Prospective analysis of stroke recognition, stroke risk factors, thrombolysis rates and outcomes in Indigenous Australians from a large rural referral hospital.

BACKGROUND: Cardiovascular disease is the most common cause of death and disability in indigenous communities but limited prospective data exist about stroke. AIMS: To estimate the difference in stroke recognition, risk factors, treatment rates and outcomes between indigenous and non-indigenous peoples admitted to the Wagga Wagga Rural Referral Hospital (WWRRH) over a 5-year period with a suspected acute stroke. METHODS: All suspected strokes presenting to the 33 peripheral hospitals within the Murrumbidgee Local Health District (MLHD) were transferred to the WWRRH and prospectively assessed over a 5-year period from 1 January 2012 to 31 December 2017. Actions at stroke onset, risks factors, stroke type, treatment and outcomes were analysed. RESULTS: A total of 1843 patients were included. Of these, 45 (2.5%) patients were indigenous. Only 26.6% of indigenous and 34% of non-indigenous patients knew of the face, arm, speech, time (FAST) acronym. Indigenous patients were younger (mean age 62.0 years vs 74.4 years) and more likely to have diabetes (risk difference (RD) 22.3% (95% CI: 3%, 41.7%)), dyslipidaemia (RD 19.4% (95% CI: 21.%, 36.7%)), and be ever smokers (RD 24.9% (95% CI: 9.5%, 40.3%)). Stroke types were similar except lacunar infarcts were more common (19.2% vs 8.4%). Treatment rates and outcomes were similar between the two groups. CONCLUSIONS: Indigenous Australians with stroke are a decade younger and have a higher prevalence of important, modifiable stroke-risk factors. Delayed presentation to hospital is more common, due in part to stroke symptoms being underrecognised. When admitted to a specialised stroke unit, treatment rates and outcomes are comparable.

Factors Associated With 90-Day Readmission After Stroke or Transient Ischemic Attack: Linked Data From the Australian Stroke Clinical Registry.

Background and Purpose- Readmissions after stroke are common and appear to be associated with comorbidities or disability-related characteristics. In this study, we aimed to determine the patient and health-system level factors associated with all-cause and unplanned hospital readmission within 90 days after acute stroke or transient ischemic attack (TIA) in Australia. Methods- We used person-level linkages between data from the Australian Stroke Clinical Registry (2009-2013), hospital admissions data and national death registrations from 4 Australian states. Time to first readmission (all-cause or unplanned) for discharged patients was examined within 30, 90, and 365 days, using competing risks regression to account for deaths postdischarge. Covariates included age, stroke severity (ability to walk on admission), stroke type, admissions before stroke/TIA and the Charlson Comorbidity Index (derived from International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, [Australian modified] coded hospital data in the preceding 5 years). Results- Among the 13 594 patients discharged following stroke/TIA (45% female; 65% ischemic stroke; 11% intracerebral hemorrhage; 4% undetermined stroke; and 20% TIA), 25% had an all-cause readmission and 15% had an unplanned readmission within 90 days. In multivariable analyses, the factors independently associated with a greater risk of unplanned readmission within 90 days were being female (subhazard ratio, 1.13 [95% CI, 1.03-1.24]), greater Charlson Comorbidity Index scores (subhazard ratio, 1.11 [95% CI, 1.09-1.12]) and having an admission ≤90 days before the index event (subhazard ratio, 1.85 [95% CI, 1.59-2.15]). Compared with being discharged to rehabilitation or aged care, those who were discharged directly home were more likely to have an unplanned readmission within 90 days (subhazard ratio, 1.44 [95% CI, 1.33-1.55]). These factors were similar for readmissions within 30 and 365 days. Conclusions- Apart from comorbidities and patient-level characteristics, readmissions after stroke/TIA were associated with discharge destination. Greater support for transition to home after stroke/TIA may be needed to reduce unplanned readmissions.

Acute intermittent porphyria presenting with posterior reversible encephalopathy syndrome (PRES) and abdominal pain.

Acute intermittent porphyria is a rare genetic condition in which disrupted haem synthesis causes overproduction of porphyrin precursors. Occasionally, it is associated with posterior reversible encephalopathy syndrome (PRES), presenting with headache, confusion, seizures and visual disturbance. We describe a patient with acute intermittent porphyria who presented with seizures and PRES, and who had previous unexplained severe abdominal pain. Acute intermittent porphyria should be considered as a possible cause of PRES, especially in those with unexplained abdominal pain, since delays in its diagnosis can result in permanent complications.

Disparities in Antihypertensive Prescribing After Stroke: Linked Data From the Australian Stroke Clinical Registry.

Background and Purpose- Despite evidence to support the prescription of antihypertensive medications before hospital discharge to promote medication adherence and prevent recurrent events, many patients with stroke miss out on these medications at discharge. We aimed to examine patient, clinical, and system-level differences in the prescription of antihypertensive medications at hospital discharge after stroke. Methods- Adults with acute ischemic stroke or intracerebral hemorrhage alive at discharge were included (years 2009-2013) from 39 hospitals participating in the Australian Stroke Clinical Registry. Patient comorbidities were identified using the International Statistical Classification of Diseases and Related Health Problems (Tenth Edition, Australian Modification) codes from the hospital admissions and emergency presentation data. The outcome variable and other system factors were derived from the Australian Stroke Clinical Registry dataset. Multivariable, multilevel logistic regression was used to examine factors associated with the prescription of antihypertensive medications at hospital discharge. Results- Of the 10 315 patients included, 79.0% (intracerebral hemorrhage, 74.1%; acute ischemic stroke, 79.8%) were prescribed antihypertensive medications at discharge. Prescription varied between hospital sites, with 6 sites >2 SDs below the national average for provision of antihypertensives at discharge. Prescription was also independently associated with patient and clinical factors including history of hypertension, diabetes mellitus, management in an acute stroke unit, and discharge to rehabilitation. In patients with acute ischemic stroke, females (odds ratio, 0.85; 95% CI, 0.76-0.94), those who had greater stroke severity (odds ratio, 0.81; 95% CI 0.72-0.92), or dementia (odds ratio, 0.65; 95% CI, 0.52-0.81) were less likely to be prescribed. Conclusions- Prescription of antihypertensive medications poststroke varies between hospitals and according to patient factors including age, sex, stroke severity, and comorbidity profile. Implementation of targeted quality improvement initiatives at local hospitals may help to reduce the variation in prescription observed.

Recombinant tissue plasminogen activator (rt-PA) utilisation by rural clinicians in acute ischaemic stroke: a survey of barriers and enablers.

OBJECTIVE: This paper identified barriers which prevent rural health care providers from utilising rt-PA in acute ischaemic stroke and proposes possible support mechanisms to increase its utilisation. METHODS: This descriptive study uses data from anonymous surveys distributed to health care providers involved in acute stroke patient care in three rural hospitals with rt-PA pathways. Saturation sampling was used. Surveys gathered self assessed ratings of experience, practice environment, attitudes, existing support, barriers and possible enablers regarding rt-PA use in acute stroke. RESULTS: Physicians reported the strongest barriers to the use of rt-PA in acute stroke as pre-hospital delays (91%), risk of intracerebral haemorrhage (ICH) (73%) and clinical diagnostic uncertainty (60%). They reported high levels of confidence in the support received from their stroke units (90%). Nurses identified a poor level of stroke education and knowledge on rt-PA utilisation in acute stroke. A third of nurses could correctly list six different stroke signs. The risk of ICH following rt-PA administration in stroke was also a significant barrier for nurses. Response rate from physicians was 26% (10/38) and 19% (13/69) for nurses. CONCLUSIONS: To reduce barriers to rt-PA utilisation in rural facilities physicians require education on the calculated risk of ICH as well as exposure and experience to improve their ability to confidently diagnose stroke patients who are eligible for rt-PA treatment. Education for nurses on symptoms of stroke and rt-PA utilisation and administration is recommended.

Recombinant tissue plasminogen activator (rt-PA) utilisation by rural clinicians in acute ischaemic stroke: an audit of current practice and clinical outcomes.

OBJECTIVE: This audit of activity reports on current rates of recombinant tissue plasminogen activator (rt-PA) use within specialised stroke care units in rural New South Wales (NSW). It measures stroke onset-to-treatment time and morbidity outcomes for patients treated with rt-PA and aims to establish the safety and effectiveness of rt-PA use in rural NSW. DESIGN, SETTING AND PARTICIPANTS: Medical records reviews of patients admitted with acute ischaemic stroke at two rural NSW hospitals between 1 July 2008 and 30 June 2010. MAIN OUTCOME MEASURES: Treatment with rt-PA, morbidity scores 5 days post-stroke or discharge, incidence of intracranial haemorrhage and mortality rate 6 months post-stroke were recorded. Treatment protocol violations were assessed and time to treatment from stroke onset and hospital admission. RESULTS: Of 605 patients admitted with acute ischaemic stroke, 20 (3.3%) received rt-PA treatment. Of these two, 10% had symptomatic intracranial haemorrhage and one died within 6 months. Morbidity scores for those treated with rt-PA were similar to those not treated. The median onset-to-needle time was 2 hours and 34 min, and the median door-to-needle time was 1 hour and 40 min. There were no treatment protocol violations. CONCLUSION: Recombinant tissue plasminogen activator can be delivered in rural Australian hospitals in a timely manner within recommended implementation guidelines. Acute stroke thrombolytic services in rural Australian facilities had comparable outcomes to metropolitan facilities. Small numbers of thrombolysed patients prevented a validation study of the well-defined outcome benefits from rt-PA. The need for ongoing data collection in regional settings is supported.

Acute Fluctuant Neurological Symptoms in Stable Chronic Cryptococcus gattii Cryptococcomas: A Novel Disease Complication.

BACKGROUND: Cryptococcus, a yeast-like fungus, is the most common cause of fungal meningitis worldwide. The Cryptococcus gattii variety is concentrated in Australia has a greater propensity to infect immunocompetent hosts, cause meningitis and form crytococcomas. This case presents a novel disease complication, that is, acute neurological symptoms without seizures, disease progression or reactivation. CASE PRESENTATION: A 58-year-old immunocompetent male was brought to the emergency department with dysarthria and right arm paraesthesias. Computed tomography of the brain brain and magnetic resonance imaging revealed no stroke but found several previously identified crytococcomas that demonstrated no interval change. Blood tests and lumbar puncture found only a low cryptococcal antigen complex titer (CRAG) (1:10) and a negative cell culture. He had remained compliant on his maintenance fluconazole therapy and had no immunocompromise or seizure activity. He was initially treated as a relapse of cryptococcal disease and restarted on induction therapy but after the cell culture returned negative and the symptoms resolved over the following days he was reverted back to maintenance therapy. DISCUSSION AND CONCLUSIONS: Central nervous system cryptococcomas are difficult to treat, chronic infections, that in our patient had lasted over 10 years despite treatment compliance. A true cryptococcal meningitis relapse is indicated by positive cell cultures in previously sterile fluid but cryptococcoma progression is measured by serial magnetic resonance imaging or computed tomography scans. In the case of progression or relapse induction and consolidation therapy should be restarted. Our patient demonstrated neither relapse nor progression but presented with a novel disease complication of acute fluctuating neurology in chronic stable cryptococcomas.