RESUMEN
BACKGROUND: Social inequities affecting minority populations after Hurricane Katrina led to an expansion of environmental justice literature. In August 2017, Hurricane Harvey rainfall was estimated as a 3000- to 20,000-year flood event, further affecting minority populations with disproportionate stroke prevalence. The Stomp Out Stroke initiative leveraged multimedia engagement, creating a patient-centered cerebrovascular health intervention. OBJECTIVE: This study aims to address social inequities in cerebrovascular health through the identification of race- or ethnicity-specific health needs and the provision of in-person stroke prevention screening during two community events (May 2018 and May 2019). METHODS: Stomp Out Stroke recruitment took place through internet-based channels (websites and social networking). Exclusively through web registration, Stomp Out Stroke participants (aged >18 years) detailed sociodemographic characteristics, family history of stroke, and stroke survivorship. Participant health interests were compared by race or ethnicity using Kruskal-Wallis or chi-square test at an α=.05. A Bonferroni-corrected P value of .0083 was used for multiple comparisons. RESULTS: Stomp Out Stroke registrants (N=1401) were 70% (973/1390) female (median age 45 years) and largely self-identified as members of minority groups: 32.05% (449/1401) Hispanic, 25.62% (359/1401) African American, 13.63% (191/1401) Asian compared with 23.63% (331/1401) non-Hispanic White. Stroke survivors comprised 11.55% (155/1401) of our population. A total of 124 stroke caregivers participated. Approximately 36.81% (493/1339) of participants had a family history of stroke. African American participants were most likely to have Medicare or Medicaid insurance (84/341, 24.6%), whereas Hispanic participants were most likely to be uninsured (127/435, 29.2%). Hispanic participants were more likely than non-Hispanic White participants to obtain health screenings (282/449, 62.8% vs 175/331, 52.9%; P=.03). Asian (105/191, 54.9%) and African American (201/359, 55.9%) participants were more likely to request stroke education than non-Hispanic White (138/331, 41.6%) or Hispanic participants (193/449, 42.9%). African American participants were more likely to seek overall health education than non-Hispanic White participants (166/359, 46.2% vs 108/331, 32.6%; P=.002). Non-Hispanic White participants (48/331, 14.5%) were less likely to speak to health care providers than African American (91/359, 25.3%) or Asian participants (54/191, 28.3%). During the 2018 and 2019 events, 2774 health screenings were completed across 12 hours, averaging four health screenings per minute. These included blood pressure (1031/2774, 37.16%), stroke risk assessment (496/2774, 17.88%), bone density (426/2774, 15.35%), carotid ultrasound (380/2774, 13.69%), BMI (182/2774, 6.56%), serum lipids (157/2774, 5.65%), and hemoglobin A1c (102/2774, 3.67%). Twenty multimedia placements using the Stomp Out Stroke webpage, social media, #stompoutstroke, television, iQ radio, and web-based news reached approximately 849,731 people in the Houston area. CONCLUSIONS: Using a combination of internet-based recruitment, registration, and in-person assessments, Stomp Out Stroke identified race- or ethnicity-specific health care needs and provided appropriate screenings to minority populations at increased risk of urban flooding and stroke. This protocol can be replicated in Southern US Stroke Belt cities with similar flood risks.
Asunto(s)
Multimedia , Participación del Paciente , Negro o Afroamericano , Anciano , Femenino , Hispánicos o Latinos , Humanos , Medicare , Persona de Mediana Edad , Estados UnidosRESUMEN
BACKGROUND: Minorities have an increased incidence of early-onset, obesity-related cerebrovascular disease. Unfortunately, effective weight management in this vulnerable population has significant barriers. OBJECTIVE: Our objective was to determine the feasibility and preliminary treatment effects of a smartphone-based weight loss intervention versus food journals to monitor dietary patterns in minority stroke patients. METHODS: Swipe out Stroke was a pilot prospective randomized controlled trial with open blinded end point. Minority stroke patients and their caregivers were screened for participation using cluster enrollment. We used adaptive randomization for assignment to a behavior intervention with (1) smartphone-based self-monitoring or (2) food journal self-monitoring. The smartphone group used Lose it! to record meals and communicate with us. Reminder messages (first 30 days), weekly summaries plus reminder messages on missed days (days 31-90), and weekly summaries only (days 91-180) were sent via push notifications. The food journal group used paper diaries. Both groups received 4 in-person visits (baseline and 30, 90, and 180 days), culturally competent counseling, and educational materials. The primary outcome was reduced total body weight. RESULTS: We enrolled 36 stroke patients (n=23, 64% African American; n=13, 36% Hispanic), 17 in the smartphone group, and 19 in the food journal group. Mean age was 54 (SD 9) years; mean body mass index was 35.7 (SD 5.7) kg/m2; education, employment status, and family history of stroke or obesity did not differ between the groups. Baseline rates of depression (Patient Health Questionnaire-9 [PHQ-9] score median 5.5, IQR 3.0-9.5), cognitive impairment (Montreal Cognitive Assessment score median 23.5, IQR 21-26), and inability to ambulate (5/36, 14% with modified Rankin Scale score 3) were similar. In total, 25 (69%) stroke survivors completed Swipe out Stroke (13/17 in the smartphone group, 12/19 in the food journal group); 1 participant in the smartphone group died. Median weight change at 180 days was 5.7 lb (IQR -2.4 to 8.0) in the smartphone group versus 6.4 lb (IQR -2.2 to 12.5; P=.77) in the food journal group. Depression was significantly lower at 30 days in the smartphone group than in the food journal group (PHQ-9 score 2 vs 8; P=.03). Clinically relevant depression rates remained in the zero to minimal range for the smartphone group compared with mild to moderate range in the food journal group at day 90 (PHQ-9 score 3.5 vs 4.5; P=.39) and day 180 (PHQ-9 score 3 vs 6; P=.12). CONCLUSIONS: In a population of obese minority stroke survivors, the use of a smartphone did not lead to a significant difference in weight change compared with keeping a food journal. The presence of baseline depression (19/36, 53%) was a confounding variable, which improved with app engagement. Future studies that include treatment of poststroke depression may positively influence intervention efficacy. TRIAL REGISTRATION: ClinicalTrials.gov NCT02531074; https://www.clinicaltrials.gov/ct2/show/NCT02531074.
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Aplicaciones Móviles , Accidente Cerebrovascular , Humanos , Persona de Mediana Edad , Obesidad/terapia , Proyectos Piloto , Estudios Prospectivos , Teléfono Inteligente , Accidente Cerebrovascular/terapia , SobrevivientesRESUMEN
PURPOSE: The provision of conscientious nursing care is at the forefront of health quality. Unfortunately, a lack of standardization in the assignment of patients to nurses can lead to care inequities. Rehab MATRIX is a nursing-led tool that equitably assigns patients using select acuity variables. DESIGN AND METHODS: In this initial study, we asked focus groups of 19 registered nurses and 8 patient care assistants to identify medical interventions that increase the effort of nursing care at a 24-bed inpatient rehabilitation facility (IRF). This IRF is affiliated with a comprehensive heart and vascular institute, a level I trauma center, and a The Joint Commission (TJC) Comprehensive Stroke Center. FINDINGS: Thirteen acuity variables were included in the Rehab MATRIX patient assignment grid. High-acuity patients with greater than 6 variables were color-coded "red," medium-acuity patients with 3 to 5 variables were color-coded "yellow," and low-acuity patients with less than 3 variables were color-coded "green." Each registered nurse and patient care assistant were assigned an equitable number of red-, yellow-, and green-coded patients per shift. New admissions were Rehab MATRIX color-coded during nursing report and assigned objectively. CONCLUSIONS: Nursing staff at a wide-ranging IRF created Rehab MATRIX, an equitable patient assignment tool, representative of nursing effort needed to provide quality care. CLINICAL RELEVANCE: Nursing-led patient assignment tools increase autonomy and provide the opportunity for all nursing staff to influence healthcare practice. These factors may lead to increased nursing satisfaction and decreased burnout.
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Algoritmos , Hospitales de Rehabilitación , Personal de Enfermería en Hospital , Grupos Focales , Humanos , Enfermería en Neurociencias , Asistentes de Enfermería , Calidad de la Atención de Salud/clasificación , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND AND PURPOSE: Women minorities have an overall increased lifetime incidence of cerebrovascular disease. The provision of risk factor modification in this group can prove difficult. In a population-based study, we used cluster enrollment to identify vascular risk factors in the female caregivers of stroke survivor study participants. METHODS: Obese women caregivers were identified as part of Swipe out Stroke, a Phase I PROBE study assessing the use of SmartPhone based intervention for dietary modification in minority stroke survivors. After written informed consent was obtained, both patients and caregivers were screened for vascular risk factors at study enrollment. Descriptive statistics were used to depict the study population. Continuous baseline variables were compared using 2 sample t-test or Wilcoxon rank-sum test by caregivers and patients. Categorical baseline variables were compared using Fisher's exact test. RESULTS: Thirty-six stroke patients (63.9% African-American, 36.1% Hispanic) and thirteen female caregivers (69.2% African-American, 30.8% Hispanic) were enrolled. Mean age, patients - 54.1 (SD 9.4), caregivers - 51.3 (SD 15.6) years, education, employment status and family history of stroke or obesity did not differ significantly. Compared to stroke patients, female caregivers were significantly less likely to self-report hypertension (69.2 versus 97.2%; P = 0.01) and hyperlipidemia (16.7 versus 60%; P = 0.02). Female caregivers were more likely to have elevated systolic blood pressure (147.6 vs 127.7 mmHg; P = 0.05), total cholesterol (207.5 versus 167 mg/dL; P = 0.01) and low density lipoprotein values (119.5 versus 88 mg/dL; P = 0.03) compared to stroke patients. CONCLUSIONS: Using cluster enrollment, we discovered minority female caregivers were more likely to have unknown or poorly controlled vascular risk factors compared to stroke patients. Innovative health screening tools may benefit the extended family of minority patients participating in clinical trials.
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Negro o Afroamericano/estadística & datos numéricos , Cuidadores/estadística & datos numéricos , Hispánicos o Latinos/estadística & datos numéricos , Tamizaje Masivo/métodos , Accidente Cerebrovascular/prevención & control , Femenino , Humanos , Hipercolesterolemia/diagnóstico , Hipertensión/diagnóstico , Persona de Mediana Edad , Factores de RiesgoRESUMEN
RATIONALE: Swipe out Stroke (SOS) examines the use of a smartphone-based mobile application to reduce obesity in high-risk minority stroke patients. At record-high levels in the United States, obesity disproportionately affects minorities and is highly correlated with cerebrovascular disease. Unfortunately, structured weight loss programs are expensive, and compliance significantly decreases upon program completion. Mobile health (mHealth) technology is an innovative, cost-effective way to bridge this gap. Minorities spend over 4.5 billion dollars annually on consumer electronics, making studies that utilize mHealth applications ideal for health promotion and disease prevention. AIMS AND DESIGN: SOS is a prospective, randomized-controlled trial with open blinded endpoint comparing an mHealth based dietary intervention to usual care to facilitate weight reduction. Ischemic and hemorrhagic stroke survivors and their carers are recruited from the acute care service of a Houston-based comprehensive stroke center. A neurorehabilitation physician or vascular neurologist meets with participants during the index hospitalization, a baseline clinic visit, followed by visits at 1, 3, and 6 month intervals. The SOS Team focuses on feasible modifications to the Southern dietary pattern (fried foods, fatty foods, added fats, eggs, processed meats, such as bacon and ham, organ meats (e.g., liver), and sweetened drinks) and caloric restriction to facilitate a 5% reduction in total body weight. Practical barriers to adherence are addressed, such as access to transportation, financial limitations, and depression. STUDY OUTCOMES: The primary dependent measure is a reduction of total body weight. Secondary outcomes include systolic blood pressure, hemoglobin A1c, low-density lipoprotein, triglycerides, and Factor VIII. CONCLUSION: SOS will determine whether a Phase III effectiveness trial of a smartphone-based mobile application to address obesity-related health disparities is warranted throughout the Southeastern United States (Stroke Belt).
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Aplicaciones Móviles , Obesidad/complicaciones , Obesidad/terapia , Teléfono Inteligente , Accidente Cerebrovascular/complicaciones , Programas de Reducción de Peso , Biomarcadores/sangre , Cuidadores , Dieta Reductora , Familia , Estudios de Factibilidad , Humanos , Obesidad/sangre , Obesidad/etnología , Cooperación del Paciente/etnología , Selección de Paciente , Método Simple Ciego , Accidente Cerebrovascular/sangre , Accidente Cerebrovascular/etnología , Accidente Cerebrovascular/terapia , Texas , Resultado del Tratamiento , Pérdida de PesoRESUMEN
BACKGROUND AND PURPOSE: Faster treatment with intravenous tissue-type plasminogen activator (tPA) is likely to improve outcomes. Optimizing prehospital triage by mobile stroke units (MSUs) may speed treatment times. The Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit (BEST-MSU) study was launched in May 2014 using the first MSU in the United States to compare stroke management using an MSU versus standard management (SM). Herein, we describe the results of the prespecified, nonrandomized run-in phase designed to obtain preliminary data on study logistics. METHODS: The run-in phase consisted of 8 MSU weeks when all-patient care occurred on the MSU and 2 SM weeks when the MSU nurse met personnel on scene or at the emergency department to ensure comparability with MSU patients. Telemedicine was independently performed in 9 MSU cases. RESULTS: Of 130 alerts, 24 MSU and 2 SM patients were enrolled. Twelve of 24 MSU patients received tPA on board; 4 were treated within 60 minutes of last seen normal, and 4 went on to endovascular treatment. There were no hemorrhagic complications. Four had primary intracerebral hemorrhage. Agreement on tPA eligibility between the onsite and telemedicine physician was 90%. CONCLUSIONS: The run-in phase provided a tPA treatment rate of 1.5 patients per week, assured us that treatment within 60 minutes of onset is possible, and enabled enrollment of patients on SM weeks. We also recognized the opportunity to assess the effect of the MSU on endovascular treatment and intracerebral hemorrhage. Challenges include the need to control biased patient selection on MSU versus SM weeks and establish inter-rater agreement for tPA treatment using telemedicine.
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Manejo de la Enfermedad , Unidades Móviles de Salud/estadística & datos numéricos , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/tratamiento farmacológico , Telemedicina/estadística & datos numéricos , Activador de Tejido Plasminógeno/administración & dosificación , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Accidente Cerebrovascular/epidemiología , Telemedicina/métodos , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND AND PURPOSE: Recently, the Mobile Stroke Unit (MSU) concept was introduced in Germany demonstrating prehospital treatment of more patients within the first hour of symptom onset. However, the details and complexities of establishing such a program in the United States are unknown. We describe the steps involved in setting up the first MSU in the United States. METHODS: Implementation included establishing leadership, fund-raising, purchase and build-out, knitting a collaborative consortium of community stakeholders, writing protocols to ensure accountability, radiation safety, purchasing supplies, licensing, insurance, establishing a base station, developing a communication plan with city Emergency Medical Services, Emergency Medical Service training, staffing, and designing a research protocol. RESULTS: The MSU was introduced after ≈1 year of preparation. Major obstacles to establishing the MSU were primarily obtaining funding, licensure, documenting radiation safety protocols, and establishing a smooth communication system with Emergency Medical Services. During an 8 week run-in phase, ≈2 patients were treated with recombinant tissue-type plasminogen activator per week, one-third within 60 minutes of symptom onset, with no complications. A randomized study to determine clinical outcomes, telemedicine reliability and accuracy, and cost effectiveness was formulated and has begun. CONCLUSION: The first MSU in the United States has been introduced in Houston, TX. The steps needed to accomplish this are described.
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Unidades Móviles de Salud/organización & administración , Accidente Cerebrovascular/terapia , Presupuestos , Comunicación , Interpretación Estadística de Datos , Servicios Médicos de Urgencia/organización & administración , Política de Salud , Humanos , Hemorragias Intracraneales/complicaciones , Hemorragias Intracraneales/terapia , Unidades Móviles de Salud/economía , Accidente Cerebrovascular/diagnóstico , Texas , Terapia Trombolítica/métodos , Tiempo de Tratamiento , Activador de Tejido Plasminógeno/uso terapéutico , Estados Unidos , Recursos HumanosRESUMEN
BACKGROUND AND PURPOSE: Behavioral measures are often used to distinguish subgroups of patients with stroke (eg, to predict treatment gains, stratify clinical trial enrollees, or select rehabilitation therapy). In studies of the upper extremity, measures of brain function using functional magnetic resonance imaging (fMRI) have also been found useful, but this approach has not been examined for the lower extremity. The current study hypothesized that an fMRI-based measure of cortical function would significantly improve prediction of treatment-induced lower extremity behavioral gains. Biomarkers of treatment gains were also explored. METHODS: Patients with hemiparesis 1 to 12 months after stroke were enrolled in a double-blind, placebo-controlled, randomized clinical trial of ropinirole+physical therapy versus placebo+physical therapy, results of which have previously been reported (NCT00221390).(15) Primary end point was change in gait velocity. Enrollees underwent baseline multimodal assessment that included 19 measures spanning 5 assessment categories (medical history, impairment, disability, brain injury, and brain function), and also underwent reassessment 3 weeks after end of therapy. RESULTS: In bivariate analysis, 8 baseline measures belonging to 4 categories (medical history, impairment, disability, and brain function) significantly predicted change in gait velocity. Prediction was strongest, however, using a multivariate model containing 2 measures (leg Fugl-Meyer score and fMRI activation volume within ipsilesional foot sensorimotor cortex). Increased activation volume within bilateral foot primary sensorimotor cortex correlated positively with treatment-induced leg motor gains. CONCLUSIONS: A multimodal model incorporating behavioral and fMRI measures best predicted treatment-induced changes in gait velocity in a clinical trial setting. Results also suggest potential use of fMRI measures as biomarkers of treatment gains.
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Corteza Cerebral/fisiopatología , Indoles/uso terapéutico , Extremidad Inferior/fisiopatología , Paresia/rehabilitación , Rehabilitación de Accidente Cerebrovascular , Adulto , Anciano , Terapia Combinada , Método Doble Ciego , Femenino , Marcha/fisiología , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Paresia/etiología , Paresia/fisiopatología , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/fisiopatología , Resultado del TratamientoRESUMEN
PURPOSE: The purpose was to compare the effectiveness of robotic-assisted body weight supported treadmill training using the Lokomat(®) to over-ground gait training (OGT) in adults with chronic stroke. METHODS: Participants were randomly assigned to the Lokomat(®) or OGT interventions. Both protocols included 40 sessions over 8 weeks. Primary outcome measures were the 10-meter walk test and 6-minute walk distance. Secondary measures included the Functional Independence Measure(TM) locomotion score, Fugl-Meyer Lower Extremity Motor Score (FM-LE), Barthel Index, and Stroke Impact Scale. Blinded assessors tested the participants at baseline, post-intervention, and 3-month follow-up. RESULTS: Eleven Lokomat(®) and nine OGT participants completed the study. Within group differences in the FM-LE score and Barthel Index occurred over time from baseline to post-intervention and baseline to 3-month follow-up. No other within group differences and no between group differences were observed. CONCLUSIONS: Although walking measures did not show significant changes between groups, LE motor function and physical functional levels improved over time within both groups. The Lokomat(®) may allow aggressive locomotor training, particularly for the lower functioning patients who wish to improve walking ability due to apparent eased therapist physical burden, when compared to OGT, although an increased risk of skin breakdown is present.
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Terapia por Ejercicio/métodos , Trastornos Neurológicos de la Marcha/rehabilitación , Robótica/instrumentación , Rehabilitación de Accidente Cerebrovascular , Caminata/fisiología , Adulto , Factores de Edad , Anciano , Análisis de Varianza , Enfermedad Crónica , Método Doble Ciego , Prueba de Esfuerzo/métodos , Femenino , Estudios de Seguimiento , Trastornos Neurológicos de la Marcha/etiología , Trastornos Neurológicos de la Marcha/fisiopatología , Humanos , Locomoción/fisiología , Masculino , Persona de Mediana Edad , Valores de Referencia , Medición de Riesgo , Robótica/métodos , Índice de Severidad de la Enfermedad , Factores Sexuales , Accidente Cerebrovascular/complicaciones , Análisis y Desempeño de Tareas , Resultado del TratamientoRESUMEN
The purpose of this case report is to describe attempts to prevent skin-related adverse events from occurring and protect the skin once breakdown occurred in a person with chronic stroke during locomotor training. There is scant literature in how to address skin during locomotor training with the Lokomat(®), particularly when a patient presents with sensory deficits and frail skin. The patient was a 75-year-old male survivor of stroke who participated in the Lokomat(®) group of a randomized clinical pilot study comparing locomotor training with the Lokomat(®) and conventional means. He had diminished sensation to light touch and proprioception on his left leg with skin on both lower legs presenting as thin, flaky, and virtually hairless. Although much effort was put towards prevention of skin breakdown, he developed numerous skin-related adverse events during his training. However, his skin healed completely with reduced training intensity and initiation of "pre-wrapping" his lower legs with Akton(®) viscoelastic polymer sheets and elastic bandages. Significant improvements were noted in his Functional Improvement Measure(™) locomotion score and Stroke Impact Scale domains of strength, participation/role function, and total recovery, though not in his 10-m walk test velocity or 6-min walk test. The Akton(®) sheets and team approach between study team, patient, and his wife allowed simultaneous safe continuation of locomotor training with the Lokomat(®) and healing of his skin breakdown.
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Vendajes de Compresión , Terapia por Ejercicio/efectos adversos , Actividad Motora , Robótica , Envejecimiento de la Piel , Enfermedades de la Piel/terapia , Rehabilitación de Accidente Cerebrovascular , Terapia Asistida por Computador , Sustancias Viscoelásticas/uso terapéutico , Soporte de Peso , Anciano , Fenómenos Biomecánicos , Evaluación de la Discapacidad , Diseño de Equipo , Prueba de Esfuerzo , Terapia por Ejercicio/instrumentación , Terapia por Ejercicio/métodos , Humanos , Masculino , Recuperación de la Función , Robótica/instrumentación , Enfermedades de la Piel/diagnóstico , Enfermedades de la Piel/etiología , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/fisiopatología , Terapia Asistida por Computador/instrumentación , Factores de Tiempo , Resultado del Tratamiento , Cicatrización de HeridasRESUMEN
OBJECTIVE: To test the role of hospital-acquired symptomatic urinary tract infection (SUTI) as an independent predictor of discharge disposition in the acute stroke patient. STUDY DESIGN: A retrospective study of data collected from a stroke registry service. The registry is maintained by the Specialized Programs of Translational Research in Acute Stroke Data Core. The Specialized Programs of Translational Research in Acute Stroke is a national network of 8 centers that perform early phase clinical projects, share data, and promote new approaches to therapy for acute stroke. SETTING: A single university-based hospital. PARTICIPANTS: We performed a data query of the fields of interest from our university-based stroke registry, a collection of 200 variables collected prospectively for each patient admitted to the stroke service between July 2004 and October 2009, with discharge disposition of home, inpatient rehabilitation, skilled nursing facility, or long-term acute care. MAIN OUTCOME MEASURES: Baseline demographics, including age, gender, ethnicity, and National Institutes of Health Stroke Scale (NIHSS) score, were collected. Cerebrovascular disease risk factors were used for independent risk assessment. Interaction terms were created between SUTI and known covariates, such as age, NIHSS, serum creatinine level, history of stroke, and urinary incontinence. Because patients who share discharge disposition tend to have similar length of hospitalization, we analyzed the effect of SUTI on the median length of stay for a correlation. Days in the intensive care unit and death were used to evaluate morbidity and mortality. By using multivariate logistic regression, the data were analyzed for differences in poststroke disposition among patients with SUTI. RESULTS: Of 4971 patients admitted to the University of Texas at Houston Stroke Service, 2089 were discharged to home, 1029 to inpatient rehabilitation, 659 to a skilled nursing facility, and 226 to a long-term acute care facility. Patients with an SUTI were 57% less likely to be discharged home compared with the other levels of care (P < .0001; odds ratio 0.430 [95% confidence interval 0.303-0.609]). When considering inpatient rehabilitation versus skilled nursing facility, patients with SUTI were 38% less likely to be discharged to inpatient rehabilitation (P < .0058; odds ratio 0.626 [95% confidence interval, 0.449-0.873]). We performed interaction analyses for SUTI and age, NIHSS, urinary incontinence, serum creatinine level, and history of stroke. We noted an interaction between SUTI and NIHSS for discharge disposition to a skilled nursing facility versus a long-term acute care facility. For patients with SUTI, a 1-unit increase in NIHSS results in a 10.6% increase in the likelihood of stroke rehabilitation in a long-term acute care facility compared with 5.6% increased likelihood for patients without SUTI (P = .0370). CONCLUSIONS: Acute stroke patients with hospital-acquired SUTI are less likely to be discharged home. In our analysis, if poststroke care is necessary, then patients with SUTI are more likely to receive inpatient stroke rehabilitation at the level of care suggestive of lower functional status. For every point increase in NIHSS, stroke patients with SUTI are 10.6% more likely to require continued rehabilitation care in a long-term acute care facility versus a skilled nursing facility compared with 5.6% for patients without SUTI. The combination of premorbid urinary incontinence and urinary tract infection has no additional impact on discharge disposition. This study is limited by its retrospective nature and the undetermined role of psychosocial factors related to discharge. Prospective studies are warranted on the efficacy of early catheter discontinuation, identification of new-onset urinary incontinence, use of genitourinary barriers, and catheter care every shift as variables that can decrease the risk of infection. The information obtained from prospective studies will have an impact on resource use that is of prime importance in the current health care climate.
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Centros Médicos Académicos , Infección Hospitalaria/epidemiología , Alta del Paciente/estadística & datos numéricos , Sistema de Registros , Medición de Riesgo , Rehabilitación de Accidente Cerebrovascular , Infecciones Urinarias/epidemiología , Anciano , Infección Hospitalaria/etiología , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Estados Unidos/epidemiología , Infecciones Urinarias/etiologíaRESUMEN
BACKGROUND AND PURPOSE: Acute ischemic stroke patients who receive recombinant tissue plasminogen activator (rt-PA) within 3 hours of symptom onset are 30% more likely to have minimal to no disability at 3 months. During hospitalization, short-term disability is subjectively measured by discharge disposition, whether to home, inpatient rehabilitation, a skilled nursing facility, or subacute care. There are no studies assessing the role of recombinant tissue plasminogen activator use as a predictor of poststroke discharge disposition. METHODS: We conducted a retrospective analysis of all patients with ischemic stroke who presented within the original three hour window for intravenous thrombolysis, and who were admitted to the University of Texas Houston Medical School Stroke Service at Memorial Hermann Hospital - Texas Medical Center between January 2004 and October 2009. Baseline demographics and National Institute of Health Stroke Scale score were collected. Cerebrovascular disease risk factors were used for risk stratification in the multivariate regression. RESULTS: Out of 2225 patients with acute ischemic stroke, 1019 were discharged to home, 719 to inpatient rehabilitation, 371 to a skilled nursing facility and 116 to subacute care. Patients who received recombinant tissue plasminogen activator therapy were more likely to be discharged home compared to the other levels of care (P<0.0001; OR, 1.945; 95% CI, 1.538 to 2.459). Considering post-acute inpatient rehabilitation versus skilled nursing facility/subacute care and disposition at a skilled nursing facility versus subacute care, there were no differences in disposition between patients who received recombinant tissue plasminogen activator therapy. Inpatient Rehabilitation versus Skilled Nursing Facility or Subacute Care (P = 0.123); Skilled Nursing Facility versus Subacute Care (P = 0.605). CONCLUSIONS: Patients who receive intravenous recombinant tissue plasminogen activator as treatment for acute ischemic stroke are more likely to be discharged directly home after hospitalization. This study is limited by its retrospective nature and the undetermined role of psychosocial factors related to discharge.
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Isquemia Encefálica/tratamiento farmacológico , Alta del Paciente/tendencias , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica/tendencias , Activador de Tejido Plasminógeno/administración & dosificación , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/fisiopatología , Femenino , Humanos , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Sistema de Registros , Estudios Retrospectivos , Accidente Cerebrovascular/fisiopatología , Terapia Trombolítica/métodos , Resultado del TratamientoRESUMEN
BACKGROUND AND PURPOSE: Evidence suggests the potential to improve motor status in patients with stroke by modifying brain catecholaminergic tone. The current study hypothesized that increased dopaminergic tone via the dopamine agonist ropinirole, when combined with physiotherapy (PT), would significantly and safely increase gait velocity. METHODS: Patients with moderate motor deficits due to stroke 1 to 12 months prior were randomized (double blinded) to 9 weeks of immediate-release ropinirole or placebo, each with PT, and followed up for 3 additional weeks. Drug dose (0.25 to 4 mg once daily) was titrated weekly, as tolerated. The primary end point was gait velocity during the 12 weeks of study participation. RESULTS: Patients in the ropinirole+PT group averaged 2.4 mg/d by end of week 9, although the target dose was at least 3 mg/d. Ropinirole+PT was generally safe and well tolerated, including no drug-related serious adverse events. Across all 33 enrollees, significant gains were found over time for gait velocity and for most secondary end points. However, gains did not differ by treatment assignment. PT and occupational therapy were commonly prescribed outside of the trial, although the extent of these was not correlated with study outcomes. CONCLUSIONS: At doses achieved in this trial, increased dopaminergic tone via ropinirole+PT was generally well tolerated but did not show any improvement over and above the effects of PT alone.
Asunto(s)
Agonistas de Dopamina/administración & dosificación , Marcha/efectos de los fármacos , Indoles/administración & dosificación , Accidente Cerebrovascular/terapia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Enfermedad Crónica , Método Doble Ciego , Femenino , Humanos , Masculino , Persona de Mediana Edad , Modalidades de Fisioterapia , Factores de TiempoRESUMEN
BACKGROUND AND PURPOSE: Studies have established a relation between recanalization and improved clinical outcome in acute ischemic stroke patients; however, intra-arterial clot size has not been routinely assessed. The aim of the study was to determine the impact of intra-arterial thrombus burden on intra-arterial treatment (IAT) and clinical outcome. METHODS: A retrospective review of our IAT stroke database included procedure time, recanalization, symptomatic intracranial hemorrhage, poor outcome (modified Rankin Scale score >/=4 at discharge), and mortality. The modified Thrombolysis in Myocardial Infarction thrombus grade was dichotomized into grades 0 to 3 (no clot or moderate thrombus, <2 vessel diameters) versus grade 4 (large thrombus, >2 vessel diameters). RESULTS: Data were collected on 135 patients with thrombus grading. The baseline median National Institutes of Health Stroke Scale score was higher in patients of grade 4 compared with grades 0 to 3 (19 vs 17, P=0.012). Grade 4 thrombi required longer (median, range) times for IAT (113, 37 to 415 minutes vs 74, 22 to 215 minutes, respectively; P<0.001) and higher rates of mechanical clot disruption (wire, angioplasty, snare, stent, or Merci retriever) compared with grades 0 to 3 (76% vs 53%, P=0.005). There were no differences in rates of symptomatic intracranial hemorrhage (6.6% vs 4.1%, P=0.701) or recanalization (50% vs 61%, P=0.216) in grade 4 versus grades 0 to 3. Multivariate analysis adjusted for age, baseline National Institutes of Health Stroke Scale score, and artery of involvement showed that grade 4 thrombi were independently associated with poor outcome (odds ratio=2.4; 95% CI, 1.06 to 5.57; P=0.036) and mortality (odds ratio=4.0; 95% CI, 1.2 to 13.2; P=0.023). CONCLUSIONS: High thrombus grade as measured by the modified Thrombolysis in Myocardial Infarction criteria may be a risk factor that contributes to poor clinical outcome.
Asunto(s)
Angioplastia , Isquemia Encefálica/patología , Trombosis Intracraneal/cirugía , Anciano , Angioplastia/instrumentación , Angioplastia/métodos , Angioplastia/estadística & datos numéricos , Daño Encefálico Crónico/epidemiología , Daño Encefálico Crónico/etiología , Daño Encefálico Crónico/prevención & control , Isquemia Encefálica/etiología , Angiografía Cerebral , Hemorragia Cerebral/inducido químicamente , Hemorragia Cerebral/epidemiología , Terapia Combinada , Femenino , Fibrinolíticos/administración & dosificación , Fibrinolíticos/efectos adversos , Fibrinolíticos/uso terapéutico , Humanos , Infusiones Intraarteriales , Trombosis Intracraneal/complicaciones , Trombosis Intracraneal/diagnóstico por imagen , Trombosis Intracraneal/tratamiento farmacológico , Trombosis Intracraneal/patología , Masculino , Persona de Mediana Edad , Reperfusión , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Stents , Terapia Trombolítica/efectos adversos , Terapia Trombolítica/estadística & datos numéricos , Resultado del TratamientoRESUMEN
BACKGROUND: Most patients with cardioembolic stroke require long-term anticoagulation. Still, uncertainty exists regarding the best mode of starting long-term anticoagulation. Design, Setting, and Patients We conducted a retrospective review of all patients with cardioembolic stroke admitted to our center from April 1, 2004, to June 30, 2006, and not treated with tissue plasminogen activator. Patients were grouped by treatment: no treatment, aspirin only, aspirin followed by warfarin sodium, intravenous heparin sodium in the acute phase followed by warfarin (heparin bridging), and full-dose enoxaparin sodium combined with warfarin (enoxaparin bridging). Outcome measures and adverse events were collected prospectively. Laboratory values were captured from the records. MAIN OUTCOME MEASURES: Symptomatic hemorrhagic transformation, stroke progression, and discharge modified Rankin Scale score. RESULTS: Two hundred four patients were analyzed. Recurrent stroke occurred in 2 patients (1%). Progressive stroke was the most frequent serious adverse event, seen in 11 patients (5%). Hemorrhagic transformation occurred in a bimodal distribution-an early benign hemorrhagic transformation and a late symptomatic hemorrhagic transformation. All of the symptomatic hemorrhagic transformation cases were in the enoxaparin bridging group (10%) (P = .003). Systemic bleeding occurred in 2 patients (1%) and was associated with heparin bridging (P = .04). CONCLUSIONS: Anticoagulation of patients with cardioembolic stroke can be safely started with warfarin shortly after stroke. Heparin bridging and enoxaparin bridging increase the risk for serious bleeding.
Asunto(s)
Anticoagulantes/administración & dosificación , Embolia/tratamiento farmacológico , Cardiopatías/tratamiento farmacológico , Accidente Cerebrovascular/tratamiento farmacológico , Anciano , Anciano de 80 o más Años , Anticoagulantes/efectos adversos , Fibrilación Atrial/inducido químicamente , Fibrilación Atrial/patología , Embolia/complicaciones , Embolia/patología , Femenino , Cardiopatías/complicaciones , Cardiopatías/patología , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Recurrencia , Estudios Retrospectivos , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/patología , Factores de TiempoRESUMEN
BACKGROUND AND PURPOSE: Recombinant-activated factor VII (rFVIIa) is an investigational treatment for intracerebral hemorrhage (ICH). We have evaluated the drug's treatment effect based on time to treatment. METHODS: ICH patients treated up to 4 hours from symptom onset were divided based on time to treatment: Asunto(s)
Hemorragia Cerebral/sangre
, Hemorragia Cerebral/tratamiento farmacológico
, Factor VIIa/administración & dosificación
, Adulto
, Anciano
, Anciano de 80 o más Años
, Hemorragia Cerebral/mortalidad
, Estudios de Cohortes
, Factor VIIa/efectos adversos
, Hematoma/sangre
, Hematoma/tratamiento farmacológico
, Hematoma/mortalidad
, Humanos
, Persona de Mediana Edad
, Factores de Tiempo
, Resultado del Tratamiento
RESUMEN
BACKGROUND: Limited data are available about the effectiveness of early rehabilitation after stroke. OBJECTIVE: This is the 1st randomized controlled trial of constraint-induced movement therapy (CIMT) in subacute stroke to investigate neurophysiologic mechanisms and long-term outcome. METHODS: Within 2 weeks after stroke, 23 patients with upper extremity (UE) weakness were randomized to 2 weeks of CIMT or traditional therapy at an equal frequency of up to 3 h/day. Motor function of the affected UE was blindly assessed before treatment, after treatment, and 3 months after stroke. Transcranial magnetic stimulation (TMS) measured the cortical area evoking movement of the affected hand. RESULTS: Long-term improvement in motor function of the affected UE did not differ significantly between patients who received CIMT versus intensive traditional therapy. All outcome comparisons showed trends favoring CIMT over intensive traditional therapy, but none was statistically significant except for improvements in the Fugl-Meyer (FM) UE motor scale immediately following treatment and in reported quality of hand function at 3 months. Improvement in UE motor function on the FM was associated with a greater number of sites on the affected cerebral hemisphere where responses of the affected hand were evoked by TMS. CONCLUSIONS: Future trials of CIMT during early stroke rehabilitation need greater statistical power, more inclusive eligibility criteria, and improved experimental control over treatment intensity. The relationship between changes in motor function and in evoked motor responses suggests that motor recovery during the 1st 3 months after stroke is associated with increased motor excitability of the affected cerebral hemisphere.
Asunto(s)
Terapia por Ejercicio/métodos , Rehabilitación de Accidente Cerebrovascular , Adulto , Anciano , Brazo/fisiopatología , Estudios de Factibilidad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Actividad Motora/fisiología , Restricción Física , Método Simple Ciego , Accidente Cerebrovascular/fisiopatología , Factores de Tiempo , Estimulación Magnética Transcraneal , Resultado del TratamientoRESUMEN
BACKGROUND AND PURPOSE: The optimal approach for acute ischemic stroke patients who do not respond to intravenous recombinant tissue plasminogen activator (IV rt-PA) is uncertain. This study evaluated the safety and response to intra-arterial thrombolytics (IATs) in patients unresponsive to full-dose IV rt-PA. METHODS: A case series from a prospectively collected database on consecutive acute ischemic stroke patients treated with IATs after 0.9 mg/kg IV rt-PA during a 7-year interval was collected. Primary outcome measures included symptomatic intracranial hemorrhage and mortality. As indicators of response, secondary outcome measures were recanalization and discharge disposition. RESULTS: Sixty-nine patients (mean+/-SD age, 60+/-13 years; range, 26 to 85 years; 55% male) with a median pretreatment National Institutes of Health Stroke Scale score of 18 (range, 6 to 39) were included. IV rt-PA was started at 124+/-32 minutes (median, 120 minutes) and IAT, at 288+/-57 minutes (median, 285 minutes). IATs consisted of reteplase (n=56), alteplase (n=7), and urokinase (n=6), with an average total dosage of 2.8 U, 8.6 mg, and 700 000 U, respectively. Symptomatic intracranial hemorrhage occurred in 4 of 69 (5.8%) patients; 3 cases were fatal. Recanalization was achieved in 50 (72.5%) and a favorable outcome (home or inpatient rehabilitation) in 38 (55%). CONCLUSIONS: IAT therapy after full-dose IV rt-PA in patients with persisting occlusion and/or lack of clinical improvement appears safe compared with IV rt-PA alone or low-dose IV rt-PA followed by IAT. A high rate of recanalization and favorable outcome can be achieved.
Asunto(s)
Isquemia Encefálica/tratamiento farmacológico , Fibrinolíticos/efectos adversos , Accidente Cerebrovascular/tratamiento farmacológico , Activador de Tejido Plasminógeno/efectos adversos , Enfermedad Aguda/terapia , Adulto , Anciano , Anciano de 80 o más Años , Relación Dosis-Respuesta a Droga , Femenino , Fibrinolíticos/administración & dosificación , Humanos , Inyecciones Intraarteriales/efectos adversos , Inyecciones Intravenosas/efectos adversos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Proteínas Recombinantes de Fusión/efectos adversos , Proteínas Recombinantes/administración & dosificación , Proteínas Recombinantes/efectos adversos , Activador de Tejido Plasminógeno/administración & dosificación , Activador de Plasminógeno de Tipo Uroquinasa/administración & dosificación , Activador de Plasminógeno de Tipo Uroquinasa/efectos adversosRESUMEN
Preliminary assessments of the feasibility, safety, and effects on neuronal reorganization measured with transcranial magnetic stimulation (TMS) from Constraint-Induced Movement Therapy (CIMT) of the upper extremity were made in eight cases of subacute stroke. Within fourteen days of their stroke, patients were randomly assigned to two weeks of CIMT or traditional therapy. Baseline motor performance and cortical/subcortical representation for movement with TMS were assessed before treatment. Post-treatment assessments were made at the end of treatment and at three months after the stroke. The TMS mapping showed a larger motor representation in the lesioned hemisphere of the CIMT patients as compared to the controls at the three-month follow-up assessment. The enlarged motor representation in the lesioned hemisphere for hand movement correlated with improved motor function of the affected hand, suggesting a link between movement representation size as measured with TMS and functionality. These results suggest that TMS can be safely and effectively used to assess brain function in subacute stroke and further suggest that CIMT may enhance cortical/subcortical motor reorganization and accelerate motor recovery when started within the first two weeks after stroke.
Asunto(s)
Mapeo Encefálico/instrumentación , Corteza Cerebral/fisiopatología , Terapia por Ejercicio/métodos , Mano/fisiopatología , Recuperación de la Función/fisiología , Rehabilitación de Accidente Cerebrovascular , Estimulación Magnética Transcraneal , Anciano , Anciano de 80 o más Años , Corteza Cerebral/fisiología , Técnicas de Ejercicio con Movimientos/métodos , Femenino , Estudios de Seguimiento , Mano/inervación , Mano/fisiología , Humanos , Masculino , Persona de Mediana Edad , Modalidades de Fisioterapia , Accidente Cerebrovascular/fisiopatología , Resultado del TratamientoRESUMEN
BACKGROUND: Endovascular therapy (ET) of internal carotid artery (ICA) stenosis is equivalent to carotid endarterectomy for stroke prevention; however, patients with ICA occlusion and acute symptoms are traditionally not candidates for ET. We report our experience in endovascular recanalization of acute stroke patients with ICA occlusion. PATIENTS AND TECHNIQUES: We reviewed our registry for acute stroke patients treated with ET who had (1) ICA occlusion by digital subtraction angiography (thrombolysis in myocardial ischemia=0) with location of type II (above ophthalmic artery involving M1 or A1 but not both) or type III (proximal to the ophthalmic artery but distal to the bifurcation); (2) acute stroke symptoms from the index lesion presenting 3 hours after onset of symptoms; (3) minimal ischemic changes on brain CT scan (less than one third of the MCA territory); (4) attempted ET. Neuroradiologists reviewed angiograms for thrombolysis in cerebral infarction. A blinded vascular neurologist reviewed post-procedural brain imaging for Alberta Stroke Program Early CT (ASPECT) scoring. Outcome scales were assessed. RESULTS: We identified 14 patients, 10 of whom were men (mean age, 58 +/- 14 years; median age, 54 years; age range, 40-74 years). There were 8 left ICA occlusions, 3 type II; and 6 right ICA occlusions, one type II. Median baseline National Institutes of Health Stroke Scale score was 17 (range, 11-25; mean, 18 +/- 4.9). Mean time to ET was 389 +/- 103 minutes (median, 306 minutes; range, 197-1290 minutes). Immediate recanalization occurred in 64%. Decrease in expected stroke volume by brain imaging occurred in 50% with mean ASPECT score of 4 +/- 2.9 (median, 3; range, 0-8; 21% > or = 8). Two hemorrhages occurred, one symptomatic; 3 patients died. Good outcome was achieved in 64% of cases. CONCLUSION: Endovascular therapy of carotid occlusion in hyperacute stroke patients is feasible and may help to reduce stroke volume and increase good outcome in some patients.