The Cost and the Value of Stroke Care in Greece: Results from the SUN4P Study.

The aim of this study was to measure the one-year total cost of strokes and to investigate the value of stroke care, defined as cost per QALY. The study population included 892 patients with first-ever acute strokes, hemorrhagic strokes, and ischemic strokes, (ICD-10 codes: I61, I63, and I64) admitted within 48 h of symptoms onset to nine public hospitals located in six cities. We conducted a bottom-up cost analysis from the societal point of view. All cost components including direct medical costs, productivity losses due to morbidity and mortality, and informal care costs were considered. We used an annual time horizon, including all costs for 2021, irrespective of the time of disease onset. The average cost (direct and indirect) was extrapolated in order to estimate the national annual burden associated with stroke. We estimated the total cost of stroke in Greece at EUR 343.1 mil. a year in 2021, (EUR 10,722/patient or EUR 23,308 per QALY). Out of EUR 343.1 mil., 53.3% (EUR 182.9 mil.) consisted of direct healthcare costs, representing 1.1% of current health expenditure in 2021. Overall, productivity losses were calculated at EUR 160.2 mil. The mean productivity losses were estimated to be 116 work days with 55.1 days lost due to premature retirement and absenteeism from work, 18.5 days lost due to mortality, and 42.4 days lost due to informal caregiving by family members. This study highlights the burden of stroke and underlines the need for stakeholders and policymakers to re-organize stroke care and promote interventions that have been proven cost-effective.

Stroke Patients' Management During COVID-19 Pandemic: Results from the Sun4Patients Web-Based Registry.

Covid-19 pandemic has influenced stroke care in different ways. Recent reports demonstrated a sharp decline in acute stroke admissions worldwide. Even for patients presented to dedicated healthcare services, management at the acute phase may be sub-optimal. On the other hand, Greece has been praised for the early initiation of restriction measures which were associated with a 'milder' surge of SARS-CoV-2 infection. Methods Data derived from a prospective cohort multicenter registry. The study population consisted of first-ever acute stroke patients, hemorrhagic or ischemic, admitted within 48 hours of symptom onset in seven national healthcare system (NHS) and University hospitals in Greece. Two different time periods have been considered, defined as "before Covid-19" (15/12/2019-15/02/2020) and "during Covid-19" (16/02/2020-15/04-2020) era. Statistical comparisons on acute stroke admission characteristics between the two different time periods have been performed. Results This exploratory analysis of 112 consecutive patients showed a reduction of acute stroke admissions by 40during Covid-19 period. No significant differences were observed regarding stroke severity, risk factor profile and baseline characteristics for patients admitted before and during Covid-19 pandemic period. There is a significant delay between symptom onset to CT scan during Covid-19 era compared to the period before pandemic reached Greece (p=0.03). Conclusions The rate of acute stroke admissions has been reduced by 40% during Covid-19 pandemic. Further research is needed to clarify whether the reduction in stroke volume is actual or not and identifying the reasons underlying the paradox.

Stroke Units Necessity for Patients, Web-Based "SUN4P" Registry: Descriptive Characteristics of the Population.

The aim of this study was to present the descriptive characteristics of the Stroke Units Necessity for Patients (SUN4P) registry. METHODS: The study population derived from the web-based SUN4P registry included 823 patients with first-ever acute stroke. Descriptive statistics were used to present patients' characteristics. RESULTS: The vast majority of patients (80.4%) had an ischemic stroke, whereas 15.4% had a hemorrhagic stroke. Hypertension was the leading risk factor in both patients. The patients with ischemic stroke had higher prevalence of traditional cardiovascular risk factors such as diabetes mellitus, dyslipidemia and smoking and most commonly cryptogenic stroke (39%). National Institutes of Health Stroke Scale (NIHSS) was higher among patients with hemorrhagic in comparison to those with ischemic stroke (10.5 vs 6 respectively). Moreover, all patients had similar rate of disability prior to stroke, as shown by Modified Rankin Scale (mRS=0). CONCLUSIONS: These data are in accordance with current evidence and should be thoroughly assessed in order to ensure optimal therapeutic management of stroke patients.

Assessing Staff's and Stroke Patients' Experiences in 8 Hospitals in Greece: Results from a Prospective Multi-Center Study ("SUN4Patients").

To assess stroke patient-reported experiences and hospital staff experiences, during hospital stay. METHODS: Stroke patient-reported experiences (n=387) were recorded using the translated and culturally adapted NHS-Stroke Questionnaire into Greek and staff experiences (n=236) were investigated using the Compassion Satisfaction and Burnout subscales of the ProQOL questionnaire. RESULTS: Staff's mean compassion satisfaction score was 39.2 (SD=6.3) and mean burnout score was 24.3 (SD=5.6). Only 38.5% of the staff stated that there is smooth cooperation with healthcare professionals of other specialties/disciplines. Personnel working in an NHS Hospital was more satisfied and less burned-out when compared to personnel working at a University Hospital (p=0.02 and p<0.001, respectively). Mean total patient-reported experiences score was 81.9 (SD=9.5). Bivariate analysis revealed statistically significant differences for total patient-reported experiences among the eight study hospitals (p>0.001). CONCLUSIONS: Health policy planners and decision-makers must take into consideration the results of such self-reported measures to establish innovative techniques to accomplish goals such as staff-specialization, continuous training and applying formal frameworks for efficient cooperation amongst different disciplines.

Inpatient Cost of Stroke Care in Greece: Preliminary Results of the Web-Based "SUN4P" Registry.

The aim of this study was to calculate the average operational cost per sub-type of stroke patient and to investigate cost drivers (e.g. ALoS, NIHSS score, age) correlated to cost. METHODS: Direct medical costs (diagnostic imaging and clinical laboratory exams, overheads/bed cost, pharmaceuticals, ringers and other non-durables and inpatient rehabilitation) per patient were calculated from the providers' (hospitals') perspective. Resource use data derived from the "SUN4P" web-based registry and unit costs were retrieved from publically available sources and were assigned to resource use. RESULTS: The sample comprised 6,282 inpatient days of 750 patients (mean age: 75.5±13.3 years) admitted from July 2019 to July 2021, in nine public hospitals. Mean length of stay was 8.4±7.6 days and mean total operational cost was calculated to €1,239.4 (from which 45% and 35% related to diagnostic exams and overheads/bed cost respectively). Mean cost related to hemorrhagic stroke patients that were discharged alive was calculated significantly higher compared to mean cost related to ischemic stroke patients who didn't undertake thrombolysis and were also discharged alive from the hospital (€2,155.2 vs. €945.2, p<0.001). Linear regression analysis revealed that length of stay was significantly correlated with cost (coefficient beta=232, 95% CI confidence interval = 220-243, p<0.001). CONCLUSIONS: These findings are in accordance with current evidence and should be thoroughly assessed to rationalize inpatient reimbursement rates in order to achieve improved value of care.

Access of Stroke Patients' to Optimal Healthcare Technology in Greece: Messages to Policy Makers.

The aim of this study was to evaluate accessibility of stroke patients to optimal healthcare technology in Greece. Methods: The study population consisted of 313 first ever stroke patients derived from the "Stroke Units Necessity for Patients, SUN4P" registry. Descriptive statistics were used, to present patients' characteristics and resources utilization Results: The vast majority of patients (91.7%) conducted a CT scan during the acute phase (within the first 24hours). Almost, (65%) were admitted to wards of Internal Medicine Departments, whereas only 21% of patients were admitted to a Stroke Unit. Of note, a total of 6.9% of ischemic stroke patients received intravenous thrombolytic therapy with recombinant tissue plasminogen activator (rtPA). Conclusions: Preliminary results from SUN4P underline the urgent necessity for the re-organization of acute stroke care in Greece, as rates of admissions to stroke units and rtPA treatment during the acute phase are currently below optimal.

Developing Patients' Experiences Database After Hospital Discharge: Another Step in Improving Stroke Care.

The aim of this study was to assess stroke patients' experiences in regards to hospital stay and during discharge. A cross-sectional study with retrospective data collection was conducted including patients (n=135) with first-ever acute stroke, who were admitted in seven Public Hospitals in Greece ("Stroke Units Necessity for Patients, SUN4P" registry). The translated version of the NHS-Stroke Questionnaire in the Greek was used. 48.2% of patients rated their overall experience from the care they received as very good/excellent. 66% of patients reported that they participated in decision making about their care and 21.5% reported not having received help from the hospital's social services regarding any benefits/aids, thus lowering their overall patient experience score (p=0.017). Decision and policymakers must consider factors affecting stroke patients 'experiences during their hospitalization. The development of a national stroke patients' experiences database can help prioritize relevant actions and draw up a commonly accepted management and services redesign framework for patients.

Photophobia in primary headaches, in essential blepharospasm and in major depression.

OBJECTIVES: Although photophobia is a well-known symptom in various disorders, it has rarely been studied explicitly and its definition in a clinical setting can be somewhat elusive. Here, we assessed photophobia with a common psychometric tool in different conditions, in which light intolerance is considered part of the syndrome. PATIENTS AND METHODS: A prospective study was undertaken in patients with migraine (MH), cluster headache (CH), tension-type headache (TH), essential blepharospasm (BS) and major depression (MD). Photophobia was assessed by the photophobia questionnaire (range 0-8). Symptom severity was measured in each patient group with appropriate scales. Finally, depression was assessed explicitly in each condition. RESULTS: Hundred and six subjects met the inclusion criteria (MH: 27, CH: 21, TH: 20, BS: 18, MD: 20). Photophobia scores differed between patient groups, with migraineurs showing the highest (6.63) and TH patients the lowest (2.10) scores (ranking: MH, BS, CH, MD and TH). Symptom severity as well as depression had little, if any, influence on the degree of photophobia. DISCUSSION: Photophobia is a core symptom of migraine but also constitutes a feature of other neurological conditions. The relative independence from other, disease-specific features, suggests that photophobia is a rather autonomous symptom.

Diagnosis and Treatment of Anterior-Canal Benign Paroxysmal Positional Vertigo: A Systematic Review.

BACKGROUND AND PURPOSE: In contrast to the posterior- and horizontal-canal variants, data on the frequency and therapeutic management of anterior-canal benign paroxysmal positional vertigo (AC-BPPV) are sparse. To synthesize the existing body of evidence into a systematic review regarding the incidence and treatment of AC-BPPV. METHODS: Systematic search of medical databases employing predefined criteria, using the term "anterior canal benign paroxysmal positional vertigo." RESULTS: The electronic search retrieved 178 unique citations, 31 of which were considered eligible for further analysis. Analysis of the collected data revealed an estimated occurrence of AC-BPPV among benign paroxysmal positional vertigo patients of 3% (range 1-17.1%). No controlled therapeutic trials could be identified, and so the analysis was focused on uncontrolled case series. Treatment was categorized into three groups: Epley maneuver, Yacovino maneuver, and specific, nonstandard maneuvers described in individual articles. All three categories demonstrated success rates of over 75%, and the overall sample-size-weighted mean was 85.6%. CONCLUSIONS: The present analysis demonstrated that AC-BPPV comprises about 3% of all BPPV cases. It can be treated safely using the Epley, Yacovino, and other maneuvers with rates of symptom resolution lying in the range of that reported for the other, more frequent canal variants. Multicenter controlled trials are needed in order to develop evidence-based guidelines for the treatment of AC-BPPV.

Motor unit number estimation and quantitative needle electromyography in stroke patients.

OBJECTIVE: To evaluate the effect of upper motor neuron damage upon motor units' function by means of two separate and supplementary electrophysiological methods. METHODS: The abductor digiti minimi muscle of the non-paretic and the paretic side was studied in forty-six stroke patients with (a) motor unit number estimation (MUNE) - adapted multiple point stimulation method and (b) computerized quantitative needle electromyography (EMG) assessing the configuration of voluntary recruited motor unit potentials. Main outcome comparisons were focused on differences between non-paretic and paretic side. RESULTS: On the affected hands mean MUNE value was significantly lower and mean area of the surface recorded single motor unit potentials was significantly larger than the corresponding ones on the non-paretic hands. EMG findings did not reveal remarkable differences between the two sides. Neither severity nor chronicity of stroke was related to MUNE or EMG parameters. DISCUSSION: MUNE results, which suggested reduced motor unit numbers in stroke patients, in conjunction with the normal EMG features in these same muscles has given rise to different interpretations. In a clinical setting, reinnervation type changes in the EMG similar to that occurring in neuronopathies or axonal neuropathies should not be expected in muscles with central neurogenic lesion.

Painful ophthalmoplegia: the role of imaging and steroid response in the acute and subacute setting.

BACKGROUND AND PURPOSE: Although reports of single cases of painful ophthalmoplegia (PO) are common, studies considering larger case series are lacking. Here, we aimed to determine the relative frequencies of ocular neuropathies, the causes, the usefulness of diagnostic procedures and the role of steroid treatment in PO. METHODS: Between January 2006 and September 2012, 149 patients' charts who presented with diplopia in our emergency department were studied retrospectively. 34 of them met the inclusion criteria that included recent (≤3 days) symptom onset and a minimum of diagnostic work. RESULTS: 32% of single or combined ocular motor nerve palsies were of diabetic microvascular etiology and most of them were IIIrd or VIth nerve neuropathies. The most useful, in terms of sensitivity and specificity of diagnostic test in the acute setting was ESR, whereas MR-angiography and focused cavernous sinus imaging led to diagnosis in the post-acute phase. Pain response to steroids was non-specific, in contrast to palsy improvement after steroid administration which was indicative of Tolosa-Hunt syndrome or temporal arteritis. CONCLUSIONS: Although acute and subacute PO might be intuitively associated with Tolosa-Hunt syndrome or sinister pathology such as aneurysmal hemorrhage, our data show that these causes are far less common than diabetic microvascular palsies. Brain CT, MR-imaging of brainstem, cerebellum or hemispheres, CSF analysis and pain response to steroids are nonspecific and hence less helpful in order to arrive at a diagnosis. Instead, improved ocular motility after steroid treatment, as well as MR-angiography and cavernous sinus imaging appear more useful for this purpose.

Spontaneous eyeblink rate in focal cerebrovascular lesions.

BACKGROUND: The involvement of different brain areas in spontaneous eyeblink rate control is largely unknown. METHODS: Spontaneous eyeblink rate was assessed in 211 consecutive acute stroke patients within two days after symptom onset and was correlated with infarction location as well as with other parameters such as the presence of hemineglect or significant small vessel disease in MRI or CT scans. Blink rates were measured in two conditions: (1) during a trivial conversation requiring no cognitive effort and (2) during mental arithmetic. RESULTS: Patients and healthy controls displayed similar average blink rates at rest (19.1 and 17.3 blinks/min, respectively) and during mental arithmetic (22.6 and 20.2 blinks/min, respectively). The latter condition reliably increased blinking frequency in both patients and control subjects. The subgroups of patients with frontal, frontoparietal and frontotemporal infarctions exhibited a significantly higher blink rate modulation, expressed as an increased relative difference of blinking at rest compared with blinking during mental arithmetic. CONCLUSION: As a whole, patients with acute cerebrovascular disease do not show changes in blink rate. Subjects with frontal infarcts, however, systematically increase their blink rates during cognitive effort, most probably due to a lack of frontal inhibitory control on blinking modulation.