Presentation, Management, and Outcomes of Acute Stroke in Palestine

Background Stroke is a leading cause of death and disability in the Middle East. Data on the uptake of evidence-based practices are limited in the region. We aimed to examine patterns of stroke presentation, management, and outcomes at public Palestinian hospitals. Methods and Results Comprehensive data from all patients with acute stroke admitted to 2 public hospitals in the West Bank of Palestine were prospectively collected. Acute stroke presentation patterns, in-hospital evaluation and management, mortality, and stroke complications were evaluated. Data were available for 150 patients with acute stroke between September 2017 and May 2018. The mean ( SD ) age was 65 (14) years and 49% were women. Only 25% of patients utilized ambulance services for transportation to the hospital. All patient received head computed tomography scans, although few received other investigations such as magnetic resonance imaging (8%) or carotid Doppler (4%). Most patients with ischemic stroke received antiplatelet therapy (98%), although none received thrombolysis. Only 17% received physical therapy evaluation. In-hospital mortality was 12%, 23% of patients had at least 1 poststroke complication, and the median modified Rankin Score at discharge was 4 (interquartile range, 2-5). Conclusions We identified high stroke mortality and discharge disability rates in Palestine. Key evidence-based gaps were highlighted, suggesting opportunities for quality improvement.

Prescribing Aerobic Exercise Intensity without a Cardiopulmonary Exercise Test Post Stroke: Utility of the Six-Minute Walk Test

BACKGROUND

The cardiopulmonary exercise test (CPET) is an established method for determining target exercise training intensity (ventilatory threshold [VAT]) and cardiovascular risk; unfortunately, CPET is not readily accessible to people post stroke. The objective of this study was to determine the utility of the 6-minute walk test (6MWT) as a less resource-intensive alternative to CPET for prescribing exercise intensity to people post stroke with motor impairments.

METHODS

Sixty participants (male, 71.7%; 13.5 ± 22.5 [mean ± standard deviation] months post stroke; age 64.5 ± 12.5 years, with a Chedoke-McMaster Stroke Assessment score of 4.9 ± .9 of the leg) underwent 6MWT, CPET, balance, strength, and cognition assessments.

RESULTS

6MWT heart rate (hr) was significantly lower than VAT-hr (92.3 ± 14.8 beats⋅min(-1) versus 99.8 ± 15.7 beats⋅min(-1), respectively, P < .001; correlation r = .7, P < .001). Bland-Altman analysis revealed that the 6MWT underestimated the VAT-hr by 7.7 ± 11.5%. The 95% confidence interval of the mean bias was large (14.8% and -30.3%), reflecting poor agreement, with 71.7% (n = 43) of the participants unable to reach a walking intensity at or above the VAT-hr. Lower oxygen uptake at the VAT (β = .655, P = .004), higher 6MWT-hr (β = 1.07, P = .01), and better balance (β = 1.128, P = .04) were associated with greater utility of the 6MWT for prescribing exercise.

CONCLUSIONS

The 6MWT-hr was not interchangeable with the target training VAT-hr determined by CPET. However, in combination with CPET, the 6MWT will indicate when deficits preclude walking alone as the primary exercise modality for optimizing cardiovascular fitness. Future studies to develop a less resource-intensive, multimodal alternative to the CPET for prescribing exercise are needed. A modality that minimizes the effect of stroke deficits, specifically poor balance, should be included.

Outcomes in people after stroke attending an adapted cardiac rehabilitation exercise program: does time from stroke make a difference?

BACKGROUND

Individuals referred to cardiac rehabilitation programs (CRPs) after stroke have demonstrated postprogram improvements in cardiovascular fitness (VO2peak). However, the effect of CRPs on other physiological/quality-of-life outcomes and effect of time from stroke on these results has not been investigated. The objectives of the present study are (1) to evaluate the effects of a CRP in participants with motor impairment after stroke and (2) to explore the effects of elapsed time from stroke on physiological/quality-of-life outcomes.

METHODS

The CRP included 24 weeks of resistance and aerobic training. Primary outcomes in 120 participants, 25.4±42.3 (mean±standard deviation) months after stroke, included 6-minute walk distance (6MWD), VO2peak, timed repeated sit-to-stand performance, and affected-side isometric knee extensor strength (IKES). Secondary measures included gait characteristics (cadence, step lengths, and symmetry), walking speed, balance (Berg Balance Scale), affected-side range of motion (ROM), elbow flexor and grip strength, anaerobic threshold, and perceptions of participation/social reintegration.

RESULTS

After adjusting for multiple comparisons, participants demonstrated significant improvements (all P<.001) in 6MWD (283.2±126.6 to 320.7±141.8 m), sit-to-stand performance (16.3±9.5 to 13.3±7.1 seconds), affected-side IKES (25.9±10.1 to 30.2±11 kg as a percentage of body mass), and VO2peak (15.2±4.5 to 17.2±4.9 mL·kg·min(-1)). Participants also demonstrated post-CRP improvements in secondary outcomes: anaerobic threshold, balance, affected-side hip/shoulder ROM, grip and isometric elbow flexor strength, participation, walking speed, cadence (all P<.001), and bilateral step lengths (P<.04). In a linear regression model, there was a negative association between the change in 6MWD and time from stroke (β=-42.1; P=.002) independent of baseline factors.

CONCLUSIONS

A CRP yields improvements over multiple domains of recovery; however, those who start earlier demonstrate greater improvement in functional ambulation independent of baseline factors. These data support the use of adapted CRPs as a standard of care practice after conventional stroke rehabilitation.

Evaluation of rural stroke services: does implementation of coordinators and pathways improve care in rural hospitals?

BACKGROUND AND PURPOSE

The quality of hospital care for stroke varies, particularly in rural areas. In 2007, funding to improve stroke care became available as part of the Rural Stroke Project (RSP) in New South Wales (Australia). The RSP included the employment of clinical coordinators to establish stroke units or pathways and protocols, and more clinical staff. We aimed to describe the effectiveness of RSP in improving stroke care and patient outcomes.

METHODS

A historical control cohort design was used. Clinical practice and outcomes at 8 hospitals were compared using 2 medical record reviews of 100 consecutive ischemic or intracerebral hemorrhage patients ≥12 months before RSP and 3 to 6 months after RSP was implemented. Descriptive statistics and multivariable analyses of patient outcomes are presented.

RESULTS

SAMPLE

pre-RSP n=750; mean age 74 (SD, 13) years; women 50% and post-RSP n=730; mean age 74 (SD, 13) years; women 46%. Many improvements in stroke care were found after RSP: access to stroke units (pre 0%; post 58%, P<0.001); use of aspirin within 24 hours of ischemic stroke (pre 59%; post 71%, P<0.001); use of care plans (pre 15%; post 63%, P<0.001); and allied health assessments within 48 hours (pre 65%; post 82% P<0.001). After implementation of the RSP, patients directly admitted to an RSP hospital were 89% more likely to be discharged home (adjusted odds ratio, 1.89; 95% confidence interval, 1.34-2.66).

CONCLUSIONS

Investment in clinical coordinators who implemented organizational change, together with increased clinician resources, effectively improved stroke care in rural hospitals, resulting in more patients being discharged home.

Outcomes for people with atrial fibrillation in an Australian national audit of stroke care

BACKGROUND

Atrial fibrillation is associated with poorer outcomes poststroke. It is unclear how the quality of stroke care in hospitals influences outcomes in these patients.

AIMS

The study aims to compare outcomes in stroke patients with and without atrial fibrillation and identify hospital processes of care associated with poor outcomes.

METHODS

Data were collected using retrospective, consecutive medical record audits from participating hospitals in the 2009 and 2011 National Stroke Foundation acute services audit program. Patient characteristics, stroke severity, and hospital management data were compared for those with and without atrial fibrillation. Multiple regression analyses for outcomes of in-hospital death, dependency at discharge (modified Rankin Score 3-5), and discharge destination were undertaken, adjusted for patient clustering by hospital.

RESULTS

Atrial fibrillation status was known for 5473 (80%) cases; 2049 had atrial fibrillation. Atrial fibrillation was independently associated with in-hospital mortality (aOR 1.46, 95% CI 1.06, 2.02). Management on a stroke unit (aOR 0.57, 95% CI 0.40, 0.80) and having a swallow assessment within 24 h (aOR 0.71, 95% CI 0.51, 0.98) were associated with increased survival among all stroke types, as was receiving aspirin within 48 h poststroke (aOR 0.65, 95% CI 0.44, 0.97), for patients with an ischemic stroke. Stroke patients with atrial fibrillation were less likely to receive important processes of care associated with reduced mortality.

CONCLUSIONS

Hospital processes of care can influence outcomes in stroke patients with atrial fibrillation. The greater in-hospital mortality experienced by stroke patients with atrial fibrillation may be attenuated by admission to a stroke unit, and for ischemic stroke, early administration of aspirin.

Stroke literacy, behavior, and proficiency in a South Florida population

BACKGROUND

Our goal was to assess stroke literacy, behavior, and proficiency in our South Florida service population.

METHODS

Data were obtained from the 2006 to 2010 Cleveland Clinic Florida annual "stroke prevention screening" questionnaires. "Stroke risk factor awareness" was attributed to participants correctly identifying at least 5 out of the 7 stroke risk factors presented. "Stroke symptom awareness" was assigned if one correctly selected all 5 listed stroke symptoms and not any of the 3 inappropriate responses. Participants had "stroke literacy" if they: (1) demonstrated stroke risk factor awareness; (2) demonstrated stroke symptom awareness; and (3) they correctly identified the brain as where a stroke occurs. To assess appropriate "stroke behavior," respondents had to choose "call 911 immediately" if one were to experience stroke symptoms. "Stroke proficiency" was attributed to individuals showing both stroke literacy and appropriate stroke behavior.

RESULTS

There were a total of 298 participants. Sixty-seven percent of participants correctly identified the brain as the organ where stroke occurs. Almost three-fourths (74.2%) demonstrated stroke risk factor awareness, 28.2% had stroke symptom awareness, 17.8% had stroke literacy, 87.9% declared appropriate stroke behavior, and 16.1% had stroke proficiency.

CONCLUSIONS

Stroke behavior and stroke proficiency are useful novel concepts in stroke epidemiology. Although our South Florida community is relatively well-educated and affluent, there are tangible gaps in knowledge, attitudes, and behavior as it pertains to stroke, similar to that seen in less advantaged populations. We recommend intensified usage of the media with information provided by qualified health professionals in a variety of formats and languages appropriate to the ethnic and cultural diversities that define this population.