Comparative global analysis of stroke rehabilitation recommendations across income levels.

OBJECTIVE: Successful implementation of stroke rehabilitation guidelines demands high-quality practice standards tailored to targeted sociodemographic contexts. The primary objective is to determine the quality differences in post-stroke rehabilitation practice guidelines (PGs), when comparing high-income countries (HIC) and low or middle-income countries (LMIC). STUDY DESIGN AND SETTING: We conducted a scoping review of PGs in English or Spanish, published between 2012 and 2021, and providing recommendations on post-stroke rehabilitation. We used Search engines, databases, guideline libraries, gray literature, and references from previous reviews on post-stroke rehabilitation as sources of evidence. Quality assessment of PGs was performed using 6P's, ELSE, IOM, and AGREE II instruments. We evaluated each item using a scale between 0 to 3, based on the confidence of adherence to the standard. For AGREE II, we followed the instruction manual for scoring. At least two reviewers were independently involved in every step of the process. A cloud-based spreadsheet was used to chart data. We compared the results of PGs originating from HIC with those from LMIC. RESULTS: The inclusion criteria were met by 35 documents, which were subjected to evaluation. The study included 21 documents from HIC and 14 from middle-income countries (MIC). No manuscripts from low-income countries were available for inclusion in the study. The quality of PGs from MIC was found to be lower, in terms of methodological rigor and adherence to international recommendations for guidelines development. PGs from both groups of countries failed to include all target audiences and stakeholders (according to the 6P's criteria) and integration of ethical, legal, social, and economic considerations. CONCLUSION: There are gaps in the quality and availability of stroke rehabilitation guidelines worldwide, especially in LMIC. Designing and providing financial support for the implementation of high-quality guidelines will contribute to more effective implementation strategies in stroke rehabilitation programs and lead to improved patient outcomes.

Barriers in Access to Idarucizumab in Ischemic Stroke in a Middle-Income Country.

Background and Purpose: Current stroke guidelines contraindicate the use of thrombolytics if oral anticoagulants are taken within 48 hours of symptom onset. Idarucizumab is an alternative for patients on dabigatran who experience an acute stroke, so that alteplase may be used. However, this treatment may not be readily available in low/middle-income countries. Our objective is to describe barriers to access to the administration of idarucizumab. Methods: We applied a structured survey for health personnel, consulted databases of drug providers, and analyzed reports from the National Pharmacologic Surveillance Data to describe idarucizumab use and the related knowledge among prescribers and the drug distribution in health institutions in Colombia between January 2018 and January 2022. Results: In total, 23.6% of the 337 interviewed physicians' hospitals had access to idarucizumab, and 34.9% of the physicians were unaware of the use of this medication for ischemic stroke. Only 11 private institutions had access to this medication in Colombia. Four male patients with atrial fibrillation received thrombolytics for acute stroke, and two required subsequent mechanical thrombectomy. No fatal complications during hospitalization were observed. Complications included hematuria, hemorrhagic transformation and groin hematoma. None required transfusion or further intervention. All had favorable mRS scores at the 90-day follow-up. Conclusions: There are multiple barriers to access idarucizumab in Colombia. The main factors identified are the low medication availability in provincial hospitals and the low medical knowledge. However clinical results in this limited group are satisfactory. Stronger public policies are needed to guarantee optimal stroke treatment in patients on DOACs in Colombia.

Tratamiento posterior a un ataque cerebrovascular con estatinas y metas de colesterol de baja densidad / Statin treatment and low density cholesterol targets in patients post stroke

RESUMEN INTRODUCCIÓN: El ACV es uno de los eventos cardiovasculares más prevalentes en el mundo, en Colombia es la segunda causa de muerte y la primera de discapacidad. Uno de los factores de riesgo más importantes para tener en cuenta es el control del colesterol, la reducción de los niveles de C-LDL, principalmente por medio del tratamiento con estatinas y otros fármacos hipolipemiantes. MATERIALES Y MÉTODOS: En esta revisión narrativa de la literatura se ha recogido la información más relevante sobre el uso y los beneficios de este tratamiento y algunas consideraciones adicionales. CONCLUSIÓN: Los hallazgos de esta revisión demuestran el efecto protector de esta terapia cuando se consiguen reducir los niveles de C-LDL y colesterol, además, las otras terapias como ezetimiba o inhibidores de PSCK9. Por otro lado, los estudios mencionan posibles efectos beneficiosos en el contexto de ACV pero se requieren más ensayos clínicos.

ABSTRACT INTRODUCTION: Stroke is one of the most prevalent cardiovascular events in the world, in Colombia it is the second cause of death and first in disability. One of the most important risk factors to consider is cholesterol control, the reduction of LDL-C and cholesterol levels, mainly through treatment with statins and other lipid-lowering drugs. MATERIALS AND METHODS: The most relevant information on the use and benefits of this treatment and some additional considerations have been collected in this narrative review of the literature. CONCLUSION: The results of this narrative review show the protective effect of this therapy when it is possible to reduce LDL-C and cholesterol levels, in addition to other therapies such as ezetimibe or PSCK9 inhibitors. On the other hand, studies mention possible beneficial effects in the context of stroke but more clinical trials are required.

Análisis de costos de la atención hospitalaria en un paciente con fibrilación auricular no valvular y accidente cerebrovascular a repetición / Cost analysis of in hospital attention in a non-valvular atrial fibrillation patient and recurrent stroke

RESUMEN INTRODUCCIÓN: Paciente de 71 años con diagnóstico de fibrilación auricular y ataques cerebrovasculares recurrentes, tratada con varios anticoagulantes. El costo del tratamiento del ictus en Colombia para el año 2008 fue de $450.000 millones de pesos colombianos. OBJETIVO: Estimar el costo hospitalario de la atención de un paciente con ictus a repetición secundario a fibrilación auricular. MÉTODOS: Estudio económico parcial de microcosteo de la atención intrahospitalaria para un caso de espectro severo recurrente, que no necesariamente refleja el caso promedio. El consumo de recursos se valoró mediante el uso de tarifas de referencia nacionales. Los resultados se presentan en precios actuales del 2019 (peso colombiano y dólar americano). RESULTADOS: Paciente con 3 eventos hospitalarios, que estuvo 31 días hospitalizada. Las hospitalizaciones tuvieron unos costos de: $53.883.490 (USD 16.141,1), $6.343.096 (USD 1.900,1) y $15.719.443 (USD 4.708,9) respectivamente, con un precio promedio por cada hospitalización de $25.315.343 (USD 7.583,4), costo total de $75.946.029 (USD 22.750,1) costo día de $2.449.872 (USD 729,5). El rubro que aumentó consistentemente los costos fueron los procedimientos (35,7 %). CONCLUSIONES: El ictus recurrente causado por fibrilación auricular no valvular se asocia con un incremento significativo de los costos directos, con un impacto de casi dos veces el PIB per cápita. Un diagnóstico oportuno y una selección adecuada pueden reducirlo.

ABSTRACT INTRODUCTION: A 71-year-old patient with a diagnosis of atrial fibrillation and recurrent strokes, treated with various anticoagulants, the stroke treatment in Colombia for 2008 was $ 450 billion Colombian pesos. OBJECTIVE: To estimate the hospital cost of caring for a patient with recurrent stroke secondary to atrial fibrillation. METHODS: Partial economic study of micro costing of in-hospital care for a case of recurrent severe spectrum stroke, which does not necessarily reflect the average case. Resource consumption was valued using national reference rates. The results are presented in current 2019 prices (Colombian pesos and US dollars). RESULTS: Patient with 3 hospital events, who was hospitalized for 31 days. Hospitalizations had costs of $ 53,883,490 (USD 16,141.1), $ 6,343,096 (USD 1,900.1) and $ 15,719,443 (USD 4,708.9) respectively, with an average price for each hospitalization of $ 25,315,343 (USD 7,583.4), total cost of $ 75,946,029 (USD 22,750.1) daily cost of $ 2,449,872 (USD 729.5). The item that consistently increased costs was procedures (35.7 %). CONCLUSIONS: Recurrent stroke caused by nonvalvular atrial fibrillation is associated with a significant increase in direct costs, with an impact of almost twice the GDP per capita. A timely diagnosis and proper selection can reduce it.

Ischemic stroke: A paradoxical manifestation of cancer.

INTRODUCTION: Approximately 5-10 % of the patients with cryptogenic stroke have an underlying malignancy. Stroke as a complication of cancer increases the morbidity and mortality among cancer patients, leading to increased disability and healthcare costs. OBJECTIVE: To provide elements to guide physicians for when to suspect and evaluate for cancer in stroke patients. DEVELOPMENT: We performed a narrative review, portrayed in a question-answer format, to report relevant aspects of cancer stroke patients in the clinical practice and provide a guide based on the state-of-the-art literature. Conventional stroke mechanisms are only found in a fraction of patients with cancer. Although cardiovascular risk factors play an important role in both cancer and stroke pathogenesis, the recognition of more specific cancer-associated risk factors raises clinical suspicion for occult malignancy. We also expose the main type location and histology of tumors that are most commonly associated with stroke as well as potential blood biomarkers and current treatment considerations in the scenario of cancer associated stroke. CONCLUSION: Subjects with active cancer are a patient population at increased risk for developing an ischemic stroke. Cryptogenic stroke patients have a higher risk of cancer diagnosis in the following 6-12 months. We recommend a multidisciplinary approach considering the high probability of a hidden malignancy and running a comprehensive evaluation including neurologic imaging, serological biomarkers and tight follow up.

Hallazgos estructurales en imágenes cerebrales de pacientes con diagnóstico de delirium en un hospital de alta complejidad de Bogotá / Structural findings in cerebral images of patients with diagnosis of delirium in a high-complexity hospital in Bogota

RESUMEN INTRODUCCIÓN: El delirium es una falla cerebral de origen multifactorial, común, y en ocasiones relacionada con un desenlace fatal. Afecta principalmente a la población hospitalizada mayor de 65 años. La realización de imágenes cerebrales en delirium se encuentra en discusión, porque en la mayoría de los casos no se pone en evidencia una correlación entre los hallazgos de la imagen y la enfermedad. La literatura médica actual muestra que las imágenes de rutina (tomografía o resonancia cerebral) resultan negativas para lesiones agudas hasta en el 94 % de los pacientes que cumplen criterios diagnósticos. En Colombia no hay estudios descriptivos en pacientes que presenten delirium. Por lo anterior, nuestra idea es describir los principales hallazgos radiológicos en imagen cerebral en pacientes con diagnóstico de delirium en urgencias u hospitalización en un hospital de alta complejidad de Bogotá, valorados por el departamento de neurología. MÉTODOS: Se realizó un estudio de corte transversal que incluyó a los pacientes con diagnóstico de delirium atendidos por neurología en hospitalización o urgencias entre octubre del 2015 y octubre del 2016. RESULTADOS: Se incluyeron 97 pacientes y se realizaron imágenes cerebrales a 79 (81 %). De estos, tan solo en ocho (10 %) se encontró lesión aguda en imágenes cerebrales. En los pacientes que tienen signos de focalización este porcentaje aumentó a tres pacientes (27 %), y en los que no tenían signos de focalización fue de cinco pacientes (7,3 %). CONCLUSIONES: La presencia de lesiones cerebrales agudas en pacientes con delirium es baja. El hecho de tener signos de focalización en el examen aumenta la posibilidad de tener lesiones agudas.

SUMMARY INTRODUCTION: Delirium is a brain failure of multifactorial origin, common and sometimes related to a fatal outcome. It mainly affects hospitalized population over 65 years. Work-up with cerebral images is in discussion, because in most of of the occasions it is not related to the pathology. Current medical literature shows that routine imaging (tomography or brain resonance) are negative for acute injuries in up to 94 % of patients that meets delirium diagnostic criteria. In Colombia there are no descriptive studies in patients with delirium. Therefore, our objective was to describe the main radiological findings in brain imaging in patients diagnosed with delirium in the emergency room or admitted subjects in a high complexity hospital in Bogotá-Colombia, assessed by the department of neurology between October 2015 and October 2016. METHODS: A cross-sectional study was carried out, including all patients diagnosed with delirium treated by neurology in hospitalization or emergencies. RESULTS: This research showed a total of 97 patients diagnosed with delirium; 79 (81 %) had brain images; of these, only 8 (10 %) showed acute injury in brain images, in patients who have signs of focalization this percentage was higher to 3 (27 %) than in those who did not have them 5 (7.3 %). CONCLUSIONS: The presence of acute brain injuries in patients with delirium is low. The fact of having signs of focal injury on examination increases the possibility of having acute injuries.