Development of a patient decision aid for discharge planning of hospitalized patients with stroke.

BACKGROUND: Patient involvement in discharge planning of patients with stroke can be accomplished by providing personalized outcome information and promoting shared decision-making. The aim of this study was to develop a patient decision aid (PtDA) for discharge planning of hospitalized patients with stroke. METHODS: A convergent mixed methods design was used, starting with needs assessments among patients with stroke and health care professionals (HCPs). Results of these assessments were used to develop the PtDA with integrated outcome information in several co-creation sessions. Subsequently, acceptability and usability were tested to optimize the PtDA. Development was guided by the International Patient Decision Aids Standards (IPDAS) criteria. RESULTS: In total, 74 patients and 111 HCPs participated in this study. A three-component PtDA was developed, consisting of: 1) a printed consultation sheet to introduce the options for discharge destinations, containing information that can be specified for each individual patient; 2) an online information and deliberation tool to support patient education and clarification of patient values, containing an integrated "patients-like-me" model with outcome information about discharge destinations; 3) a summary sheet to support actual decision-making during consultation, containing the patient's values and preferences concerning discharge planning. In the acceptability test, all qualifying and certifying IPDAS criteria were fulfilled. The usability test showed that patients and HCPs highly appreciated the PtDA with integrated outcome information. CONCLUSIONS: The developed PtDA was found acceptable and usable by patients and HCPs and is currently under investigation in a clinical trial to determine its effectiveness.

Experiences with information provision and preferences for decision making of patients with acute stroke.

OBJECTIVE: The aim of this study was to gain insight into experiences of patients with acute stroke regarding information provision and their preferred involvement in decision-making processes during the initial period of hospitalisation. METHODS: A sequential explanatory design was used in two independent cohorts of patients with stroke, starting with a survey after discharge from hospital (cohort 1) followed by observations and structured interviews during hospitalisation (cohort 2). Quantitative data were analysed descriptively. RESULTS: In total, 72 patients participated in this study (52 in cohort 1 and 20 in cohort 2). During hospitalisation, the majority of the patients were educated about acute stroke and their treatment. Approximately half of the patients preferred to have an active role in the decision-making process, whereas only 21% reported to be actively involved. In cohort 2, 60% of the patients considered themselves capable to carefully consider treatment options. CONCLUSIONS: Active involvement in the acute decision-making process is preferred by approximately half of the patients with acute stroke and most of them consider themselves capable of doing so. However, they experience a limited degree of actual involvement. PRACTICE IMPLICATIONS: Physicians can facilitate patient engagement by explicitly emphasising when a decision has to be made in which the patient's opinion is important.

Comparison of outcome in stroke patients admitted during working hours vs. off-hours; a single-center cohort study.

INTRODUCTION: We aimed to disprove an in-hospital off-hour effect in stroke patients by adjusting for disease severity and poor prognostic findings on imaging. PATIENTS AND METHODS: Our study included 5378 patients from a single center prospective stroke registry of a large teaching hospital in the Netherlands, admitted between January 2003 and June 2015. Patients were categorized by admission time, off-hours (OH) or working hours (WH). The in-hospital mortality, 7-day mortality, unfavorable functional outcome (modified Rankin scale > 2) and discharge to home were analyzed. Results were adjusted for age, sex, stroke severity (NIHSS score) and unfavorable findings on imaging of the brain (midline shift and dense vessel sign). RESULTS: Overall, 2796 patients (52%) were admitted during OH, which had a higher NIHSS score [3 (IQR 2-8) vs. 3 (IQR 2-6): p < 0.01] and had more often a dense vessel sign at admission (7.9% vs. 5.4%: p < 0.01). There was no difference in mortality between the OH-group and WH-group (6.2% vs. 6.0%; p = 0.87). The adjusted hazard ratio of in-hospital mortality during OH was 0.87 (95% CI: 0.70-1.08). Analysis of 7-day mortality showed similar results. Unadjusted, the OH-group had an unfavorable outcome [OR: 1.14 (95% CI: 1.02-1.27)] and could less frequently be discharged to home [OR: 1.16 (95% CI: 1.04-1.29)], which was no longer present after adjustment. DISCUSSION AND CONCLUSIONS: The overall outcome of stroke patients admitted to a large Dutch teaching hospital is not influenced by time of admission. When studying OH effects, adjustment for disease severity and poor prognostic findings on imaging is crucial before drawing conclusions on staffing and material.

Are PROMs sufficient to record late outcome of breast cancer patients treated with radiotherapy? A comparison between patient and clinician reported outcome through an outpatient clinic after 10years of follow up.

AIM: To investigate whether breast cancer patients' visits to an outpatient clinic for late outcome (OCLO) can be replaced by patient reported outcome measures (PROMs), by comparing late toxicity scored at the OCLO with PROMs. METHODS: All breast cancer patients treated in our institute with adjuvant radiotherapy 10-11years ago were invited to visit the OCLO, and for filling out PROM-questionnaires. Concordance rate between PROMs and OCLO-reported outcome and the percentage of patients with ≥2 degrees difference in toxicity level between patient and clinician was assessed. RESULTS: 686 of 1029 patients were still alive. 249 patients visited the OCLO, and 341 patients returned a questionnaire. At a group level, patients reported higher toxicity rates than clinicians. The mean concordance for individual patients was 58% between patient and clinician reported outcome. In 2.8%, the clinician reported ≥2 degrees higher toxicity than the patients did, whereas in 6.8% patients reported ≥2 degrees higher toxicity. CONCLUSION: PROMs do not underestimate late side-effects at a group level. In spite of the low concordance rate, PROMS can be used to identify patients who experience a heavy burden of side-effects, requiring specific attention. Therefore, patients can be spared a visit to the OCLO.

[Effectiveness of endarterectomy for symptomatic stenosis of the internal carotid artery; more risk factors important than only the severity of the stenosis]. / Effectiviteit van endarteriëctomie voor symptomatische stenose van de A. carotis; meer factoren belangrijk dan alleen de ernst van de stenose.

Carotid endarterectomy prevents ischaemic stroke in patients who have suffered either a transient ischaemic attack (TIA) or a non-disabling ischaemic stroke and are also diagnosed with severe stenosis of the internal carotid artery (ICA). In order to prevent the occurrence ofa single stroke, 6 patients with a symptomatic 70 to 99% ICA stenosis will have to be operated upon. A meta-analysis of individual patient data from 3 randomised trials shows that the decision whether to advise endarterectomy to an individual patient should not be based solely on the degree of the ICA stenosis, but also on the time interval between symptoms and surgery, the type and severity of symptoms and the plaque morphology. In general, endarterectomy is more effective in men than in women, it is very effective in the elderly, and it is even more effective when performed within two weeks of the symptoms occurring. A decision scheme has been set up enabling one to predict the absolute risk of an ipsilateral stroke in the next 5 years in individual patients who have symptomatic ICA stenosis. This is based on 5 factors: sex, age, the most severe symptom in the last 6 months (stroke, TIA, or ischaemic retinopathy), the number of weeks since the last incident and the morphological characteristics of the plaque.

[Efficacy of agreements within the Enchede Stroke Service to refer patients with a stroke from the stroke unit in the hospital to a nursing home for short-term rehabilitation]. / Effectiviteit van afspraken binnen de Enschedese stroke-service om patiënten met een beroerte adequaat te verwijzen van de stroke-unit in het ziekenhuis naar een verpleeghuis voor kortdurende reactivering.

OBJECTIVE: To assess the efficacy of agreements within the Enschede Stroke Service to refer patients with a stroke from the stroke unit in the hospital to a nursing home for short-term rehabilitation. DESIGN: Prospective, partly retrospective. METHOD: All patients who were referred from the stroke unit at Medisch Spectrum Twente to the CVA Rehabilitation Unit (CRU) in the period 1 July 1999-31 July 2003 were included. Referral took place via an active multidisciplinary approach and specific referral agreements. The primary outcome was the number of patients that could be discharged home after rehabilitation. In addition, we assessed the influence on final discharge destination of age, the Barthel and Rankin scores at the time of admission to the CRU and the medical complications during the period of rehabilitation. RESULTS: 232 patients were included (133 women and 99 men, mean age 76.4 years). Within 3 months, 63% of the patients were discharged home. After 6 months, 82% had returned home. 8% of the patients died within 6 months and 9% had to stay in a nursing home permanently. Of the patient aged 80 years or older, 75% could return home within 6 months. Patients with poor Barthel and Rankin scores and medical complications had a smaller chance of being discharged home. CONCLUSION: Effective referral of patients from the stroke unit to a nursing home for short-term rehabilitation is possible. With adequate patient selection, the use of good referral agreements and multidisciplinary consultations, most patients could finally return home.

Timing of aneurysm surgery in subarachnoid haemorrhage--an observational study in The Netherlands.

BACKGROUND: There is still lack of evidence on the optimal timing of surgery in patients with aneurysmal subarachnoid haemorrhage. Only one randomised clinical trial has been done, which showed no difference between early and late surgery. Other studies were observational in nature and most had methodological drawbacks that preclude clinically meaningful conclusions. We performed a retrospective observational study on the timing of aneurysm surgery in The Netherlands over a two-year period. METHOD: In eight hospitals we identified 1,500 patients with an aneurysmal subarachnoid haemorrhage. They were subjected to predefined inclusion criteria. We included all patients who were admitted and were conscious at any one time between admission and the end of the third day after the haemorrhage. We categorised the clinical condition on admission according the World Federation of Neurological Surgeons (WFNS) grading scale. Early aneurysm surgery was defined as operation performed within three days after onset of subarachnoid haemorrhage; intermediate surgery as performed on days four to seven, and late surgery as performed after day seven. Outcome was classified as the proportion of patients with poor outcome (death or dependent) two to four months after onset of subarachnoid haemorrhage. We calculated crude odds ratios with late surgery as reference. We distinguished between management results (reconstructed intention to treat analysis) and surgical results (on treatment analysis). The results were adjusted for the major prognosticators for outcome after subarachnoid haemorrhage. FINDINGS: We included 411 patients. There were 276 patients in the early surgery group, 36 in the intermediate surgery group and 99 in the late surgery group. On admission 78% were in good neurological condition (WFNS I-III). MANAGEMENT RESULTS: Overall, 93 patients (34%) operated on early had a poor outcome, 13 (36%) of those with intermediate surgery and 37 (37%) in the late surgery group had a poor outcome. For patients in good clinical condition on admission and planned for early surgery the adjusted odds ratio (OR) was 1.3 (95% CI 0.5 to 3.0). The adjusted OR for patients admitted in poor neurologicalcondition (WFNS IV-V) and planned for early surgery was 0.1 (95% CI 0.0 to 0.6). SURGICAL RESULTS: For patients in good clinical condition on admission who underwent early operation the adjusted OR was 1.1 (95% CI 0.4 to 3.2); it was 0.2 (95% CI 0.0 to 0.9) for patients admitted in poor clinical condition. CONCLUSIONS: In this observational study we found no significant difference in outcome between early and late operation for patients in good clinical condition on admission. For patients in poor clinical condition on admission outcome was significantly better after early surgery. The optimal timing of surgery is not yet settled. Ideally, evidence on this issue should come from a randomised clinical trial. However, such a trial or even a prospective study are unlikely to be ever performed because of the rapid development of endovascular coiling.

[The number of carotid artery operations in the Twente Medical Spectrum before and after the publication of relevant international research on the benefits of the relief of carotid stenosis]. / Het aantal carotisoperaties in het Medisch Spectrum Twente vóór en na de publicatie van belangrijk internationaal onderzoek naar het nut van A.-carotisdesobstructie.

OBJECTIVE: To determine the effect of adequate scientific research on the treatment of extracranial stenosis of the internal carotid artery. DESIGN: Retrospective and comparative. SETTING: Twenty Medical Spectrum, Enschede, the Netherlands. METHOD: A comparison was made of the relevant data from 2 years of carotid artery surgery before (1989-1990; period I) and after the publication of two randomized multicentre studies (1994-1995; period II). RESULTS: The number of patients treated surgically and the number of carotid artery desobstructions had increased during period II by 339% and 319%, respectively. In period I, 25% of the patients had an asymptomatic ipsilateral stenosis of the internal carotid artery; in period II, this had decreased to 11%. In period I, 65% of the patients had a stenosis in excess of 70% of the diameter of the vessel; in period II this was 85%. The combined mortality and permanent disabling morbidity after 30 days was 6% in period I and 3% in period II. CONCLUSION: After the publication of two high-quality studies in 1991, the number of carotid artery operations increased by over 300%. The indications for the surgical treatment of stenosis were stricter rather than less strict in period II. The increase of the number of carotid desobstructions can be explained by the fact that GPs' and neurologists' referral to the vascular surgeon has changed. This change in the referring pattern may be the consequences of use of 'evidence-based' medicine.

MRI locates a posterior fossa aneurysm in the fourth ventricle.

We report a rare case of a ruptured aneurysm of the choroidal branch of the left posterior inferior cerebellar artery (PICA) located in the fourth ventricle. Digital subtraction angiography revealed this PICA aneurysm but the exact location remained unknown. The unique location in the fourth ventricle was subsequently shown by magnetic resonance imaging (MRI). The patient died and the final diagnosis was confirmed by autopsy. To our knowledge, this is one of the few reported cases of a PICA aneurysm in the fourth ventricle and the only one which was confirmed by the combination of MRI and autopsy.

[Clinical judgment and decision making in clinical practice. A music conductor with epilepsy followed by memory disorders]. / Klinisch denken en beslissen in de praktijk. Een dirigent met epilepsie gevolgd door geheugenstoornissen.

A 40-year-old conductor was admitted because of increasing drowsiness and confusion. Two years before admission he had had a first seizure. One year before admission he had a generalized convulsive status epilepticus; the following months he was less able to concentrate. A second status epilepticus was followed by transient weakness of his left arm and a depressed level of consciousness for several weeks. After awakening, he had delusions, and his wife found him demented. In the following months his confusion and drowsiness gradually deteriorated. He had previously had gonorrhoea, an episode of fever and exanthema, and was found to have oligospermia as cause of his infertility. On examination he was disoriented, and he had dysarthria. His left pupil was smaller, but both pupils reacted normally. There was left hemianopia and cerebellar ataxia. CT and MR showed large ventricles and periventricular diffuse lesions in the white matter. CSF examination revealed leucocytosis and increased protein content. Further examination were focussed on serological evidence of syphilis, and finally neurosyphilis was diagnosed. After treatment with penicillin, the patient started to recover.

Noradrenaline concentrations and electrocardiographic abnormalities after aneurysmal subarachnoid haemorrhage.

Serial ECGs and serial assessment of plasma noradrenaline concentrations were carried out in 37 consecutive patients with aneurysmal subarachnoid haemorrhage and 18 operated controls. Electrocardiographic abnormalities reflecting possible signs of cardiac ischaemia occurred significantly more often in patients than in controls. By contrast, plasma noradrenaline concentrations were much higher in controls than in patients. Plasma noradrenaline concentrations were higher in patients with poor outcome, particularly after the third day, but showed covariance with established predictors of outcome such as the Glasgow coma scale score on admission, the amount of extravasated blood on the initial CT, and age. In conclusion, high plasma noradrenaline concentrations do not explain the occurrence of electrocardiographic abnormalities, and are not useful as independent predictors of poor outcome or secondary complications.

Amount of blood on computed tomography as an independent predictor after aneurysm rupture.

BACKGROUND AND PURPOSE: After admission to the hospital of patients with aneurysmal subarachnoid hemorrhage, we assessed the predictive value of the extent of the hemorrhage on computed tomography in addition to that of clinical grading scales for poor outcome, infarction, and rebleeding. METHODS: We studied 471 consecutive patients with aneurysmal subarachnoid hemorrhage and used logistic regression with step-wise forward selection of variables. RESULTS: On admission, poor outcome was predicted by a low Glasgow Coma Scale score (odds ratio, 0.8; 95% confidence interval, 0.7-0.9); treatment with fluid restriction (2.5; 1.6-4.0); age over 52 (2.6; 1.7-3.9); loss of consciousness at ictus (1.7; 1.1-2.6); or a large amount of subarachnoid blood (2.0; 1.3-3.1). Delayed infarction was predicted by a large amount of subarachnoid blood (1.8; 1.2-2.6) or treatment with tranexamic acid (1.6; 1.1-2.4). Rebleeding was predicted by treatment with tranexamic acid (0.4; 0.3-0.7; protective effect); age over 52 (1.9; 1.2-3.0); loss of consciousness at ictus (1.7; 1.1-2.7); or admission to a neurosurgery service (0.6; 0.3-0.9; protective effect). Comparison of the observed and predicted outcome events showed that inclusion of the amount of subarachnoid blood into a predictive model added little to the prediction of poor outcome in general, but much to the prediction of delayed cerebral ischemia. CONCLUSIONS: The total amount of subarachnoid blood on the initial computed tomogram has independent predictive power for the occurrence of delayed cerebral ischemia.

[Doctor's delay in HIV infection caused by blood transfusion]. / 'Doctor's delay' bij infectie met HIV door bloedtransfusie.

Transfusion-associated symptomatic HIV infection in four patients led to death in two patients and to development of serious neurological sequelae in a third patient who also transmitted HIV infection to his spouse. The tardy diagnosis of HIV-associated disease in all cases can be ascribed to ignoring the earlier blood transfusion as a possible cause of HIV infection. This was due partly to advanced age of the patients and partly to lack of familiarity of the attending physicians with HIV-associated problems. This resulted in a substantial doctor's delay.

Infarction after aneurysm rupture does not depend on distribution or clearance rate of blood.

BACKGROUND AND PURPOSE: We sought to determine the contribution of the amount, distribution, and clearance rate of extravasated blood in relation to occurrence of infarction and outcome in patients with aneurysmal subarachnoid hemorrhage. METHODS: We prospectively studied 59 consecutive patients with aneurysmal subarachnoid hemorrhage admitted within 72 hours by means of serial computed tomographic scanning, close clinical observation, and assessment of outcome after 3 months. RESULTS: Infarction occurred in 17 of the 59 patients. The arterial territories involved hardly reflected the distribution of subarachnoid blood in the basal cisterns on computed tomography, and even the side of the infarcts corresponded only weakly with the side on which most extravasated blood was seen. Infarction occurred twice as often in patients with large amounts of subarachnoid blood; this difference was not significant on its own but is in agreement with previous studies. A low clearance rate of cisternal blood was not related to the occurrence of infarction; a relation between clearance rate and poor outcome was largely explained by the amount of subarachnoid blood on the initial computed tomogram and by a low Glasgow Coma Scale score on admission. CONCLUSIONS: The fact that infarction is related to the total amount but not to the distribution or clearance rate of extravasated blood argues against a direct role of extravasated blood and in favor of systemic factors, dependent on the severity of the initial hemorrhage.

The clinical course of perimesencephalic nonaneurysmal subarachnoid hemorrhage.

We studied the early clinical course of 65 patients with perimesencephalic (nonaneurysmal) subarachnoid hemorrhage. None of the patients rebled; none had delayed cerebral ischemia; and only 3 patients (5%) developed clinical signs of acute hydrocephalus, 2 requiring ventricular shunting. Hyponatremia and electrocardiographic changes were found in the same proportions as in patients with aneurysmal rupture. All patients had a good outcome after 3 months. To control for the influence of the relatively small amount of cisternal blood in perimesencephalic hemorrhage on the absence of delayed cerebral ischemia, we compared these 65 patients with 49 patients who had aneurysmal subarachnoid hemorrhage. This control group with aneurysms was selected according to a similar amount of cisternal blood, a comparable level of consciousness on admission, and absence of other factors known to increase the risk for delayed cerebral ischemia. We found that 4 of the 49 patients with aneurysmal hemorrhage developed delayed cerebral ischemia (Fisher's exact test, p = 0.03); therefore the relatively small amount of blood does not account for the absence of delayed cerebral ischemia in perimesencephalic hemorrhage. Patients with a perimesencephalic pattern of hemorrhage and a normal angiogram should be considered to have a distinct subset of subarachnoid hemorrhage and should be excluded from future treatment trials of patients with subarachnoid hemorrhage.

Grading the amount of blood on computed tomograms after subarachnoid hemorrhage.

According to several studies, the amount of subarachnoid blood on the initial computed tomogram of patients with aneurysmal subarachnoid hemorrhage has predictive value with respect to infarction and outcome. Of several methods for assessing the amount of subarachnoid blood, none has been subjected to a study of interobserver agreement. We describe our own method, applied in previous studies, in which the amounts of blood in 10 basal cisterns and fissures and in four ventricles are graded separately. In grading single computed tomograms of 182 consecutive patients with subarachnoid hemorrhage, the agreement between pairs of three observers, studied with kappa statistics, was relatively good for individual cisterns or fissures (kappa between 0.35 and 0.65) and ventricles (kappa between 0.47 and 0.74). The Spearman rank correlation coefficients for the sum of the scores for subarachnoid and intraventricular blood were very high. Summed scores for extravasated blood are suitable as a baseline variable in follow-up studies of patients with subarachnoid hemorrhage.

Transcranial pulsed Doppler measurements of blood flow velocity in the middle cerebral artery: reference values at rest and during hyperventilation in healthy children and adolescents in relation to age and sex.

Transcranial pulsed Doppler (TCD) measurement of blood flow velocity in the middle cerebral artery was performed in 76 healthy children and adolescents (age 2-19 years), to obtain normative reference data, both at rest and during hyperventilation (from 10 years on). The Mean Flow Velocity (MFV) decreased with increasing age. Girls of 10 years or older showed a tendency for higher MFV values than boys of the same age. In combination with a previous study, this suggests that females in their reproductive years have higher maximal MFV values than males. The MFV values, during hyperventilation, were higher in girls than in boys. This gender difference, as in adults, disappeared gradually at lower levels of pCO2. At the lowest pCO2 levels, systolic minus diastolic blood flow velocity was more sensitive to vascular changes than MFV. With TCD measurements, age, sex, and pCO2 have to be taken into account, for a correct interpretation of the data obtained.