Depressive Symptoms After Ischemic Stroke: Population-Based Comparisons of Patients and Caregivers With Matched Controls.

Background and Purpose- Persistent depression after ischemic stroke is common in stroke survivors and may be even higher in family caregivers, but few studies have examined depressive symptom levels and their predictors in patient and caregiver groups simultaneously. Methods- Stroke survivors and their family caregivers (205 dyads) were enrolled from the national REGARDS study (Reasons for Geographic and Racial Differences in Stroke) into the CARES study (Caring for Adults Recovering from the Effects of Stroke) ≈9 months after a first-time ischemic stroke. Demographically matched stroke-free dyads (N=205) were also enrolled. Participants were interviewed by telephone, and depressive symptoms were assessed with the 20-item Center for Epidemiological Studies-Depression scale. Results- Significant elevations in depressive symptoms (Ps<0.03) were observed for stroke survivors (M=8.38) and for their family caregivers (M=6.42) relative to their matched controls (Ms=5.18 and 4.62, respectively). Stroke survivors reported more symptoms of depression than their caregivers (P=0.008). No race or sex differences were found, but differential prediction of depressive symptom levels was found across patients and caregivers. Younger age and having an older caregiver were associated with more depressive symptoms in stroke survivors while being a spouse caregiver and reporting fewer positive aspects of caregiving were associated with more depressive symptoms in caregivers. The percentage of caregivers at risk for clinically significant depression was lower in this population-based sample (12%) than in previous studies of caregivers from convenience or clinical samples. Conclusions- High depressive symptom levels are common 9 months after first-time ischemic strokes for stroke survivors and family caregivers, but rates of depressive symptoms at risk for clinical depression were lower for caregivers than previously reported. Predictors of depression differ for patients and caregivers, and standards of care should incorporate family caregiving factors.

Resilience among stroke survivors: A cohort study of the first 6 months.

AIMS: To explore (a) resilience among patients over the first 6 months following a first ischaemic stroke; (b) factors associated with resilience at hospitalization, 1, 3, and 6 months postdischarge; (c) baseline predictors of resilience at 6 months postdischarge. DESIGN: a cohort study. METHODS: From February 2017-January 2018, 217 patients presenting at two hospitals with a first ischaemic stroke were recruited. Their resilience, medical coping styles, general self-efficacy, functional independency, socio-demographic, and clinical data were assessed while they were still in hospital (baseline) and at 1, 3, and 6 months after discharge. RESULTS: Resilience among stroke patients decreased significantly 1 month after hospital discharge and remained stable. Predictors of resilience were as follows: self-efficacy and resignation at baseline; number of children, functional independency, general self-efficacy, and resignation at 1 month; and religion, resignation, self-efficacy, confrontation at 3 months and 6 months. The baseline factors that predicted resilience at 6 months were income level, religion, stroke severity at discharge, self-efficacy, and resignation. CONCLUSION: Stroke survivors experienced a significant decrease in resilience from hospitalization until 1-month postdischarge. Factors contributing to resilience after a stroke varied across time. Self-efficacy and coping styles were particularly important and contributed to long-term resilience. IMPACT: Understanding resilience among stroke survivors is needed to inform the development of interventions to enhance the psychological recovery of survivors. The levels of resilience among stroke survivors were low compared with those in the normal older population. Nurses should provide greater psychological support during hospitalization to stroke survivors and especially to those with lower income, higher stroke severity at discharge, no religion, lower self-efficacy, or who use resignation as a coping strategy as those survivors may have lower resilience 6 months later. Future studies are needed to test interventions designed to change or modify stroke survivors' coping styles and promote self-efficacy, thereby enhancing higher resilience.

Effectiveness of an Interdisciplinary, Nurse Driven In-Hospital Code Stroke Protocol on In-Patient Ischemic Stroke Recognition and Management.

BACKGROUND: In-hospital strokes account for up to nearly 1 in 5 strokes. Clinical outcomes, such as length of stay, disability, and mortality are worse for in-hospital strokes than for those that occur in the community. For a variety of reasons, stroke can be more difficult to recognize and treat in hospitalized patients. Earlier recognition of stroke results in better clinical outcomes, presumably due to faster diagnosis and subsequently, prompt treatment. METHODS: This investigation was a retrospective, interrupted time series, observational study of all in-hospital stroke patients between 2008 and 2017. This investigation was a quality improvement project, and a waiver was granted from the institutional review board. We used Lean methodologies to standardize our stroke protocol and optimize skill-task alignment to improve the time from onset of symptoms to brain imaging (primary outcome). RESULTS: Overall, we observed significant improvement in the time from onset of symptoms to brain imaging from a median of 69 minutes to 37 minutes (P = .002). CONCLUSIONS: If successfully implemented, this approach may be useful in other care settings with potential to improve stroke outcomes, and decrease associated complications of stroke.

Baseline feature of a randomized trial assessing the effects of disease management programs for the prevention of recurrent ischemic stroke.

BACKGROUND: Comprehensive and long-term patient education programs designed to improve self-management can help patients better manage their medical condition. Using disease management programs (DMPs) that were created for each of the risk factor according to clinical practice guidelines, we evaluate their influence on the prevention of stroke recurrence. METHODS: This is a randomized study conducted with ischemic stroke patients within 1 year from their onset. Subjects in the intervention group received a 6-month DMPs that included self-management education provided by a nurse along with support in collaboration with the primary care physician. Those in the usual care group received ordinary outpatient care. The primary end point is a difference of the Framingham risk score-general cardiovascular disease 10-year risk [corrected]. Patients were enrolled for 2 years with plans for a 2-year follow-up after the 6-month education period (total of 30 months). RESULTS: A total of 321 eligible subjects (average age, 67.3 years; females, 96 [29.9%]), including 21 subjects (6.5%) with transient ischemic attack, were enrolled in this study. Regarding risk factors for stroke, 260 subjects (81.0%) had hypertension, 249 subjects (77.6%) had dyslipidemia, 102 subjects (31.8%) had diabetes mellitus, 47 subjects (14.6%) had atrial fibrillation, and 98 subjects (30.5%) had chronic kidney disease. There were no significant differences between the 2 groups with respect to subject characteristics. CONCLUSIONS: This article describes the rationale, design, and baseline features of a randomized controlled trial that aimed to assess the effects of DMPs for the secondary prevention of stroke. Subject follow-up is in progress and will end in 2015.

Acute ischemic stroke and hyperglycemia.

To increase the comprehension about the profound effects of hyperglycemia within the first 48 hours poststroke on the outcomes of acute ischemic stroke, the authors reviewed multiple studies and literature reviews. Research supports the detrimental effects of hyperglycemia on the morbidity and mortality of patients diagnosed with acute ischemic stroke. The studies that were examined revealed that although further research is necessary, controlling hyperglycemia is overall beneficial to support superior clinical outcomes. The purpose of this article was to discuss the importance of not only glucose control but also the vital role of nurses in controlling glucose levels efficiently and immediately during the first 48 hours poststroke.

The lived experiences of nurses in one hyper-acute stroke unit.

Hyper-acute stroke units (HASUs) admit all stroke patients across London. As a novel London stroke model, the integration of thrombolysis in acute ischaemic stroke is an important element of hyper-acute stroke care for patients. In this model, nurses working in a hyper-acute stroke unit are involved in the delivery of thrombolysis treatment. By use of a phenomenological approach, the study investigates the 'lived experiences' of nurses' preparation for their role and explores any factors that affect nurses' participation in thrombolysis treatment. The nurses' roles-which facilitate, support, monitor, anticipate and result in prevention-are central to effective thrombolysis treatment. However, factors such as communication, teamwork, clinical decision, training, staffing and safety affect their thrombolysis roles. Addressing factors that affect nurses' thrombolysis roles could lead to improved communication, collaborative teamwork and better patient outcomes.

Satisfaction with palliative care after stroke: a prospective cohort study.

BACKGROUND AND PURPOSE: The determinants of satisfaction for families of acute stroke patients receiving palliative care have not been extensively studied. We surveyed families to determine how they perceived palliative care after stroke. METHODS: Families of patients palliated after ischemic stroke, intracerebral, or subarachnoid hemorrhage were approached. Four weeks after the patient's death, families were administered the After-Death Bereaved Family Member Interview to determine satisfaction with the care provided. RESULTS: Fifteen families participated. Families were most satisfied with participation in decision making and least satisfied with attention to emotional needs. In stroke-specific domains, families had less satisfaction with artificial feeding, hydration, and communication. Overall satisfaction was high (9.04 out of 10). CONCLUSIONS: Families of patients receiving palliative care at our institution showed generally high satisfaction with palliation after stroke; specific domains were identified for improvement. Further study in larger populations is required.

Home time is extended in patients with ischemic stroke who receive thrombolytic therapy: a validation study of home time as an outcome measure.

BACKGROUND AND PURPOSE: "Home time" (HT) refers to the number of days over the first 90 after stroke onset that a patient spends residing in their own home or a relative's home versus any institutional care. It is an accessible and objective parameter, free from subjective bias, with potential as an outcome measure in acute stroke trials. We sought to validate HT and assess treatment responsiveness using independent data. METHODS: We estimated HT in the Stroke Acute Ischemic NXY Treatment (SAINT) I neuroprotection trial. We compared outcomes between thrombolyzed (T) and nonthrombolyzed comparators (C) using HT and the modified Rankin Scale. For our primary analysis, we adjusted for baseline covariates that significantly influence HT and in sensitivity analyses considered all variables that differed between groups at baseline. We report ordinal logistic regression and analysis of covariance with 95% CIs. We describe the relationship of HT with baseline National Institutes of Health Stroke Scale and its components and with Day 90 modified Rankin Scale and Barthel Index. RESULTS: SAINT I included 1699 patients from 23 countries, of whom 28.7% received alteplase. HT correlated with age, baseline severity, alteplase use, side of ischemic lesion, presence of diabetes, and country of patient enrollment (each P<0.05). We found an association between use of alteplase with better adjusted outcomes by either measure (OR for extended HT, 1.36; 95% CI, 1.08 to 1.72; P=0.009; analysis of covariance P=0.007 with a 5.5-day advantage; OR for more favorable modified Rankin Scale, 1.6; 95% CI, 1.28 to 2.00; P<0.0001; Cochran-Mantel-Haenszel P=0.046). HT was significantly associated with baseline National Institutes of Health Stroke Scale and each component of the National Institutes of Health Stroke Scale except level of consciousness, dysarthria, and ataxia. HT was significantly associated with Day 90 modified Rankin Scale and Barthel Index. CONCLUSIONS: HT is a responsive measure for use in multinational acute stroke trials. Its inclusion as a complementary outcome is reasonable. We propose treatment effects are adjusted for age, baseline National Institutes of Health Stroke Scale, side of stroke lesion, country of enrollment, and the presence of diabetes.

Effectiveness of Rehabilitation Nursing versus Usual Therapist-Led Treatment in Patients with Acute Ischemic Stroke: A Randomized Non-Inferiority Trial.

PURPOSE: To determine the effectiveness of rehabilitation nursing program interventions in patients with acute ischemic stroke. PATIENTS AND METHODS: An assessment-blinded randomized controlled trial was conducted at a tertiary referral hospital in China. Eligible patients were stratified according to their weighted corticospinal tract lesion load and then randomly assigned to an experimental group (n = 121) or a control group (n = 103). The experimental group received rehabilitation nursing from well-trained, qualified nurses (30 minutes per session, two sessions per day for seven consecutive days). The control group received therapist-led rehabilitation with the same timing and frequency. Comparative analysis of the primary outcomes was performed to determine non-inferiority with a predetermined non-inferiority margin. The primary outcomes were the Motor Assessment Scale, Fugl-Meyer Assessment, and the Action Research Arm Test assessed at baseline and after seven days of treatment. The secondary outcomes were the modified Barthel Index, the National Institutes of Health Stroke Scale, and the modified Rankin Scale, evaluated before and after the intervention and at 4 and 12 weeks of follow-up. RESULTS: Two hundred participants completed the trial. In both groups, all outcomes improved significantly after seven days and at follow-ups. The rehabilitation nursing program was non-inferior to therapist-led treatment with lower 95% confidence limits beyond the margins for primary outcomes (P < 0.001). CONCLUSION: Both treatments had comparable effects; however, no definite conclusion could be drawn. Adequately powered studies are required.

Stroke unit care in a real-life setting: can results from randomized controlled trials be translated into every-day clinical practice? An observational study of hospital data in a large Australian population.

BACKGROUND AND PURPOSE: In randomized trials, acute stroke units are associated with improved patient outcomes. However, it is unclear whether this evidence can be successfully translated into routine clinical practice. We aimed to determine the effect of a coordinated rollout of funding for 22 stroke units on patient outcomes in Australia. METHODS: A multicenter observational study was undertaken using health administrative data recording admissions for a primary diagnosis of ischemic stroke from July 2000 to June 2006. Analyses were stratified by hospital type (major principal referral, smaller nonprincipal referral hospitals). RESULTS: We analyzed 17 659 admissions for ischemic stroke. Among major principal referral hospitals with acute stroke units, the proportion of admissions resulting in death or discharge to home was unchanged after stroke unit rollout (10.7% vs 10.6% and 44.1% vs 45.0%, respectively; P=0.37). In contrast, significant differences in discharge destination were noted across time among smaller nonprincipal referral hospitals (P<0.001). Before the rollout of stroke units, 13.8% of admissions to smaller hospitals resulted in a death, decreasing to 10.5% after stroke units were implemented. Discharges to home increased from 38.8% to 44.5%. Discharges to nursing homes decreased from 6.3% to 4.9%. Differences across time remained significant when controlling for patient demographics, comorbidities, indicators of poor prognosis, and clustering of outcomes at hospital level. Improved outcomes were observed across all ages and among patients with indicators for a poor prognosis. CONCLUSIONS: This multicenter analysis of a large Australian population of hospital stroke admissions demonstrates short-term benefits from implementing stroke units in nonprincipal referral hospitals.

Cost-effectiveness of stroke unit care followed by early supported discharge.

BACKGROUND AND PURPOSE: Stroke places a significant burden on the economy in England and Wales with the overall societal costs estimated at pound7 billion per annum. There is evidence that both stroke units (SUs) and early supported discharge (ESD) are effective in treating patients with stroke. This study assesses the cost-effectiveness of the combination of these 2 strategies and compares it with the care provided in SU without ESD and in a general medical ward without ESD. The objective of this study was to model the long-term (10 years) cost-effectiveness of SU care followed by ESD. METHODS: The study design was cost-effectiveness modeling. The study took place in SUs in the coverage area of the South London Stroke Register, UK. The modeled population was incident ischemic stroke cases (N=844) observed between 2001 and 2006. SU care followed by ESD was compared with SU care without ESD and general medical ward care without ESD. Main outcome measures were health service and societal costs and cost per quality-adjusted life-year gained. RESULTS: Using the cost-effectiveness threshold of pound30000, as commonly used in the UK, SU care followed by ESD is the cost-effective strategy compared with the other 2 options. The incremental cost-effectiveness ratio of SU care followed by ESD is pound10661 compared with the general medical ward without ESD care and pound17721 compared with the SU without ESD. CONCLUSIONS: SU care followed by ESD is both an effective and a cost-effective strategy with the main gains in years of life saved.

Do all age groups benefit from organized inpatient stroke care?

BACKGROUND AND PURPOSE: Organized inpatient stroke care consists of a multidisciplinary approach aimed at improving stroke outcomes. It is unclear whether elderly individuals benefit from these interventions to the same extent as younger patients. We sought to determine whether the reduction in mortality or institutionalization seen with organized stroke care was similar across all age groups. METHODS: This was a case-cohort study of patients with acute ischemic stroke seen between July 2003 and March 2005 and captured in the Registry of the Canadian Stroke Network. After stratifying by age category, we assessed for evidence of effect modification by age on the reduction in stroke fatality associated with stroke unit/organized care. RESULTS: Among 3631 patients with ischemic stroke, stroke case-fatality at 30 days was lower for patients admitted to a stroke unit compared with those admitted to general medical wards (10.2% versus 14.8%; P<0.0001 with an absolute risk reduction=4.6%, number needed to treat=22). All age groups achieved a similar benefit of stroke unit care versus general medical ward care (absolute risk reduction for 30-day stroke fatality was 4.5% for <60 years; 3.4% for 60 to 69 years; 5.3% for 70 to 79 years; and 5.5% for those >80 years). Increasing levels of organized care were associated with lower stroke fatality or institutionalization. The beneficial effect of stroke units/organized care on survival was seen even after adjustment for multiple prognostic factors and after excluding patients on palliative approach. There was no evidence of effect modification by age in any analyses. CONCLUSIONS: Stroke units and organized inpatient care reduce death or institutionalization with the same magnitude of effect across all age groups.

Acute Ischemic Stroke.

Acute ischemic stroke is a major cause of mortality and morbidity in the United States and worldwide. Despite the development of specialized stroke centers, mortality and morbidity as a result of acute ischemic strokes can and do happen anywhere. These strokes are emergency situations requiring immediate intervention. This article covers the fundamentals of care involved in treating patients with acute ischemic stroke, including essentials for the initial evaluation, basic neuroimaging, reperfusion therapies, critical care management, and palliative care, as well as current controversies. National guidelines and current research are presented, along with recommendations for implementation.

Low-Molecular-Weight Heparin or Heparinoids vs. Unfractionated Heparin in Acute Ischemic Stroke.

Editor's note: This is a summary of a nursing care-related systematic review from the Cochrane Library. For more information, see http://nursingcare.cochrane.org.

Weekends: a dangerous time for having a stroke?

BACKGROUND AND PURPOSE: Weekend admissions are associated with higher in-hospital mortality. However, limited information is available concerning the "weekend effect" on stroke mortality. Our aim was to evaluate the impact of weekend admissions on stroke mortality in different settings. METHODS: We analyzed all hospital admissions for ischemic stroke from April 2003 to March 2004 through the Hospital Morbidity Database. The Hospital Morbidity Database is a national database that contains patient-level sociodemographic, diagnostic, procedural, and administrative information including all acute care facilities across Canada. The major inclusion criterion was admission to an acute care facility with a principal diagnosis of ischemic stroke. Clinical variables and facility characteristics were included in the analysis. RESULTS: Overall, 26,676 patients were admitted to 606 hospitals for ischemic stroke. Weekend admissions comprised 6629 (24.8%) of all admissions. Seven-day stroke mortality was 7.6%. Weekend admissions were associated with a higher stroke mortality than weekday admissions (8.5% vs 7.4%; odds ratio, 1.17; 95% CI, 1.06 to 1.29). Mortality was similarly affected among patients admitted to rural versus urban hospitals or when the most responsible physician was a general practitioner versus specialist. In the multivariable analysis, weekend admissions were associated with higher early mortality (odds ratio, 1.14; 95% CI, 1.02 to 1.26) after adjusting for age, sex, comorbidities, and medical complications. CONCLUSIONS: Stroke patients admitted on weekends had a higher risk-adjusted mortality than did patients admitted on weekdays. Disparities in resources, expertise, and healthcare providers working during weekends may explain the observed differences in weekend mortality.

Feasibility of acute clinical trials during aerial interhospital transfer.

BACKGROUND AND PURPOSE: In rural America, patients are often first seen at a small community hospital and then transferred to a tertiary care center by helicopter for further care. If acute clinical research were feasible during the aerial interhospital transport, more patients might be enrolled in trials at a critical earlier stage. METHODS: Prospective data were collected for all aerial transfers of a university-based helicopter service from April 2005 to January 2006. Flight nurses were educated about stroke research and offered certification and participation. Data collected included patient characteristics and the availability of relatives to provide surrogate consent. RESULTS: All 12 flight nurses completed the institutional review board certification requirements and collected data on 215 transfers. Sixty-one patients had acute stroke or myocardial events (MIs). The median time from symptom onset to helicopter arrival at an outside hospital was 213 minutes (range, 90 to 2135) for ischemic stroke (n=12), 186 (45 to 1332) for intracranial hemorrhage (n=28), and 157 (47 to 1044) for MI (n=21). A relative was available in >74% of those transfers. A trial with a 4-hour window would permit enrollment of 67% of the ischemic strokes, 82% of intracranial hemorrhage cases, and 76% of MI patients. CONCLUSIONS: Clinical trials are feasible during aerial interhospital transport of patients. Flight nurses became successful investigators in clinical research and were exposed to potentially eligible patients with the ability to consent either directly or through surrogates. This approach could improve current clinical trial recruitment in rural areas, as well as permit testing of inflight ancillary interventions to improve outcome during patient transport.

Temporal Profiles of Cerebral Perfusion Pressure After Subarachnoid Hemorrhage.

INTRODUCTION: Insufficient cerebral perfusion pressure (CPP) after aneurysmal subarachnoid hemorrhage can impair cerebral blood flow. We examined the temporal profiles of CPP change and tested whether these profiles were associated with delayed cerebral ischemia (DCI). METHOD: CPP values were retrospectively reviewed for 238 subjects. Intracranial pressure and mean arterial pressure values were obtained every 2 hours for 14 days. Induced hypertension was utilized to prevent vasospasm. The linear and quadratic CPP changes over time were tested using growth curve analysis. Multivariable logistic regression was utilized to examine the association between DCI and percentages of CPP values of >110, >100, <70, and <60 mm Hg. DCI was defined as neurological deterioration because of impaired cerebral blood flow. RESULTS: Between-subject differences accounted for 39% of variation in CPP values. There was a significant linear increase in CPP values over time (ß = 0.06, SE = 0.006, p < .001). The covariance (-0.52, SE = 0.09, p < .001) between initial CPP and linear parameter was negative, indicating that subjects with high CPP on admission had a slower rate of increase whereas those with low CPP had a faster rate of increase. For every 10% increase in the proportion of CPP of >100 or >110 mm Hg, the odds of DCI increased by 1.21 and 1.43, respectively (p < .05). CONCLUSIONS: The longer the time patients spent with high CPP, the greater the odds for DCI. When used prophylactically, induced hypertension contributes to higher CPP values. On the basis of the CPP trends and correlations observed, induced hypertension may not confer expected benefits in patients with aneurysmal subarachnoid hemorrhage.