From guidelines to clinical practice in care for ischaemic stroke patients: A systematic review and expert opinion.

BACKGROUND AND PURPOSE: Guidelines help physicians to provide optimal care for stroke patients, but implementation is challenging due to the quantity of recommendations. Therefore a practical overview related to applicability of recommendations can be of assistance. METHODS: A systematic review was performed on ischaemic stroke guidelines published in scientific journals, covering the whole acute care process for patients with ischaemic stroke. After data extraction, experts rated the recommendations on dimensions of applicability, that is, actionability, feasibility and validity, on a 9-point Likert scale. Agreement was defined as a score of ≥8 by ≥80% of the experts. RESULTS: Eighteen articles were identified and 48 recommendations were ultimately extracted. Papers were included only if they described the whole acute care process for patients with ischaemic stroke. Data extraction and analysis revealed variation in terms of both content and comprehensiveness of this description. Experts reached agreement on 34 of 48 (70.8%) recommendations in the dimension actionability, for 16 (33.3%) in feasibility and for 15 (31.3%) in validity. Agreement on all three dimensions was reached for seven (14.6%) recommendations: use of a stroke unit, exclusion of intracerebral haemorrhage as differential diagnosis, administration of intravenous thrombolysis, performance of electrocardiography/cardiac evaluation, non-invasive vascular examination, deep venous thrombosis prophylaxis and administration of statins if needed. DISCUSSION AND CONCLUSION: Substantial variation in agreement was revealed on the three dimensions of the applicability of recommendations. This overview can guide stroke physicians in improving the care process and removing barriers where implementation may be hampered by validity and feasibility.

The impact of gastrointestinal diseases on oral and maxillofacial surgery outcomes.

OBJECTIVE: We analyzed the complication rates and outcomes in patients with gastrointestinal disorders who had undergone maxillofacial surgery. STUDY DESIGN: We retrospectively analyzed 289 patients with inflammatory bowel disease (IBD), 142 with gastroesophageal reflux disease (GERD), and 42 with celiac disease (452 total) who had undergone oral and/or maxillofacial surgery. We examined their characteristics, medications they had taken, surgeries they had undergone, and complications they had experienced. Based on the results of univariate analysis, we selected variables for multivariable logistic regression to identify independent predictors of postoperative complications. RESULTS: We found a complication rate of 10% in patients with IBD, 6.9% in patients with GERD, and 9.5% in patients with celiac disease. Dentoalveolar treatment was significantly associated with an increased risk of postoperative complications in patients with IBD and GERD. CONCLUSIONS: Oral and/or maxillofacial surgery is safe in most patients with IBD, GERD, and celiac disease. Preventive measures for postoperative complications should be considered in patients with IBD and GERD undergoing dentoalveolar treatment.

Variation in stroke care at the hospital level: A cross-sectional multicenter study.

Introduction: Stroke is one of the leading causes of mortality and disability. Improving patient outcomes can be achieved by improving stroke care and adherence to guidelines. Since wide variation in adherence rates for stroke guidelines still exists, we aimed to describe and compare stroke care variability within Belgian hospitals. Materials and methods: An observational, multicenter study was performed in 29 Belgian hospitals. We retrospectively collected patient characteristics, quality indicators, and time metrics from the last 30 consecutive patients per hospital, diagnosed with ischemic stroke in 2019 with structured questionnaires. Mean adherence ratios (%) ± SD (minimum - maximum) were calculated. Results: We analyzed 870 patient records from 29 hospitals. Results showed large inter- and intrahospitals variations in adherence for various indicators. Almost all the patients received brain imaging (99.7%) followed by admission at a stroke unit in 82.9% of patients. Of patients not receiving thrombolysis, 92.5% of patients were started on antithrombotic drugs. Indicators with moderate median adherence but large interhospital variability were glycemia monitoring [82.3 ± 16.7% (26.7-100.0%)], performing clinical neurological examination and documentation of stroke severity [63.1 ± 36.8% (0-100%)], and screening for activities of daily living [51.1 ± 40.3% (0.0-100.0%)]. Other indicators lacked adequate adherence: swallowing function screening [37.0 ± 30.4% (0.0-93.3%)], depression screening [20.2 ± 35.8% (0.0-100%)], and timely body temperature measurement [15.1 ± 17.0% (0.0-60%)]. Conclusion: We identified high adherence to guidelines for some indicators, but lower rates with large interhospital variability for other recommendations also based on robust evidence. Improvement strategies should be implemented to improve the latter.

Patient Reported Outcomes Measurements Information System in Stroke Patients in Full and Shortened Format.

Introduction: The modified Rankin Scale (mRS) after 90 days documents outcome in stroke patients, but focusses only on activities of daily living. Here we studied stroke outcome beyond these activities by the Dutch-Flemish version of the Patient Reported Outcomes Measurement Information System (PROMIS) questionnaire. Patients and Methods: We documented the mRS at day 90 in stroke patients who filled out a questionnaire on pain intensity and seven PROMIS domains: physical function, ability to participate in social roles, anxiety, fatigue, depression, sleep disturbance, pain interference. In a subgroup of patients this questionnaire was reduced to one overall question per PROMIS domain. We correlated these findings with the mRS. Results: We received 102 questionnaires and identified physical function as the most affected PROMIS domain. The strongest correlation with mRS was found for the health domains of physical function (ρs = 0.70, p < 0.001) and ability to participate in social roles (ρs = 0.61, p < 0.001). The other domains with substantial proportions of patients with worse scores compared to the general population (19-44%) correlated weakly with the mRS. We identified a strong correlation between the single question per health domain and the overall score per PROMIS domain. Discussion and Conclusion: PROMIS better reflects the overall health status of stroke patients beyond functional outcome as measured by the mRS. Simplification of the questionnaire with a single question per PROMIS domain could potentially replace the full questionnaire, but needs further validation.

Reassessment of the antioxidative mixture for the challenging electrochemical determination of dopamine, noradrenaline and serotonin in microdialysis samples.

In recent years, the simultaneous monitoring of the monoamine neurotransmitters dopamine, noradrenaline and serotonin in vivo is advancing due to innovations in miniaturized and fast chromatographic techniques. However, the determination of the most hydrophilic compound, noradrenaline, in microdialysis samples by (ultra-)high performance liquid chromatography ((U)HPLC) with electrochemical detection (ECD) is impeded by a broad solvent front, caused by the addition of antioxidative agents. Hence, an elaborate reassessment of currently used antioxidative mixtures is necessary for further analytical improvements. The proposed mixture, containing 100mM acetic acid, 0.27mM Na2EDTA and 12.5µM ascorbic acid (pH 3.2), is less complex than previously described mixtures and shows minimal ECD interference. It stabilizes the three monoamines in standard solutions and in microdialysis samples, considering both autosampler stability at 4°C for 48h and long term stability at -20°C for a duration of six months. An in vivo microdialysis experiment demonstrates the possibility to monitor changes in extracellular levels of the three monoamines simultaneously in the rat hippocampus with UHPLC-ECD using the optimized antioxidative mixture.