[Quality of care of acute ischemic stroke in Germany 2018]. / Versorgungsqualität des akuten ischämischen Schlaganfalls in Deutschland 2018.

In this overview the current quality of acute in-hospital care of stroke patients in Germany in 2018 is described based on standardized and evidence-based quality indicators. For this purpose the reports of the regional quality assurance projects for stroke care, which collaborated within the German-speaking Stroke Registers Study Group (ADSR) were analyzed. Overall, more than 280,000 acute admissions of stroke patients were documented in the included quality assurance projects. The results regarding the defined 16 quality indicators comprising diagnostics, acute treatment, rehabilitation and secondary prevention showed a high level of acute inpatient treatment of stroke in Germany. Only a few quality indicators, such as early transfer for thrombectomy indicated a great necessity for process optimization.

Stroke unit admission is associated with better outcome and lower mortality in patients with intracerebral hemorrhage.

BACKGROUND AND PURPOSE: There is no clear consensus among current guidelines on the preferred admission ward [i.e. intensive care unit (ICU) or stroke unit (SU)] for patients with intracerebral hemorrhage. Based on expert opinion, the American Heart Association and European Stroke Organization recommend treatment in neurological/neuroscience ICUs (NICUs) or SUs. The European Stroke Organization guideline states that there are no studies available directly comparing outcomes between ICUs and SUs. METHODS: We performed an observational study comparing outcomes of 10 811 consecutive non-comatose patients with intracerebral hemorrhage according to admission ward [ICUs, SUs and normal wards (NWs)]. Primary outcomes were the modified Rankin Scale score at discharge and intrahospital mortality. An additional analysis compared NICUs with SUs. RESULTS: Treatment outside an SU was associated with higher odds for an unfavorable outcome [ICU vs. SU: odds ratio (OR), 1.27; 95% confidence interval (CI), 1.09-1.46; NW vs. SU: OR, 1.28; 95% CI, 1.08-1.52] and higher odds for intrahospital mortality (ICU vs. SU: OR, 2.11; 95% CI, 1.75-2.55; NW vs. SU: OR, 1.52; 95% CI, 1.23-1.89). A subgroup analysis of severely affected patients treated in dedicated NICUs (vs. SUs) showed that they had a lower risk of a poor outcome (OR, 0.45; 95% CI, 0.26-0.79). CONCLUSIONS: Treatment in SUs was associated with better functional outcome and reduced mortality compared with ICUs and NWs. Our findings support the current guideline recommendations to treat patients with intracerebral hemorrhage in SUs or NICUs and suggest that some patients may further benefit from NICU treatment.

Intravenous thrombolysis for acute ischaemic stroke in the elderly: data from the Baden-Wuerttemberg stroke registry.

BACKGROUND AND PURPOSE: In Europe intravenous thrombolysis (IVT) for ischaemic stroke is still not approved for patients aged >80 years. However, elderly patients are frequently treated based on individual decision making. In a retrospective observational study a consecutive and prospective stroke registry in southwest Germany was analysed. METHODS: The data registry collected 101,349 patients with ischaemic stroke hospitalized from January 2008 to December 2012. Of these, 38,575 (38%) were aged 80 years and older and 10 286 (10.1%) underwent IVT. Favourable outcome at discharge was defined as modified Rankin Scale (mRS) ≤1 or not worse than prior to stroke. Multiple logistic regression models stratified by 10-year age groups were used to assess the relationship between IVT and mRS at discharge, adjusted for patient characteristics, admitting facility and length of hospital stay. RESULTS: The highest IVT rate was 15% in patients aged <50 years, with a continuous decline down to 8% in patients aged ≥90 years. Adjusted odds ratios and 95% confidence intervals for patients 80-89 years of age were 2.20 (1.95-2.47) (P < 0.0001) and 1.25 (0.88-1.78) (P = 0.21) for patients >90 years of age, compared to patients of the same age decade not treated with IVT. CONCLUSIONS: The evidence from routine hospital care in southwest Germany indicates that IVT is an effective treatment also for aged patients with ischaemic stroke in an age range between 80 and 89 years. Although no clear evidence for the effectiveness of IVT beyond 90 years was found, treatment should also be carefully considered in these patients. High age should not discourage from treatment.

A consecutive and prospective stroke database covers the state of Baden-Wuerttemberg with 10.8 million inhabitants in Germany.

BACKGROUND: In 1998 Baden-Wuerttemberg (BW), a federal state in southwest Germany with 10.8 million inhabitants, implemented a structured medical concept for the treatment of acute stroke. METHODS: Since 2004 participation in the BW stroke database is mandatory for all hospitals in BW involved in acute stroke care. The stroke database includes all inpatients ≥18 years of age who have suffered an ischemic or hemorrhagic stroke within 7 days before hospitalization. This article presents methodological aspects and first results of the BW stroke database in the time period from 2007 to 2011. RESULTS: Annual inclusion numbers increased continuously (29,422 vs. 35,724, p < 0.001). Median age of stroke onset was stable over time. The proportion of stroke patients ≥80 years increased from 36.9 to 38.8% (p < 0.001). Rates of patients treated in neurology departments rose from 50.7 to 60.9% (p < 0.001) and numbers of patients treated in stroke units rose from 59.1 to 68.4% (p < 0.001). Admission via emergency medical systems increased from 42.8 to 49.7% (p < 0.001) and arrival within 3 h increased from 29.8 to 34.4% (p < 0.001). CONCLUSION: We present results from a large, prospective and consecutive stroke patient database. This first analysis demonstrates a continuous increase of absolute and relative numbers of stroke patients who arrive within 3 h after onset, are hospitalized in neurology departments and treated in stroke units, and are aged ≥80 years.

[Optoacoustic tissue alterations for optimizing laser cyclophotocoagulation. Transscleral detection of laser-induced optoacoustic pressure transients]. / Optoakustische Gewebsdifferenzierung zur Optimierung von Laserzyklophotokoagulation. Transsklerale Detektion laserinduzierter optoakustischer Drucktransienten.

BACKGROUND: Considerable problems occur in transscleral laser cyclophotocoagulation concerning energy dosage. We investigated the feasibility of localizing the ciliary body by the detection of thermoelastic pressure transients and of supervising on-line the degree of tissue damage during treatment. METHOD: We used a specially designed handpiece to apply short pulsed laser radiation with low energy levels to enucleated bulbs of rabbits. With an adjusted pressure transducer we examined acoustical transients generated in the area of absorption of the ciliary muscle or the pigmented epithelial layer and measured axial resolution of the method at various distances to the corneoscleral limbus. RESULTS: We detected acoustic transients that allowed rough localization of the target area. A marked change in signal was recorded with increasing level of ciliary destruction. CONCLUSION: This procedure can serve as an essential tool in the on-line supervision of the coagulation process. The laser parameters can thus be adjusted optimally to the progress of the treatment.

[Ophthalmological rehabilitation - experience at the University Eye Hospital Heidelberg]. / Ophthalmologische Rehabilitation. Erfahrungen an der Heidelberger Universitäts-Augenklinik.

BACKGROUND: The rehabilitation of low vision patients is of increasing importance since the number of these patients has grown rapidly. We wanted to evaluate the actual spectrum of patients concerning age and diagnoses and the appropriate low vision aids (LVA) in 1 year. METHODS: The records of the patients seen in our low-vision unit in 1996 were retrospectively evaluated. We correlated visual function, ophthalmological diagnoses and age to the magnification needed for rehabilitation and the use or prescribed LVAs. RESULTS: There was a nearly homogeneous distribution concerning age with a range from 0 to 99 years. Most patients presented with age-related macular degeneration (25.6 %) while 10 % each had retinitis pigmentosa and optic atrophy. Simple low vision aids such as high plus reading additions (29 %) and magnifiers (18.5 %) were prescribed in the majority of patients. However, closed-circuit TV (CCTV) systems were necessary in 25 %. CONCLUSIONS: Rehabilitation of low vision patients is often possible with simple LVAs. This is especially true for patients suffering from age-related macular degeneration. Since there is a tremendous-amount of different diseases, adequate diagnostic and individual counseling is of major importance.

[Use of a new optoelectronic vision aid for highly visually handicapped patients]. / Anwendungen einer neuen optoelektronischen Sehhilfe für hochgradig Sehbehinderte (LVES).

UNLABELLED: A new low vision aid (LVA)-the Low Vision Enhancement System or LVES, which were as developed at the Johns Hopkins University in Baltimore, is now commercially available. This instrument allows a magnification up to 10 times with control of contrast and luminance while the field of view is very large: 60 x 40 degrees. We present first results concerning LVES in comparison to conventional LVAs. PATIENTS AND METHODS: 60 consecutive patients suffering from macular dystrophy, macular degeneration, optic atrophy, tapetoretinal degeneration, or diabetic retinopathy were included in this study. We compared visual acuity with glasses, with telescope and using LVES. Furthermore we compared contrast acuity by the use of the Pelli-Robson-charts as well as the subjective impression of the patients. RESULTS: Improvement of visual acuity with LVES compared to correction with glasses was 8 log steps on average and up to 3 steps as compared to the use of telescopes. More important is the improvement of contrast sensitivity (0-16 steps) and the reduced glare. Despite the subjective improvement of visual acuity and contrast sensitivity the majority of patients could not imagine to use LVES regularly. A significant improvement as compared to conventional low vision aids is possible for special applications such as office work, recognition of faces or images or for looking at a blackboard. CONCLUSION: In addition to traditional LVAs, the Low Vision Enhancement System opens up possibilities for a very small group of patients. Especially patients suffering from macular dystrophy or Lebers optic atrophy may benefit from this new system. The most important advantage of LVES is the improvement of contrast sensitivity and the significantly decreased glare sensitivity. Additionally the near working distance is changeable. The variable magnification allows an easier fitting to various tasks. Prior to the prescription of LVES a detailed and time consuming testing is necessary.