine haemorrhage Evacuation (STIPE): study protocol for a multi-centre, randomised, controlled, open-label trial. BMJ Open 2022; 12:e062233. [PMID: 35998952 PMCID: PMC9403110 DOI: 10.1136/bmjopen-2022-062233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Primary pontine haemorrhage (PPH) is the most devastating subtype of intracerebral haemorrhage and is associated with poor prognosis, especially for the severe patients. Although medical treatment (MT) is widely accepted, a large number of studies have shown surgical haematoma evacuation (HE) might dramatically reduce mortality and improve prognosis outcome in severe PPH (sPPH). However, evidence to clarify the safety of HE remains insufficient. METHODS AND ANALYSIS The Safety of surgical Treatment In severe primary Pontine haemorrhage Evacuation study is a multi-centre, randomised, controlled, open-label trial, conducted from January 2022 to November 2024 in 20 tertiary hospitals in China. A total of 64 patients with sPPH will be randomly assigned to MT or HE group. Eligible patients will receive the corresponding treatment according to the result of randomisation. The primary outcomes are related to the safety of surgery including rate of symptomatic rebleeding at 3 days and rate of mortality and intracranial infection at 30 days. The secondary outcomes are the neurological function indexes following up at 30 days, 90 days, 180 days and 365 days. ETHICS AND DISSEMINATION The clinical trial has been approved by the Biomedical Research Ethics Committee of West China Hospital of Sichuan University (unique identifiers: No. 2020-894). All results of the trial will be published in international peer-reviewed scientific journals and will be disseminated through scientific conferences. Academic dissertation will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBERS NCT04647162, ChiCTR2000039679.
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Affiliation(s)
- Qiang He
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jiajing Wang
- Department of Post Anesthesia Care Unit, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chuanyuan Tao
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Gallucci L, Umarova RM. Association of cognitive reserve with stroke outcome: a protocol for a systematic review. BMJ Open 2022; 12:e059378. [PMID: 35803623 PMCID: PMC9272103 DOI: 10.1136/bmjopen-2021-059378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION The concept of cognitive reserve (CR) was introduced to account for individual differences in the clinical manifestation of neurodegenerative diseases. Though several mechanisms and risk factors are shared between neurodegeneration and stroke, the effect of CR on poststroke functional outcome has been poorly addressed. This systematic review aims to synthesise the available research evidence on the association of CR with stroke outcome, in order to implement the understanding of interindividual variability in stroke outcome and to improve its prediction. METHODS AND ANALYSIS Cochrane Library, Embase, PubMed, Web of Science and reference lists of relevant literature will be searched for publications on CR proxies (eg, education, years of education, occupational attainment, premorbid intelligence) and stroke outcome, published between 1 January 1980 and 10 March 2022. Two reviewers will independently perform the study selection, data extraction and quality assessment. Disagreements between reviewers will be resolved by a third independent reviewer. The Quality In Prognosis Studies tool will be used to assess the quality of each included study. The primary outcome will be functional outcome after stroke assessed with modified Rankin Scale, activities of daily living (eg, Barthel Index), National Institute of Health Stroke Scale, dichotomised as favourable versus not favourable as well as reported as continuous or ordinal variables. Qualitative and quantitative findings will be summarised and, if possible, data will be synthesised using appropriate meta-analytical methods. The quality of evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation framework. ETHICS AND DISSEMINATION No ethical approval is required as it is a protocol for a systematic review and the data used will be extracted from published studies. The findings from this systematic review will be disseminated in a peer-reviewed scientific journal and presented at conferences. The data will be made freely available. PROSPERO REGISTRATION NUMBER CRD42021256175.
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Affiliation(s)
- Laura Gallucci
- Department of Neurology, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Roza M Umarova
- Department of Neurology, Inselspital, University Hospital, University of Bern, Bern, Switzerland
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González-Pérez A, Roberts L, Vora P, Saez ME, Brobert G, Fatoba S, García Rodríguez LA. Safety and effectiveness of appropriately and inappropriately dosed rivaroxaban or apixaban versus warfarin in patients with atrial fibrillation: a cohort study with nested case-control analyses from UK primary care. BMJ Open 2022; 12:e059311. [PMID: 35654463 PMCID: PMC9163551 DOI: 10.1136/bmjopen-2021-059311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To investigate effects of appropriately and inappropriately dosed apixaban/rivaroxaban versus warfarin on effectiveness and safety outcomes in patients with non-valvular atrial fibrillation (NVAF). DESIGN Cohort study with nested case-control analyses using primary care electronic health records (IQVIA Medical Research Data UK database). SETTING UK primary care. PARTICIPANTS Patients aged ≥18 years with NVAF newly prescribed apixaban (N=14 701), rivaroxaban (N=14 288) or warfarin (N=16 175) between 1 January 2012 and 30 June 2018, and followed up to 31 December 2018. PRIMARY AND SECONDARY OUTCOME MEASURES Incident cases of ischaemic stroke/systemic embolism (IS/SE) and intracranial bleeding (ICB). Cases were matched to controls on age, sex and OAC naïve status. Using logistic regression, adjusted ORs with 95% CIs were calculated for the outcomes comparing apixaban/rivaroxaban use (appropriate or inappropriate dosing based on the product label criteria) and warfarin. RESULTS For IS/SE, ORs (95% CIs) for apixaban versus warfarin were 1.19 (0.92-1.52) for appropriate dose and 1.01 (0.67-1.51) for inappropriate dose; for rivaroxaban versus warfarin, estimates were 1.07 (0.83-1.37) for appropriate dose and 1.21 (0.78-1.88) for inappropriate dose. For ICB, ORs (95% CIs) for apixaban versus warfarin were 0.67 (0.44-1.00) for appropriate dose and 0.45 (0.21-0.95) for inappropriate dose; for rivaroxaban versus warfarin, estimates were 0.81 (0.55-1.20) for appropriate dose and 1.14 (0.56-2.31) for inappropriate dose. CONCLUSIONS Dosing appropriateness in NVAF was not associated with a significant difference in IS/SE risk or increase in ICB risk versus warfarin. These findings may reflect residual confounding and biases that were difficult to control, as also seen in other observational studies. They should, therefore, be interpreted with caution, and prescribers should adhere to the dosing instructions in the respective Summary of Product Characteristics. Further studies on this topic from real-world populations are needed.
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Affiliation(s)
- Antonio González-Pérez
- Spanish Centre for Pharmacoepidemiologic Research, Madrid, Spain
- Andalusian Bioinformatics Research Centre (CAEBi), Seville, Spain
- Pharmacoepidemiology Research Group, Institute for Health Research (IRYCIS), Madrid, Spain
| | | | | | - Maria Eugenia Saez
- Spanish Centre for Pharmacoepidemiologic Research, Madrid, Spain
- Andalusian Bioinformatics Research Centre (CAEBi), Seville, Spain
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Chen Y, Fang M, Wu P, Xie Z, Wu H, Wu Q, Xu S, Li Y, Sun B, Pang B, Zheng N, Zhang J, Hu X, You C. Seizure prophylaxis following aneurysmal subarachnoid haemorrhage (SPSAH): study protocol for a multicentre randomised placebo-controlled trial of short-term sodium valproate prophylaxis in patients with acute subarachnoid haemorrhage. BMJ Open 2022; 12:e057917. [PMID: 35508338 PMCID: PMC9073395 DOI: 10.1136/bmjopen-2021-057917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Seizures are a common complication that leads to neurological deficits and affects outcomes after aneurysmal subarachnoid haemorrhage (aSAH). However, whether to use prophylactic anticonvulsants in patients with aSAH remains controversial. Our study aims to determine whether short-term (7 days) sodium valproate could prevent seizure occurrence and improve neurological function in patients with SAH caused by anterior circulation aneurysm rupture and treated with clipping. METHODS AND ANALYSIS In this multicentre randomised evaluator-blind placebo-controlled trial, 182 eligible patients with good-grade aSAH planned for surgical clipping will be enrolled from four neurosurgical centres in China. In addition to standard care, patients will be randomly assigned to receive sodium valproate 20 mg/kg daily or matching placebo. After aneurysmal clipping, patients will be followed up at discharge, 90 days and 180 days. The primary outcomes are the incidence of early and late seizures. The secondary outcomes include aSAH-related complications, sodium valproate-related adverse effects, modified Rankin Scale (mRS) (on discharge, at 90 days, 180 days), rate of good outcome (defined as mRS 0-2), all-cause death (at 90 days, 180 days) and Montreal Cognitive Assessment score (at 180 days). All analyses are by intention-to-treat. ETHICS AND DISSEMINATION This study will be conducted according to the principles of Declaration of Helsinki and good clinical practice guidelines. This trial involves human participants and has been approved by the ethics committee of West China Hospital. Informed consent will be achieved from each included patient and/or their legally authorised representative. Preliminary and final results from this study will be disseminated through manuscript publishing and international congresses presentations. Any protocol amendments will be approved by the ethics committee of West China Hospital and subsequently updated on ChiCTR. TRIAL REGISTRATION NUMBER ChiCTR.org identifier: ChiCTR2100050161.
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Affiliation(s)
- Yuqi Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Mei Fang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Pei Wu
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Zhiyi Xie
- Department of Neurosurgery, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Honggang Wu
- Department of Neurosurgery, People's Hospital of Leshan, Leshan, Sichuan, China
| | - Qiaowei Wu
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Shancai Xu
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Yuchen Li
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Bowen Sun
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Bo Pang
- Department of Neurosurgery, People's Hospital of Leshan, Leshan, Sichuan, China
| | - Niandong Zheng
- Department of Neurosurgery, People's Hospital of Leshan, Leshan, Sichuan, China
| | - Jianmin Zhang
- Department of Neurosurgery, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xin Hu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Bivard A, Zhao H, Coote S, Campbell B, Churilov L, Yassi N, Yan B, Valente M, Sharobeam A, Balabanski A, Dos Santos A, Ng F, Langenberg F, Stephenson M, Smith K, Bernard S, Thijs V, Cloud G, Choi P, Ma H, Wijeratne T, Chen C, Olenko L, Davis SM, Donnan GA, Parsons M. Tenecteplase versus Alteplase for Stroke Thrombolysis Evaluation Trial in the Ambulance (Mobile Stroke Unit-TASTE-A): protocol for a prospective randomised, open-label, blinded endpoint, phase II superiority trial of tenecteplase versus alteplase for ischaemic stroke patients presenting within 4.5 hours of symptom onset to the mobile stroke unit. BMJ Open 2022; 12:e056573. [PMID: 35487712 PMCID: PMC9058803 DOI: 10.1136/bmjopen-2021-056573] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Mobile stroke units (MSUs) equipped with a CT scanner are increasingly being used to assess and treat stroke patients' prehospital with thrombolysis and transfer them to the most appropriate hospital for ongoing stroke care and thrombectomy when indicated. The effect of MSUs in both reducing the time to reperfusion treatment and improving patient outcomes is now established. There is now an opportunity to improve the efficacy of treatment provided by the MSU. Tenecteplase is a potent plasminogen activator, which may have benefits over the standard of care stroke lytic alteplase. Specifically, in the MSU environment tenecteplase presents practical benefits since it is given as a single bolus and does not require an infusion over an hour like alteplase. OBJECTIVE In this trial, we seek to investigate if tenecteplase, given to patients with acute ischaemic stroke as diagnosed on the MSU, improves the rate of early reperfusion. METHODS AND ANALYSIS TASTE-A is a prospective, randomised, open-label, blinded endpoint (PROBE) phase II trial of patients who had an ischaemic stroke assessed in an MSU within 4.5 hours of symptom onset. The primary endpoint is early reperfusion measured by the post-lysis volume of the CT perfusion lesion performed immediately after hospital arrival. ETHICS AND DISSEMINATION The study was approved by the Royal Melbourne Hospital Human Ethics committee. The findings will be published in peer-reviewed journals, presented at academic conferences and disseminated among consumer and healthcare professional audiences. TRIAL REGISTRATION NUMBER NCT04071613.
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Affiliation(s)
- Andrew Bivard
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Henry Zhao
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Skye Coote
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Bruce Campbell
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nawaf Yassi
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Michael Valente
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - Angelos Sharobeam
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Anna Balabanski
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
- Department of Neurology, Monash University, Melbourne, Victoria, Australia
| | - Angela Dos Santos
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
- Department of Neurology, Monash University, Melbourne, Victoria, Australia
| | - Felix Ng
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - Francesca Langenberg
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Karen Smith
- Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | | | - Vincent Thijs
- Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Victoria, Australia
- Stroke Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Geoffrey Cloud
- Department of Neurology, Alfred Health, Monash University, Melbourne, Victoria, Australia
| | - Philip Choi
- Department of Neurology, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Henry Ma
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Tissa Wijeratne
- Department of Neurology, Western Health, Footscray, Victoria, Australia
| | - Chushuang Chen
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Liudmyla Olenko
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Melbourne Brain Centre at Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
- Melbourne Brain Centre at Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Mark Parsons
- School of Medicine and Public Health, Department of Neurology Liverpool Hospital, University of New South Wales South Western Sydney Clinical School, Liverpool, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
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Clark CE, Boddy K, Warren FC, Taylor RS, Aboyans V, Cloutier L, McManus RJ, Shore AC, Campbell JL. Associations between interarm differences in blood pressure and cardiovascular disease outcomes: protocol for an individual patient data meta-analysis and development of a prognostic algorithm. BMJ Open 2017; 7:e016844. [PMID: 28674148 PMCID: PMC5734572 DOI: 10.1136/bmjopen-2017-016844] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Individual cohort studies in various populations and study-level meta-analyses have shown interarm differences (IAD) in blood pressure to be associated with increased cardiovascular and all-cause mortality. However, key questions remain, such as follows: (1) What is the additional contribution of IAD to prognostic risk estimation for cardiovascular and all-cause mortality? (2) What is the minimum cut-off value for IAD that defines elevated risk? (3) Is there a prognostic value of IAD and do different methods of IAD measurement impact on the prognostic value of IAD? We aim to address these questions by conducting an individual patient data (IPD) meta-analysis. METHODS AND ANALYSIS This study will identify prospective cohort studies that measured blood pressure in both arms during recruitment, and invite authors to contribute IPD datasets to this collaboration. All patient data received will be combined into a single dataset. Using one-stage meta-analysis, we will undertake multivariable time-to-event regression modelling, with the aim of developing a new prognostic model for cardiovascular risk estimation that includes IAD. We will explore variations in risk contribution of IAD across predefined population subgroups (eg, hypertensives, diabetics), establish the lower limit of IAD that is associated with additional cardiovascular risk and assess the impact of different methods of IAD measurement on risk prediction. ETHICS AND DISSEMINATION This study will not include any patient identifiable data. Included datasets will already have ethical approval and consent from their sponsors. Findings will be presented to international conferences and published in peer reviewed journals, and we have a comprehensive dissemination strategy in place with integrated patient and public involvement. PROSPERO REGISTRATION NUMBER CRD42015031227.
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Affiliation(s)
- Christopher E Clark
- Primary Care Research Group, Institute of Health Services Research, University of Exeter Medical School, Exeter, Devon, UK
| | - Kate Boddy
- Patient and Public Involvement Team, PenCLAHRC, University of Exeter Medical School, Exeter, Devon, UK
| | - Fiona C Warren
- Primary Care Research Group, Institute of Health Services Research, University of Exeter Medical School, Exeter, Devon, UK
| | - Rod S Taylor
- Primary Care Research Group, Institute of Health Services Research, University of Exeter Medical School, Exeter, Devon, UK
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, and Inserm 1098, Tropical Neuroepidemiology, Limoges, France
| | - Lyne Cloutier
- Département des sciences infirmières, Université du Québec à Trois-Rivières, Trois-Rivières, Canada
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Angela C Shore
- NIHR Exeter Clinical Research Facility, Royal Devon and Exeter Hospital and University of Exeter Medical School, Exeter, Devon, UK
| | - John L Campbell
- Primary Care Research Group, Institute of Health Services Research, University of Exeter Medical School, Exeter, Devon, UK
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Abstract
OBJECTIVES Our aim was to provide nationwide age-standardised rates (ASR) on the usage of endovascular coiling and neurosurgical clipping for unruptured intracranial aneurysm (UIA) treatment in Germany. SETTING Nationwide observational study using the Diagnosis-Related-Groups (DRG) statistics for the years 2005-2009 (overall 83 million hospitalisations). PARTICIPANTS From 2005 to 2009, overall 39 155 hospitalisations with a diagnosis of UIA occurred in Germany. PRIMARY OUTCOME MEASURES Age-specific and age-standardised hospitalisation rates for UIA with the midyear population of Germany in 2007 as the standard. RESULTS Of the 10 221 hospitalisations with UIA during the observation period, 6098 (59.7%) and 4123 (40.3%) included coiling and clipping, respectively. Overall hospitalisation rates for UIA increased by 39.5% (95% CI 24.7% to 56.0%) and 50.4% (95% CI 39.6% to 62.1%) among men and women, respectively. In 2005, the ASR per 100 000 person years for coiling was 0.7 (95% CI 0.62 to 0.78) for men and 1.7 (95% CI 1.58 to 1.82) for women. In 2009, the ASR was 1.0 (95% CI 0.90 to 1.10) and 2.4 (95% CI 2.24 to 2.56), respectively. Similarly, the ASR for clipping in 2005 amounted to 0.6 (95% CI 0.52 to 0.68) for men and 1.1 (95% CI 1.00 to 1.20) for women. These rates increased in 2009 to 0.8 (95% CI 0.72 to 0.88) and 1.7 (95% CI 1.58 to 1.82), respectively. We observed a marked geographical variation of ASR for coiling and less pronounced for clipping. For the federal state of Saarland, the ASR for coiling was 5.64 (95% CI 4.76 to 6.52) compared with 0.68 (95% CI 0.48 to 0.88; per 100 000 person years) in Saxony-Anhalt, whereas, ASR for clipping were highest in Rhineland-Palatinate (2.48, 95% CI 2.17 to 4.75) and lowest in Saxony-Anhalt (0.52, 95% CI 0.34 to 0.70). CONCLUSIONS To the best of our knowledge, we presented the first representative, nationwide analysis of the clinical management of UIA in Germany. The ASR increased markedly and showed substantial geographical variation among federal states for all treatment modalities during the observation period.
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Affiliation(s)
- Victor Walendy
- Zentrum für Klinische Epidemiologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Germany
| | - Andreas Stang
- Zentrum für Klinische Epidemiologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Germany
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts, USA
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Geraghty O, Korompoki E, Filippidis FT, Rudd A, Veltkamp R. Cardiac diagnostic work-up for atrial fibrillation after transient ischaemic attacks in England and Wales: results from a cross-sectional survey. BMJ Open 2016; 6:e012714. [PMID: 28186939 PMCID: PMC5129110 DOI: 10.1136/bmjopen-2016-012714] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Transient ischaemic attacks (TIAs) are an important precursor of stroke. Atrial fibrillation (AF) is among the most dangerous aetiologies shared between TIAs and strokes. Detection of AF after TIAs is essential for the initiation of oral anticoagulants. We aimed to identify variations in the use of cardiac investigations used to detect AF and cardiac pathology in patients with TIA in the UK. SETTING All TIA clinical leads in England and Wales received an invitation by email to participate in an online survey in February 2015. The questionnaire consisted of 36 multiple choice questions covering the domains: (1) general information about stroke units, (2) ECG diagnostics and cardiologic work-up and (3) management of AF. RESULTS 146 survey invitations were sent. The response rate was 40% (n=59). Diagnosis of AF largely depends on medical history and 12-channel ECG which is performed in the vast majority of patients with TIA (>75%) in 94.1% of the TIA services. Many patients with TIA either do not receive 24-hour Holter recording (requested regularly in 42% of the services) or only after considerable delay (>2 weeks). Prolonged event recording is only rarely performed (16%). Only about half of patients with TIA undergo echocardiography. Cranial imaging in patients with TIA is mainly performed as CT (62%). The majority of TIA clinics rapidly initiate anticoagulation in TIA patients with AF (81.6%) preferably using new oral anticoagulants (75.5%). CONCLUSIONS Significant variation in the cardiac diagnostic work-up following TIA exists regarding the use of particular detection techniques and the duration of cardiac ECG monitoring. Only limited resources are allocated to cardiac evaluation. In addition to research establishing the optimal ECG technique for patients with TIA, healthcare delivery programmes are needed to ensure proper management to prevent strokes.
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Affiliation(s)
- Olivia Geraghty
- Department of Stroke Medicine, Imperial College London, London, UK
| | - Eleni Korompoki
- Department of Stroke Medicine, Imperial College London, London, UK
| | | | - Anthony Rudd
- Department of Stroke Medicine, Guy's and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK
- National Clinical Director of Stroke, NHS England
- London Stroke Clinical Director, London, UK
| | - Roland Veltkamp
- Department of Stroke Medicine, Imperial College London, London, UK
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Dixon P, Hollinghurst S, Ara R, Edwards L, Foster A, Salisbury C. Cost-effectiveness modelling of telehealth for patients with raised cardiovascular disease risk: evidence from a cohort simulation conducted alongside the Healthlines randomised controlled trial. BMJ Open 2016; 6:e012355. [PMID: 27670521 PMCID: PMC5051382 DOI: 10.1136/bmjopen-2016-012355] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES To investigate the long-term cost-effectiveness (measured as the ratio of incremental NHS cost to incremental quality-adjusted life years) of a telehealth intervention for patients with raised cardiovascular disease (CVD) risk. DESIGN A cohort simulation model developed as part of the economic evaluation conducted alongside the Healthlines randomised controlled trial. SETTING Patients recruited through primary care, and intervention delivered via telehealth service. PARTICIPANTS Participants with a 10-year CVD risk ≥20%, as measured by the QRISK2 algorithm, and with at least 1 modifiable risk factor, individually randomised from 42 general practices in England. INTERVENTION A telehealth service delivered over a 12-month period. The intervention involved a series of responsive, theory-led encounters between patients and trained health information advisors who provided access to information resources and supported medication adherence and coordination of care. PRIMARY AND SECONDARY OUTCOME MEASURES Cost-effectiveness measured by net monetary benefit over the simulated lifetime of trial participants from a UK National Health Service perspective. RESULTS The probability that the intervention was cost-effective depended on the duration of the effect of the intervention. The intervention was cost-effective with high probability if effects persisted over the lifetime of intervention recipients. The probability of cost-effectiveness was lower for shorter durations of effect. CONCLUSIONS The intervention was likely to be cost-effective under a lifetime perspective. TRIAL REGISTRATION NUMBER ISRCTN27508731; Results.
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Affiliation(s)
- Padraig Dixon
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sandra Hollinghurst
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Roberta Ara
- ScHARR, The University of Sheffield, Sheffield, UK
| | - Louisa Edwards
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | - Chris Salisbury
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
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Dixon P, Hollinghurst S, Edwards L, Thomas C, Gaunt D, Foster A, Large S, Montgomery AA, Salisbury C. Cost-effectiveness of telehealth for patients with raised cardiovascular disease risk: evidence from the Healthlines randomised controlled trial. BMJ Open 2016; 6:e012352. [PMID: 27566642 PMCID: PMC5013404 DOI: 10.1136/bmjopen-2016-012352] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 06/02/2016] [Accepted: 06/29/2016] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To investigate the cost-effectiveness of a telehealth intervention for primary care patients with raised cardiovascular disease (CVD) risk. DESIGN A prospective within-trial patient-level economic evaluation conducted alongside a randomised controlled trial. SETTING Patients recruited through primary care, and intervention delivered via telehealth service. PARTICIPANTS Adults with a 10-year CVD risk ≥20%, as measured by the QRISK2 algorithm, with at least 1 modifiable risk factor. INTERVENTION A series of up to 13 scripted, theory-led telehealth encounters with healthcare advisors, who supported participants to make behaviour change, use online resources, optimise medication and improve adherence. Participants in the control arm received usual care. PRIMARY AND SECONDARY OUTCOME MEASURES Cost-effectiveness measured by net monetary benefit at the end of 12 months of follow-up, calculated from incremental cost and incremental quality-adjusted life years (QALYs). Productivity impacts, participant out-of-pocket expenditure and the clinical outcome were presented in a cost-consequences framework. RESULTS 641 participants were randomised-325 to receive the telehealth intervention in addition to usual care and 316 to receive only usual care. 18% of participants had missing data on either costs, utilities or both. Multiple imputation was used for the base case results. The intervention was associated with incremental mean per-patient National Health Service (NHS) costs of £138 (95% CI 66 to 211) and an incremental QALY gain of 0.012 (95% CI -0.001 to 0.026). The incremental cost-effectiveness ratio was £10 859. Net monetary benefit at a cost-effectiveness threshold of £20 000 per QALY was £116 (95% CI -58 to 291), and the probability that the intervention was cost-effective at this threshold value was 0.77. Similar results were obtained from a complete case analysis. CONCLUSIONS There is evidence to suggest that the Healthlines telehealth intervention was likely to be cost-effective at a threshold of £20 000 per QALY. TRIAL REGISTRATION NUMBER ISRCTN27508731; Results. Prospectively registered 05 July 2012.
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Affiliation(s)
- Padraig Dixon
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sandra Hollinghurst
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Louisa Edwards
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Clare Thomas
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Daisy Gaunt
- Bristol Randomised Trials Collaboration (BRTC), School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Alexis Foster
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Alan A Montgomery
- Bristol Randomised Trials Collaboration (BRTC), School of Social and Community Medicine, University of Bristol, Bristol, UK
- Nottingham Clinical Trials Unit, Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
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Abstract
OBJECTIVE To clarify and quantify the potential association between intake of flavonoids and risk of stroke. DESIGN Meta-analysis of prospective cohort studies. DATA SOURCE Studies published before January 2016 identified through electronic searches using PubMed, Embase and the Cochrane Library. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Prospective cohort studies with relative risks and 95% CIs for stroke according to intake of flavonoids (assessed as dietary intake). RESULTS The meta-analysis yielded 11 prospective cohort studies involving 356 627 participants and more than 5154 stroke cases. The pooled estimate of the multivariate relative risk of stroke for the highest compared with the lowest dietary flavonoid intake was 0.89 (95% CI 0.82 to 0.97; p=0.006). Dose-response analysis indicated that the summary relative risk of stroke for an increase of 100 mg flavonoids consumed per day was 0.91 (95% CI 0.77 to 1.08) without heterogeneity among studies (I(2)=0%). Stratifying by follow-up duration, the relative risk of stroke for flavonoid intake was 0.89 (95% CI 0.81 to 0.99) in studies with more than 10 years of follow-up. CONCLUSIONS Results from this meta-analysis suggest that higher dietary flavonoid intake may moderately lower the risk of stroke.
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Affiliation(s)
- Zhenyu Tang
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
| | - Min Li
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
| | - Xiaowei Zhang
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
| | - Wenshang Hou
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
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Wilson A, Coleby D, Regen E, Phelps K, Windridge K, Willars J, Robinson T. Service factors causing delay in specialist assessment for TIA and minor stroke: a qualitative study of GP and patient perspectives. BMJ Open 2016; 6:e011654. [PMID: 27188815 PMCID: PMC4874118 DOI: 10.1136/bmjopen-2016-011654] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To understand how service factors contribute to delays to specialist assessment following transient ischaemic attack (TIA) or minor stroke. DESIGN Qualitative study using semistructured interviews, analysis by constant comparison. SETTING Leicester, UK. PARTICIPANTS Patients diagnosed with TIA or minor stroke, at hospital admission or in a rapid-access TIA clinic (n=42), general practitioners (GPs) of participating patients if they had been involved in the patients' care (n=18). DATA Accounts from patients and GPs of factors contributing to delay following action to seek help from a healthcare professional (HCP). RESULTS The following categories of delay were identified. First, delay in assessment in general practice following contact with the service; this related to availability of same day appointments, and the role of the receptionist in identifying urgent cases. Second, delays in diagnosis by the HCP first consulted, including GPs, optometrists, out-of-hours services, walk-in centres and the emergency department. Third, delays in referral after a suspected diagnosis; these included variable use of the ABCD(2) (Age, Blood pressure, Clinical features, Duration, Diabetes) risk stratification score and referral templates in general practice, and referral back to the patients' GP in cases where he/she was not the first HCP consulted. CONCLUSIONS Primary and emergency care providers need to review how they can best handle patients presenting with symptoms that could be due to stroke or TIA. In general practice, this may include receptionist training and/or triage by a nurse or doctor. Mechanisms need to be established to enable direct referral to the TIA clinic when patients whose symptoms have resolved present to other agencies. Further work is needed to improve diagnostic accuracy by non-specialists.
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Affiliation(s)
- Andrew Wilson
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Dawn Coleby
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Emma Regen
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Kay Phelps
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Kate Windridge
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Janet Willars
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Tom Robinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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Jamison J, Graffy J, Mullis R, Mant J, Sutton S. Stroke survivors', caregivers' and GPs' attitudes towards a polypill for the secondary prevention of stroke: a qualitative interview study. BMJ Open 2016; 6:e010458. [PMID: 27178972 PMCID: PMC4874103 DOI: 10.1136/bmjopen-2015-010458] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To understand the perspectives of stroke survivors, caregivers and general practitioners (GPs) on a polypill approach, consisting of blood pressure and cholesterol-lowering therapies, with or without aspirin, for the secondary prevention of stroke. METHODS A qualitative interview study was undertaken in 5 GP surgeries in the East of England. 28 survivors of stroke/transient ischaemic attack (TIA) were interviewed, 14 of them with a caregiver present, along with a convenience sample of 5 GPs, to assess attitudes towards a polypill and future use. Topic guides explored participants attitudes, potential uptake and long-term use, management of polypill medication and factors influencing the decision to prescribe. Data were analysed using a grounded theory approach. Key themes are presented and illustrated with verbatim quotes. RESULTS The analysis identified 3 key themes: polypill benefits, polypill concerns and polypill lessons for implementation. Stroke/TIA survivors were positive about the polypill concept and considered it acceptable in the secondary prevention of stroke. Perceived benefits of a polypill included convenience resulting in improved adherence and reduced burden of treatment. Caregivers felt that a polypill would improve medication-taking practices, and GPs were open to prescribing it to those at increased cardiovascular risk. However, concerns raised included whether a polypill provided equivalent therapeutic benefit, side effects through combining medications, consequences of non-adherence, lack of flexibility in regulating dosage, disruption to current treatment and suitability to the wider stroke population. CONCLUSIONS Participants acknowledged potential advantages in a polypill approach for secondary prevention of stroke; however, significant concerns remain. Further research on the efficacy of a polypill is needed to reassure practitioners whose concerns around inflexibility and treatment suitability are likely to influence the decision to prescribe a polypill for secondary prevention of stroke. Acceptability among survivors, caregivers and GPs is likely to determine the uptake and subsequent use of a polypill in the future.
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Affiliation(s)
- James Jamison
- Behavioural Science Group, Primary Care Unit, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Jonathan Graffy
- Primary Care Unit, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Ricky Mullis
- Primary Care Unit, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Jonathan Mant
- Primary Care Unit, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Stephen Sutton
- Behavioural Science Group, Primary Care Unit, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
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Onozuka D, Hagihara A, Nishimura K, Kada A, Nakagawara J, Ogasawara K, Ono J, Shiokawa Y, Aruga T, Miyachi S, Nagata I, Toyoda K, Matsuda S, Suzuki A, Kataoka H, Nakamura F, Kamitani S, Nishimura A, Kurogi R, Sayama T, Iihara K. Prehospital antiplatelet use and functional status on admission of patients with non-haemorrhagic moyamoya disease: a nationwide retrospective cohort study (J-ASPECT study). BMJ Open 2016; 6:e009942. [PMID: 27008684 PMCID: PMC4800148 DOI: 10.1136/bmjopen-2015-009942] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To elucidate the association between antiplatelet use in patients with non-haemorrhagic moyamoya disease before hospital admission and good functional status on admission in Japan. DESIGN Retrospective, multicentre, non-randomised, observational study. SETTING Nationwide registry data in Japan. PARTICIPANTS A total of 1925 patients with non-haemorrhagic moyamoya disease admitted between 1 April 2012 and 31 March 2014 in Japan. MAIN OUTCOME MEASURE We performed propensity score-matched analysis to examine the association between prehospital antiplatelet use and no significant disability on hospital admission, as defined by a modified Rankin Scale score of 0 or 1. RESULTS Propensity-matched patients who received prehospital antiplatelet drugs were associated with a good outcome on hospital admission (OR adjusted for all covariates, 3.82; 95% CI 1.22 to 11.99) compared with those who did not receive antiplatelet drugs prior to hospital admission. CONCLUSIONS Prehospital antiplatelet use was significantly associated with good functional status on hospital admission among patients with non-haemorrhagic moyamoya disease in Japan. Our results suggest that prehospital antiplatelet use should be considered when evaluating outcomes of patients with non-haemorrhagic moyamoya disease.
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Affiliation(s)
- Daisuke Onozuka
- Department of Health Communication, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akihito Hagihara
- Department of Health Communication, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Akiko Kada
- Clinical Research Center, Nagoya Medical Center, Aichi, Japan
| | - Jyoji Nakagawara
- Department of Integrative Stroke Imaging Center, National Cerebral and Cardiovascular Center, Osaka, Japan
| | | | | | | | | | - Shigeru Miyachi
- Department of Neurosurgery, Osaka Medical College, Osaka, Japan
| | | | - Kazunori Toyoda
- Department of Cerebrovascular Medicine and Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shinya Matsuda
- Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Akifumi Suzuki
- Akita Prefectural Hospital Organization Research Institute for Brain and Blood Vessels, Akita, Japan
| | - Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Fumiaki Nakamura
- Department of Public Health/Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Satoru Kamitani
- Department of Public Health/Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Ataru Nishimura
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryota Kurogi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tetsuro Sayama
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Laiwalla AN, Ooi YC, Van De Wiele B, Ziv K, Brown A, Liou R, Saver JL, Gonzalez NR. Rigorous anaesthesia management protocol for patients with intracranial arterial stenosis: a prospective controlled-cohort study. BMJ Open 2016; 6:e009727. [PMID: 26787251 PMCID: PMC4735305 DOI: 10.1136/bmjopen-2015-009727] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES Reducing variability is integral in quality management. As part of the ongoing Encephaloduroarteriosynangiosis Revascularisation for Symptomatic Intracranial Arterial Stenosis (ERSIAS) trial, we developed a strict anaesthesia protocol to minimise fluctuations in patient parameters affecting cerebral perfusion. We hypothesise that this protocol reduces the intraoperative variability of targeted monitored parameters compared to standard management. DESIGN Prospective cohort study of patients undergoing encephaloduroarteriosynangiosis surgery versus standard neurovascular interventions. Patients with ERSIAS had strict perioperative management that included normocapnia and intentional hypertension. Control patients received regular anaesthetic standard of care. Minute-by-minute intraoperative vitals were electronically collected. Heterogeneity of variance tests were used to compare variance across groups. Mixed-model regression analysis was performed to establish the effects of treatment group on the monitored parameters. SETTING Tertiary care centre. PARTICIPANTS 24 participants: 12 cases (53.8 years ± 16.7 years; 10 females) and 12 controls (51.3 years ± 15.2 years; 10 females). Adults aged 30-80 years, with transient ischaemic attack or non-disabling stroke (modified Rankin Scale <3) attributed to 70-99% intracranial stenosis of the carotid or middle cerebral artery, were considered for enrolment. Controls were matched according to age, gender and history of neurovascular intervention. MAIN OUTCOME MEASURES Variability of heart rate, mean arterial blood pressure (MAP), systolic blood pressure and end tidal CO2 (ETCO2) throughout surgical duration. RESULTS There were significant reductions in the intraoperative MAP SD (4.26 vs 10.23 mm Hg; p=0.007) and ETCO2 SD (0.94 vs 1.26 mm Hg; p=0.05) between the ERSIAS and control groups. Median MAP and ETCO2 in the ERSIAS group were higher (98 mm Hg, IQR 23 vs 75 mm Hg, IQR 15; p<0.001, and 38 mm Hg, IQR 4 vs 32 mm Hg, IQR 3; p<0.001, respectively). CONCLUSIONS The ERSIAS anaesthesia protocol successfully reduced intraoperative fluctuations of MAP and ETCO2. The protocol also achieved normocarbia and the intended hypertension. TRIAL REGISTRATION NUMBER NCT01819597; Pre-results.
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Affiliation(s)
- Azim N Laiwalla
- Department of Neurosurgery, David Geffen School of Medicine at the University of California (UCLA), Los Angeles, California, USA
| | - Yinn Cher Ooi
- Department of Neurosurgery, David Geffen School of Medicine at the University of California (UCLA), Los Angeles, California, USA
| | - Barbara Van De Wiele
- Department of Anesthesiology, David Geffen School of Medicine at the University of California (UCLA), Los Angeles, California, USA
| | - Keren Ziv
- Department of Anesthesiology, David Geffen School of Medicine at the University of California (UCLA), Los Angeles, California, USA
| | - Adam Brown
- Department of Anesthesiology, David Geffen School of Medicine at the University of California (UCLA), Los Angeles, California, USA
| | - Raymond Liou
- Department of Neurosurgery, David Geffen School of Medicine at the University of California (UCLA), Los Angeles, California, USA
| | - Jeffrey L Saver
- Department of Neurology, David Geffen School of Medicine at the University of California (UCLA), Los Angeles, California, USA
| | - Nestor R Gonzalez
- Department of Neurosurgery and Radiology, David Geffen School of Medicine at the University of California (UCLA), Los Angeles, California, USA
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Zheng G, Zheng X, Li J, Duan T, Qi D, Ling K, He J, Chen L. Design, methodology and baseline characteristics of Tai Chi and its protective effect against ischaemic stroke risk in an elderly community population with risk factors for ischaemic stroke: a randomised controlled trial. BMJ Open 2015; 5:e009158. [PMID: 26700278 PMCID: PMC4691734 DOI: 10.1136/bmjopen-2015-009158] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Controlling risk factors with regular exercise is effective and cost-effective for the primary prevention of ischaemic stroke. As a traditional Chinese form of exercise, Tai Chi might be beneficial in decreasing ischaemic stroke, but the evidence remains insufficient. We hypothesise that elderly community adults with risk factors for ischaemic stroke will decrease their ischaemic stroke risk by improving cerebral haemodynamic parameters, cardiopulmonary function, motor function, plasma risk indices, physical parameters or psychological outcomes after receiving 12 weeks of regular Tai Chi training compared with those who maintained their original physical activities. Therefore, we designed a randomised controlled trial that will systematically evaluate the protective effects of Tai Chi exercise on ischaemic stroke risk in an elderly community population with risk factors for ischaemic stroke. METHODS AND ANALYSIS A total of 170 eligible participants were randomly allocated into either the Tai Chi training group or the usual physical activity group. This paper reports on the design, intervention development and baseline characteristics of the participants. There were no significant differences between comparison groups in demographic characteristics or the baseline data of primary or secondary outcomes. Participants in the Tai Chi training group will receive 12 weeks of Tai Chi training with a frequency of 5 days/week and 60 min/day, while those in the usual physical activities group will maintain their original activities. Primary and secondary outcomes will be measured at the 12-week and 24-week follow-ups. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Medical Ethics Committee of The Affiliated People's Hospital of Fujian University of Traditional Chinese Medicine (number 2013-020-02). The findings of this study will be communicated to healthcare professionals, participants and the public through peer-reviewed publications or scientific conferences. TRIAL REGISTRATION NUMBER ChiCTR-TRC-13003601; Pre-results.
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Affiliation(s)
- Guohua Zheng
- College of Rehabilitation Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Xin Zheng
- College of Rehabilitation Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Junzhe Li
- College of Rehabilitation Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Tingjin Duan
- Department of Physical Education, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Dalu Qi
- Department of Physical Education, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Kun Ling
- Department of Physical Education, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Jian He
- College of Rehabilitation Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
| | - Lidian Chen
- Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China
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Abstract
INTRODUCTION NeuroAiD (MLC601, MLC901), a combination of natural products, has been shown to be safe and to aid neurological recovery after brain injuries. The NeuroAiD Safe Treatment (NeST) Registry aims to assess its use and safety in the real-world setting. METHODS AND ANALYSIS The NeST Registry is designed as a product registry that would provide information on the use and safety of NeuroAiD in clinical practice. An online NeST Registry was set up to allow easy entry and retrieval of essential information including demographics, medical conditions, clinical assessments of neurological, functional and cognitive state, compliance, concomitant medications, and side effects, if any, among patients on NeuroAiD. Patients who are taking or have been prescribed NeuroAiD may be included. Participation is voluntary. Data collected are similar to information obtained during standard care and are prospectively entered by the participating physicians at baseline (before initialisation of NeuroAiD) and during subsequent visits. The primary outcome assessed is safety (ie, non-serious and serious adverse event), while compliance and neurological status over time are secondary outcomes. The in-person follow-up assessments are timed with clinical appointments. Anonymised data will be extracted and collectively analysed. Initial target sample size for the registry is 2000. Analysis will be performed after every 500 participants entered with completed follow-up information. ETHICS AND DISSEMINATION Doctors who prescribe NeuroAiD will be introduced to the registry by local partners. The central coordinator of the registry will discuss the protocol and requirements for implementation with doctors who show interest. Currently, the registry has been approved by the Ethics Committees of Universiti Kebangsaan Malaysia (Malaysia) and National Brain Center (Indonesia). In addition, for other countries, Ethics Committee approval will be obtained in accordance with local requirements. TRIAL REGISTRATION NUMBER NCT02536079.
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Affiliation(s)
| | - Ramesh Kumar
- Department of Neurosurgery, Faculty of Medicine, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Lyna Soertidewi
- Department of Neurology, National Brain Center Hospital, Jakarta, Indonesia
| | - Azizi Abu Bakar
- Department of Neurosurgery, Faculty of Medicine, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
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Owen CG, Kapetanakis VV, Rudnicka AR, Wathern AK, Lennon L, Papacosta O, Cook DG, Wannamethee SG, Whincup PH. Body mass index in early and middle adult life: prospective associations with myocardial infarction, stroke and diabetes over a 30-year period: the British Regional Heart Study. BMJ Open 2015; 5:e008105. [PMID: 26373398 PMCID: PMC4577944 DOI: 10.1136/bmjopen-2015-008105] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Adiposity in middle age is an established risk factor for cardiovascular disease and type 2 diabetes; less is known about the impact of adiposity from early adult life. We examined the effects of high body mass index (BMI) in early and middle adulthood on myocardial infarction (MI), stroke and diabetes risks. DESIGN A prospective cohort study. PARTICIPANTS 7735 men with BMI measured in middle age (40-59 years) and BMI ascertained at 21 years from military records or participant recall. PRIMARY AND SECONDARY OUTCOME MEASURES 30-year follow-up data for type 2 diabetes, MI and stroke incidence; Cox proportional hazards models were used to examine the effect of BMI at both ages on these outcomes, adjusted for age and smoking status. RESULTS Among 4846 (63%) men (with complete data), a 1 kg/m(2) higher BMI at 21 years was associated with a 6% (95% CI 4% to 9%) higher type 2 diabetes risk, compared with a 21% (95% CI 18% to 24%) higher diabetes risk for a 1 kg/m(2) higher BMI in middle age (hazard ratio (HR) 1.21, 95% CI 1.18 to 1.24). Higher BMI in middle age was associated with a 6% (95% CI 4% to 8%) increase in MI and a 4% (95% CI 1% to 7%) increase in stroke; BMI at 21 years showed no associations with MI or stroke risk. CONCLUSIONS Higher BMI at 21 years of age is associated with later diabetes incidence but not MI or stroke, while higher BMI in middle age is strongly associated with all outcomes. Early obesity prevention may reduce later type 2 diabetes risk, more than MI and stroke.
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Affiliation(s)
- Christopher G Owen
- Population Health Research Institute, St George's, University of London, London, UK
| | | | - Alicja R Rudnicka
- Population Health Research Institute, St George's, University of London, London, UK
| | - Andrea K Wathern
- Population Health Research Institute, St George's, University of London, London, UK
| | - Lucy Lennon
- Department of Primary Care and Population Health, UCL Medical School, London, UK
| | - Olia Papacosta
- Department of Primary Care and Population Health, UCL Medical School, London, UK
| | - Derek G Cook
- Population Health Research Institute, St George's, University of London, London, UK
| | - S Goya Wannamethee
- Department of Primary Care and Population Health, UCL Medical School, London, UK
| | - Peter H Whincup
- Population Health Research Institute, St George's, University of London, London, UK
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Xiong L, Lin W, Han J, Chen X, Leung TWH, Soo YOY, Wong LKS. A retrospective pilot study of correlation of cerebral augmentation effects of external counterpulsation with functional outcome after acute ischaemic stroke. BMJ Open 2015; 5:e009233. [PMID: 26351195 PMCID: PMC4563223 DOI: 10.1136/bmjopen-2015-009233] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE External counterpulsation (ECP) is a non-invasive method used to augment cerebral blood flow of patients with ischaemic stroke via induced hypertension. We aimed to explore the correlation between the cerebral blood flow augmentation effects induced by ECP and clinical outcome after acute ischaemic stroke. METHODS We retrospectively analysed our ECP registry of patients with ischaemic stroke who were enrolled within 7 days after stroke onset. Bilateral middle cerebral arteries of patients were monitored using transcranial Doppler (TCD). Flow velocity changes before, during and after ECP were, respectively, recorded for 3 min. The cerebral augmentation index (CAI) was the increase in percentage of the middle cerebral artery mean flow velocity during ECP compared with baseline. TCD data were analysed based on the side ipsilateral or contralateral to the infarct. The modified Rankin Scale (mRS) (good outcome: mRS 0∼2; poor outcome: mRS 3∼6) was evaluated 6 months after the index stroke. RESULTS 72 patients were included (mean age, 63.8±10.7 years; 87.5% males). At month 6 after stroke onset, univariate analysis showed that the National Institutes of Health Stroke Scale at recruitment was significantly higher and ECP therapy duration was longer in the poor outcome group, while the ipsilateral CAI was significantly lower in the good outcome group than that in the poor outcome group (3.71±4.94 vs 7.73±7.66, p=0.044). Multivariate logistic regression showed that ipsilateral CAI was independently correlated with an unfavourable functional outcome after adjusting for confounding factors. CONCLUSIONS The higher degree of cerebral blood flow velocity augmentation on the side ipsilateral to the infarct induced by ECP is independently correlated with an unfavourable functional outcome after acute ischaemic stroke.
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Affiliation(s)
- Li Xiong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Wenhua Lin
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Jinghao Han
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Xiangyan Chen
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Thomas Wai Hong Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Yannie Oi Yan Soo
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Lawrence Ka Sing Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
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Wireklint Sundström B, Herlitz J, Hansson PO, Brink P. Comparison of the university hospital and county hospitals in western Sweden to identify potential weak links in the early chain of care for acute stroke: results of an observational study. BMJ Open 2015; 5:e008228. [PMID: 26351184 PMCID: PMC4563274 DOI: 10.1136/bmjopen-2015-008228] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE To identify weak links in the early chain of care for acute stroke. SETTING 9 emergency hospitals in western Sweden, each with a stroke unit, and the emergency medical services (EMS). PARTICIPANTS All patients hospitalised with a first and a final diagnosis of stroke-between 15 December 2010 and 15 April 2011. The university hospital in the city of Gothenburg was compared with 6 county hospitals. PRIMARY AND SECONDARY MEASURES: (1) The system delay, that is, median delay time from call to the EMS until diagnosis was designated as the primary end point. Secondary end points were: (2) the system delay time from call to the EMS until arrival in a hospital ward, (3) the use of the EMS, (4) priority at the dispatch centre and (5) suspicion of stroke by the EMS nurse. RESULTS In all, 1376 acute patients with stroke (median age 79 years; 49% women) were included. The median system delay from call to the EMS until (1) diagnosis (CT scan) and (2) arrival in a hospital ward was 3 h and 52 min and 4 h and 22 min, respectively. The system delay (1) was significantly shorter in county hospitals. (3) The study showed that 76% used the EMS (Gothenburg 71%; the county 79%; p<0.0001). (4) Priority 1 was given at the dispatch centre in 54% of cases. (5) Stroke was suspected in 65% of cases. A prenotification was sent in 32% (Gothenburg 52%; the county 20%; p<0.0001). CONCLUSIONS System delay is still long and only a small fraction of patients received thrombolysis. Three of four used the EMS (more frequent in the county). They were given the highest priority at the dispatch centre in half of the cases. Stroke was suspected in two-thirds of the cases, but a prenotification was seldom sent to the hospital.
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Affiliation(s)
- Birgitta Wireklint Sundström
- Faculty of Caring Science, Work Life and Social Welfare, Research Centre PreHospen, University of Borås, The Prehospital Research Centre of Western Sweden, Borås, Sweden
| | - Johan Herlitz
- Faculty of Caring Science, Work Life and Social Welfare, Research Centre PreHospen, University of Borås, The Prehospital Research Centre of Western Sweden, Borås, Sweden
| | - Per Olof Hansson
- Department of Molecular and Clinical Medicine/Cardiology, Sahlgrenska Academy, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Peter Brink
- Emergency Medical Service System, NU-Hospital Organisation,Trollhättan, Sweden
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Ellis-Hill C, Gracey F, Thomas S, Lamont-Robinson C, Thomas PW, Marques EMR, Grant M, Nunn S, Cant RPI, Galvin KT, Reynolds F, Jenkinson DF. 'HeART of Stroke (HoS)', a community-based Arts for Health group intervention to support self-confidence and psychological well-being following a stroke: protocol for a randomised controlled feasibility study. BMJ Open 2015; 5:e008888. [PMID: 26243555 PMCID: PMC4538255 DOI: 10.1136/bmjopen-2015-008888] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 06/23/2015] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Over 152,000 people in the UK have strokes annually and a third experience residual disability. Low mood also affects a third of stroke survivors; yet psychological support is poor. While Arts for Health interventions have been shown to improve well-being in people with mild-to-moderate depression post-stroke, their role in helping people regain sense of self, well-being and confidence has yet to be evaluated. The main aim of this study is to explore the feasibility of conducting a pragmatic multicentre randomised controlled trial to assess the effectiveness and cost-effectiveness of an Arts for Health group intervention ('HeART of Stroke' (HoS)) for stroke survivors. HoS is a 10-session artist-facilitated group intervention held in the community over 14 weeks. It offers a non-judgemental, supportive environment for people to explore sense of self, potentially enhancing well-being and confidence. METHODS AND ANALYSIS Sixty-four people, up to 2 years post-stroke, recruited via secondary care research staff or community stroke/rehabilitation teams in two UK centres will be randomised to either HoS plus usual care or usual care only. Self-reported outcomes, measured at baseline and approximately 5 months postrandomisation, will include stroke-related, well-being, mood, self-esteem, quality of life and process measures. Analyses will focus on estimating key feasibility parameters (eg, rates of recruitment, retention, intervention attendance). We will develop outcome and resource use data collection methods to inform an effectiveness and cost-effectiveness analysis in the future trial. Interviews, with a sample of participants, will explore the acceptability of the intervention and study processes, as well as experiences of the HoS group. ETHICS AND DISSEMINATION National Health Service (NHS), Research and Development and University ethical approvals have been obtained. Two peer-reviewed journal publications are planned plus one service user led publication. Findings will be disseminated at key national conferences, local stakeholder events and via institutional websites. TRIAL REGISTRATION NUMBER ISRCTN99728983.
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Affiliation(s)
- Caroline Ellis-Hill
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, Dorset, UK
| | - Fergus Gracey
- Department of Clinical Psychology, University of East Anglia, Norwich, UK
- Oliver Zangwill Centre, Cambridgeshire Community Services NHS Trust, Ely, Cambridgeshire, UK
| | - Sarah Thomas
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, Dorset, UK
| | | | - Peter W Thomas
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, Dorset, UK
| | - Elsa M R Marques
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Mary Grant
- Stroke Research, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, Dorset, UK
| | - Samantha Nunn
- Oliver Zangwill Centre, Cambridgeshire Community Services NHS Trust, Ely, Cambridgeshire, UK
| | - Robin P I Cant
- Service User (formerly of Canterbury Christ Church University), Kent, UK
| | - Kathleen T Galvin
- Faculty of Health and Social Care, University of Hull, Hull, Yorkshire, UK
| | - Frances Reynolds
- College of Health and Life Sciences, Brunel University London, UK
| | - Damian F Jenkinson
- Stroke Unit, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, Dorset, UK
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Ovesen C, Christensen AF, Havsteen I, Krarup Hansen C, Rosenbaum S, Kurt E, Christensen H. Prediction and prognostication of neurological deterioration in patients with acute ICH: a hospital-based cohort study. BMJ Open 2015. [PMID: 26220872 PMCID: PMC4521514 DOI: 10.1136/bmjopen-2015-008563] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Patients with intracerebral haemorrhage (ICH) are at high risk of neurological deterioration (ND). We aimed at establishing predictors of early ND (END) as well as late ND (LND) and at exploring the impact of neurological stability during the first week on long-term prognosis. DESIGN We conducted this study as a retrospective cohort study. ND was evaluated based on the consciousness and severity of neurological symptoms. ND during the first 24 h after admission was defined as early ND and from 24 h to 7 days as LND. Patients were followed up until February 2015. PARTICIPANTS We included 300 patients with acute ICH (≤4.5 h from symptom onset) who were admitted to our institution from March 2009 to January 2015. SETTING Section of Acute Neurology, Department of Neurology, Bispebjerg Hospital is a specialised referral centre receiving patients with acute stroke from the entire capital region of Denmark. RESULTS We found that a spot sign on CT angiography (OR 10.7 CI 4.79 to 24.3) and extensive degree of interventricular haemorrhage (IVH) (OR 8.73 CI 2.87 to 26.5) were independent predictors of END, whereas a degree of comorbidity (Charlton Index), admission stroke severity and degree of IVH predicted LND. On follow-up imaging, haematoma expansion was independently associated with END (OR 6.1 CI 2.2 to 17.3), and expansion of IVH was independently associated with both END (OR 1.7 CI 1.2 to 2.3 per point increase) and LND (OR 2.3 CI 1.3 to 4.2 per point increase). ND during the first week was associated with a 1-year mortality of 60.5%, compared with 9.2% among the patients who remained stable. CONCLUSIONS These results suggest that stability during the first week entails an optimistic prognosis. A relatively easy and effective risk stratification of END and LND is possible on admission based on the spot sign, IVH and clinical parameters.
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Affiliation(s)
- Christian Ovesen
- Section of Acute Neurology, Departments of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Inger Havsteen
- Department of Radiology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Christine Krarup Hansen
- Section of Acute Neurology, Departments of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Sverre Rosenbaum
- Section of Acute Neurology, Departments of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Engin Kurt
- Department of Radiology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Hanne Christensen
- Section of Acute Neurology, Departments of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
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Abstract
OBJECTIVES To evaluate symptoms presented by the caller during emergency calls regarding stroke, and to assess if symptoms in the Face-Arm-Speech-Time Test (FAST) are related to identification of stroke. SETTING Emergency calls to the Emergency Medical Communication Center (EMCC) concerning patients discharged with stroke diagnosis in a large teaching hospital in Stockholm, Sweden, in January-June 2011. PARTICIPANTS The emergency calls of 179 patients who arrived at hospital by ambulance, and who were discharged with a stroke diagnosis and consented to participate were included in the study. OUTCOME MEASURES Frequencies of stroke symptoms presented and a comparison of symptoms presented in calls with dispatch code stroke or other dispatch code. RESULTS Of the 179 emergency calls analysed, 64% were dispatched as 'Stroke'. FAST symptoms, that is, facial or arm weakness or speech disturbances, were presented in 64% of the calls and were spontaneously revealed in 90%. Speech disturbance was the most common problem (54%) in all calls, followed by fall/lying position (38%) and altered mental status (27%). For patients with dispatch codes other than stroke, the dominating problem presented was a fall or being in a lying position (66%), followed by speech disturbance (31%) and altered mental status (25%). Stroke-specific symptoms were more common in patients dispatched as stroke. FAST symptoms were reported in 80% of patients dispatched as stroke compared with 35% in those dispatched as something else. CONCLUSIONS This study implicates that fall/lying position and altered mental status could be considered as possible symptoms of stroke during an emergency call. Checking for FAST symptoms in these patients might uncover stroke symptoms. Future studies are needed to evaluate if actively asking for FAST symptoms in emergency calls presenting falls or a lying position can improve the identification of stroke. TRIAL REGISTRATION NUMBER Stroke2010/703-31/2.
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Affiliation(s)
- Annika Berglund
- Karolinska Institutet Stroke Research Network at Södersjukhuset, Stockholm, Sweden
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
- Section of Neurology, Department of Internal Medicine, Södersjukhuset, Stockholm, Sweden
- Karolinska Institutet, Center for Gender Medicine, Stockholm, Sweden
| | - Mia von Euler
- Karolinska Institutet Stroke Research Network at Södersjukhuset, Stockholm, Sweden
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
- Section of Neurology, Department of Internal Medicine, Södersjukhuset, Stockholm, Sweden
- Karolinska Institutet, Center for Gender Medicine, Stockholm, Sweden
| | - Karin Schenck-Gustafsson
- Karolinska Institutet, Center for Gender Medicine, Stockholm, Sweden
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Maaret Castrén
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Katarina Bohm
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
- Section of Emergency Medicine, Södersjukhuset, Stockholm, Sweden
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Khafaji HAR, Sulaiman K, Singh R, AlHabib KF, Asaad N, Alsheikh-Ali A, Al-Jarallah M, Bulbanat B, AlMahmeed W, Ridha M, Bazargani N, Amin H, Al-Motarreb A, AlFaleh H, Elasfar A, Panduranga P, Al Suwaidi J. Clinical characteristics, precipitating factors, management and outcome of patients with prior stroke hospitalised with heart failure: an observational report from the Middle East. BMJ Open 2015; 5:e007148. [PMID: 25908674 PMCID: PMC4410120 DOI: 10.1136/bmjopen-2014-007148] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 02/20/2015] [Accepted: 03/01/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The purpose of this study is to report the prevalence, clinical characteristics, precipitating factors, management and outcome of patients with prior stroke hospitalised with acute heart failure (HF). DESIGN Retrospective analysis of prospectively collected data. SETTING Data were derived from Gulf CARE (Gulf aCute heArt failuRe rEgistry), a prospective multicentre study of consecutive patients hospitalised with acute HF in 2012 in seven Middle Eastern countries and analysed according to the presence or absence of prior stroke; demographics, management and outcomes were compared. PARTICIPANTS A total of 5005 patients with HF. OUTCOME MEASURES In-hospital and 1-year outcome. RESULTS The prevalence of prior stroke in patients with HF was 8.1%. Patients with stroke with HF were more likely to be admitted under the care of internists rather than cardiologists. When compared with patients without stroke, patients with stroke were more likely to be older and to have diabetes mellitus, hypertension, atrial fibrillation, hyperlipidaemia, chronic kidney disease, ischaemic heart disease, peripheral arterial disease and left ventricular dysfunction (p=0.001 for all). Patients with stroke were less likely to be smokers (0.003). There were no significant differences in terms of precipitating risk factors for HF hospitalisation between the two groups. Patients with stroke with HF had a longer hospital stay (mean±SD days; 11±14 vs 9±13, p=0.03), higher risk of recurrent strokes and 1-year mortality rates (32.7% vs 23.2%, p=0.001). Multivariate logistic regression analysis showed that stroke is an independent predictor of in-hospital and 1-year mortality. CONCLUSIONS This observational study reports high prevalence of prior stroke in patients hospitalised with HF. Internists rather than cardiologists were the predominant caregivers in this high-risk group. Patients with stroke had higher risk of in-hospital recurrent strokes and long-term mortality rates. TRIAL REGISTRATION NUMBER NCT01467973.
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Affiliation(s)
- Hadi A R Khafaji
- Department of Cardiology, Saint Michael's Hospital, Toronto University, Canada
| | | | - Rajvir Singh
- Biostatistics Section, Cardiovascular Research, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Khalid F AlHabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, King Saud University, Riyadh, Saudi Arabia
| | - Nidal Asaad
- Adult Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | | | - Bassam Bulbanat
- Department of Cardiology, Sabah Al-Ahmed Cardiac Center, Kuwait
| | - Wael AlMahmeed
- Adult Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Mustafa Ridha
- Department of Cardiology, Adan Hospital, Kuwait, Kuwait
| | | | - Haitham Amin
- Department of Cardiology, Mohammed Bin Khalifa Cardiac Center, Manamah, Bahrain
| | - Ahmed Al-Motarreb
- Department of Cardiology, Faculty of Medicine, Sana'a University, Sana'a, Yemen
| | - Hussam AlFaleh
- Department of Cardiac Sciences, King Fahad Cardiac Center, King Saud University, Riyadh, Saudi Arabia
| | - Abdelfatah Elasfar
- Department of Cardiology, Prince Salman Heart Center, King Fahad Medical City, Saudi Arabia
- Department or Cardiology, Tanta University, Tanta, Egypt
| | | | - Jassim Al Suwaidi
- Biostatistics Section, Cardiovascular Research, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
- Qatar Cardiovascular Research Center and Adult Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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Kristoffersen DT, Helgeland J, Waage HP, Thalamus J, Clemens D, Lindman AS, Rygh LH, Tjomsland O. Survival curves to support quality improvement in hospitals with excess 30-day mortality after acute myocardial infarction, cerebral stroke and hip fracture: a before-after study. BMJ Open 2015; 5:e006741. [PMID: 25808167 PMCID: PMC4386226 DOI: 10.1136/bmjopen-2014-006741] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To evaluate survival curves (Kaplan-Meier) as a means of identifying areas in the clinical pathway amenable to quality improvement. DESIGN Observational before-after study. SETTING In Norway, annual public reporting of nationwide 30-day in-and-out-of-hospital mortality (30D) for three medical conditions started in 2011: first time acute myocardial infarction (AMI), stroke and hip fracture; reported for 2009. 12 of 61 hospitals had statistically significant lower/higher mortality compared with the hospital mean. PARTICIPANTS Three hospitals with significantly higher mortality requested detailed analyses for quality improvement purposes: Telemark Hospital Trust Skien (AMI and stroke), Østfold Hospital Trust Fredrikstad (stroke), Innlandet Hospital Trust Gjøvik (hip fracture). OUTCOME MEASURES Survival curves, crude and risk-adjusted 30D before (2008-2009) and after (2012-2013). INTERVENTIONS Unadjusted survival curves for the outlier hospitals were compared to curves based on pooled data from the other hospitals for the 30-day period 2008-2009. For patients admitted with AMI (Skien), stroke (Fredrikstad) and hip fracture (Gjøvik), the curves suggested increased mortality from the initial part of the clinical pathway. For stroke (Skien), increased mortality appeared after about 8 days. The curve profiles were thought to reflect suboptimal care in various phases in the clinical pathway. This informed improvement efforts. RESULTS For 2008-2009, hospital-specific curves differed from other hospitals: borderline significant for AMI (p=0.064), highly significant (p≤0.005) for the remainder. After intervention, no difference was found (p>0.188). Before-after comparison of the curves within each hospital revealed a significant change for Fredrikstad (p=0.006). For the three hospitals, crude 30D declined and they were non-outliers for risk-adjusted 30D for 2013. CONCLUSIONS Survival curves as a supplement to 30D may be useful for identifying suboptimal care in the clinical pathway, and thus informing design of quality improvement projects.
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Affiliation(s)
| | - Jon Helgeland
- Quality Measurement Unit, Norwegian Knowledge Centre for the Health Services, Oslo, Norway
| | | | | | - Dirk Clemens
- Innlandet Hospital Trust Gjøvik, Brumunddal, Norway
| | - Anja Schou Lindman
- Quality Measurement Unit, Norwegian Knowledge Centre for the Health Services, Oslo, Norway
| | - Liv Helen Rygh
- Quality Measurement Unit, Norwegian Knowledge Centre for the Health Services, Oslo, Norway
| | - Ole Tjomsland
- Quality Measurement Unit, Norwegian Knowledge Centre for the Health Services, Oslo, Norway
- South-Eastern Norway Regional Health Authority, Hamar, Norway
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Abstract
OBJECTIVE To identify multilevel correlates of former smoking in patients with cerebrovascular disease. DESIGN Secondary data analysis of the Canadian Community Health Survey. METHODS We used data from the 2007-2008 Canadian Community Health Survey (CCHS). Smoking status (former smoking vs smoker) was described by multilevel correlates of former smoking. A multilevel approach for variable selection for this study was used to understand how multiple levels in society can have an impact on former smoking. The study sample was selected from those respondents of the CCHS that reported they suffered from stroke symptoms. Logistic regression was used to predict former smoking in patients with cerebrovascular disease while controlling for multilevel confounders. Proportions were weighted to reflect the Canadian population. RESULTS There were 172 355 respondents who reported to suffer from stroke. From this sample, 36.5% were smokers and 63.5% were former smokers. Age groups 55-69 and 70-80 and higher education (secondary education +) were positively related to former smoking. Household and vehicle smoking restrictions significantly predicted former smoking. Counselling advice from a physician and having access to a general practitioner were correlates of former smoking. Finally, the use of buproprion was positively related to former smoking. CONCLUSIONS There are multilevel correlates of former smoking in smokers with reported stroke symptoms. These correlates include older age groups, higher education, household and vehicle smoking restrictions, pharmacotherapy use (bupropion), access to a general practitioner and counselling advice from a physician.
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Affiliation(s)
- Rojiemiahd K Edjoc
- Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Canada
| | - Robert D Reid
- Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Canada
| | - Mukul Sharma
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
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Fang J, Chen L, Chen L, Wang C, Keeler CL, Ma R, Xu S, Shen L, Bao Y, Ji C. Integrative medicine for subacute stroke rehabilitation: a study protocol for a multicentre, randomised, controlled trial. BMJ Open 2014; 4:e007080. [PMID: 25475247 PMCID: PMC4256536 DOI: 10.1136/bmjopen-2014-007080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 11/11/2014] [Accepted: 11/12/2014] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Many patients with stroke receive integrative medicine in China, which includes the basic treatment of Western medicine and routine rehabilitation, in conjunction with acupuncture and Chinese medicine. The question of whether integrative medicine is efficacious for stroke rehabilitation is still controversial and very little research currently exists on the integrated approach for this condition. Consequently, we will conduct a multicentre, randomised, controlled, assessor-blinded clinical trial to assess the effectiveness of integrative medicine on stroke rehabilitation. METHODS AND ANALYSIS 360 participants recruited from three large Chinese medical hospitals in Zhejiang Province will be randomly divided into the integrative medicine rehabilitation (IMR) group and the conventional rehabilitation (CR) group in a 1:1 ratio. Participants in the IMR group will receive acupuncture and Chinese herbs in addition to basic Western medicine and rehabilitation treatment. The CR group will not receive acupuncture and Chinese herbal medicine. The assessment data will be collected at baseline, 4 and 8 weeks postrandomisation, and then at 12 weeks' follow-up. The primary outcome is measured by the Modified Barthel Index. The secondary outcomes are the National Institutes of Health Stroke Scale (NIHSS), Fugl-Meyer Assessment, the mini-mental state examination and Montreal Cognitive, Hamilton's Depression Scale and Self-Rating Depression Scale, and the incidence of adverse events. ETHICS AND DISSEMINATION Ethical approval was obtained from ethics committees of three hospitals. The results will be disseminated in a peer-reviewed journal and presented at international congresses. The results will also be disseminated to patients by telephone, during follow-up calls inquiring on patient's post-study health status. TRIAL REGISTRATION NUMBER Chinese Clinical Trial Register: ChiCTR-TRC-12001972, http://www.chictr.org/en/proj/show.aspx?proj=2561.
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Affiliation(s)
- Jianqiao Fang
- Department of Acupuncture, The Third Affiliated Hospital of Zhejiang Traditional Chinese Medical University, Hangzhou, Zhejiang, China
- The Third Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Lifang Chen
- Department of Acupuncture, The Third Affiliated Hospital of Zhejiang Traditional Chinese Medical University, Hangzhou, Zhejiang, China
| | - Luni Chen
- The Third Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Chao Wang
- The Third Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Crystal Lynn Keeler
- Department of Innovations to Wellness, Affiliated with Five Branches University, San Jose, California, USA
| | - Ruijie Ma
- Department of Acupuncture, The Third Affiliated Hospital of Zhejiang Traditional Chinese Medical University, Hangzhou, Zhejiang, China
| | - Shouyu Xu
- Department of Rehabilitation, The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Laihua Shen
- Department of Acupuncture & Encephalopathy, Jiaxing Hospital of Traditional Chinese Medicine, Jiaxing, Zhejiang, China
| | - Yehua Bao
- Department of Acupuncture & Rehabilitation, Hangzhou Hospital of Traditional Chinese Medicine, Hangzhou, Zhejiang, China
| | - Conghua Ji
- The Clinical Research Institute of Zhejiang Provincial Hospital of Traditional Chinese Medicine, Hangzhou, Zhejiang, China
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Jenkins C, Price F. VOICES: the value of 6-month clinical evaluation in stroke. The protocol for a planned qualitative study to ascertain the value of stroke follow-up to people affected by stroke. BMJ Open 2014; 4:e006384. [PMID: 25351601 PMCID: PMC4212190 DOI: 10.1136/bmjopen-2014-006384] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION The National Clinical Guidelines for Stroke recommend 'routine follow-up of patients 6 months post discharge'. The Sentinel Stroke National Audit Programme sets a standard of 6 months postadmission follow-up, capturing data on process and outcomes. There appears to be no convincing model of stroke follow-up at 6 months, and despite evidence of unmet need in almost 50% of stroke survivors 1-5 years after their stroke, little work focuses on the first 12 months of recovery. By listening to the living experiences of stroke, the research aims to tailor the stroke care pathway to the needs of those affected. METHODS AND ANALYSIS A focus group of six stroke survivors and carers will be invited to identify appropriate interview questions about the value of follow-up at 6 months, ensuring that this study has its genesis in the participant experience. A pilot study of four stroke survivors will ascertain the feasibility of the method. Thirty stroke survivors from the follow-up clinic will be invited to take part in semistructured interviews. Raw data, in the form of digital recordings of the interviews, will be transcribed. Interview transcriptions will be checked by the participant for accuracy prior to analysis using NVivo software. Literal and reflective narrative analysis will be used to code transcribed text to examine shared themes and reflect on content. ETHICS AND DISSEMINATION Study documentation has been reviewed by the Coventry and Warwickshire Research Ethics Committee; the chief investigator met with the committee to scrutinise the study and justify its methodology. The committee has approved this study. A copy of the final report will be given to participants, the Stroke Association, the local Clinical Commissioning Group and participants' general practitioners. It is intended to disseminate the results locally by presentation to the Trust board, at academic conferences and by publication in a peer-reviewed scientific journal.
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Affiliation(s)
- Colin Jenkins
- Geriatric Medicine and Stroke Services Herefordshire NHS, Wye Valley NHS Trust, The County Hospital, Hereford, Herefordshire, UK
| | - Fiona Price
- Stroke Team Office, Wye Valley NHS Trust, The County Hospital, Hereford, Herefordshire, UK
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Bell KJL, Beller E, Sundström J, McGeechan K, Hayen A, Irwig L, Neal B, Glasziou P. Ambulatory blood pressure adds little to Framingham Risk Score for the primary prevention of cardiovascular disease in older men: secondary analysis of observational study data. BMJ Open 2014; 4:e006044. [PMID: 25200562 PMCID: PMC4158214 DOI: 10.1136/bmjopen-2014-006044] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To determine the incremental value of ambulatory blood pressure (BP) in predicting cardiovascular risk when the Framingham Risk Score (FRS) is known. METHODS We included 780 men without cardiovascular disease from the Uppsala Longitudinal Study of Adult Men, all aged approximately 70 years at baseline. We first screened ambulatory systolic BP (ASBP) parameters for their incremental value by adding them to a model with 10-year FRS. For the best ASBP parameter we estimated HRs and changes in discrimination, calibration and reclassification. We also estimated the difference in the number of men started on treatment and in the number of men protected against a cardiovascular event. RESULTS Mean daytime ASBP had the highest incremental value; adding other parameters did not yield further improvements. While ASBP was an independent risk factor for cardiovascular disease, addition to FRS led to only small increases to the overall model fit, discrimination (a 1% increase in the area under the receiver operating characteristic (ROC) curve), calibration and reclassification. We estimated that for every 10,000 men screened with ASBP, 141 fewer would start a new BP-lowering treatment (95% CI 62 to 220 less treated), but this would result in 7 fewer cardiovascular events prevented over the subsequent 10 years (95% CI 21 fewer events prevented to 7 more events prevented). CONCLUSIONS In addition to a standard cardiovascular risk assessment it is not clear that ambulatory BP measurement provides further incremental value. The clinical role of ambulatory BP requires ongoing careful consideration.
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Affiliation(s)
- Katy J L Bell
- Centre for Research into Evidence Based Practice (CREBP), Bond University, Gold Coast, Queensland, Australia
- Screening and Diagnostic Test Evaluation Program (STEP), School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Elaine Beller
- Centre for Research into Evidence Based Practice (CREBP), Bond University, Gold Coast, Queensland, Australia
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Kevin McGeechan
- Screening and Diagnostic Test Evaluation Program (STEP), School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Andrew Hayen
- Department of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Les Irwig
- Screening and Diagnostic Test Evaluation Program (STEP), School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Bruce Neal
- George Institute for International Health, Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Paul Glasziou
- Centre for Research into Evidence Based Practice (CREBP), Bond University, Gold Coast, Queensland, Australia
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