Efficacy of a new post-processing method for CT perfusion exams assessing acute stroke
N Ardley,1 K Lau,1 K Buchan2
1Southern Health, Diagnostic Imaging, Clayton, VIC, Australia, 2Philips Healthcare, Clinical Science, North Ryde, NSW, Australia
Background: CT brain (CTB), CT perfusion (CTP) and CT angiography (CTA) of brain and neck are critical tools for acute stroke assessment. Post processing (PP) for CTP is traditionally time consuming. This study evaluated the impact PP tools had on workups times of CTP by utilising new semi-automated algorithms and advanced image reconstruction.
Methods: Acute stroke assessment includes CTB, CTP and CTA of the brain and neck with dedicated PP of the CTP. The sample included 90 consecutive exams on patients that presented to the emergency department for assessment of acute stroke. The initial 45 exams used traditional PP workflow whilst the latter 45 exams utilised the new PP tools. All CTP workups included generation of cerebral blood volume, cerebral blood flow, mean transit time and time to peak maps. Data mining from the picture archiving and communication system (PACS) enabled quantification of CTP workup times by recording the time between scan end and last CTP PP image arriving at PACS for each exam. Comparative analysis was made between both methods of PP for the CTP workup time.
Results: Average traditional CTP PP workup time = 24.98 minutes Average CTP PP workup time using the new PP tools = 14 minutes. Average total PP time for CTP workup improved by 10.98 minutes (44%).
Conclusion: CTP images using the new PP tools were ready for review 44% faster than traditional PP methods. New PP tools have potential for expediting patient management decisions.
Reliability of the 12-step ascend and descend test and its correlation with motor functions in people with chronic stroke
S Ng, H Ng, K Chan, J Lai, A To, C Yeung
Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong (SAR), China
Background: Stair walking has been rated as the most difficult and troubling daily motor activity for stroke survivors. It is also considered the best predictor of free-living physical activity for community-dwelling people with stroke. Improving stair walking ability is a crucial element in stroke rehabilitation.
Aims: The objectives of this study is to investigate (1) the intra-rater, inter-rater and test-retest reliability of the 12-step stair test; (2) its correlation with other stroke-specific impairments.
Methods: It was a cross-sectional study with 35 with subjects chronic stroke. The 12-step ascend and descend test was administered along with the Fugl-Meyer Motor Assessment for the lower extremities (FMA-LE), hand-held dynamometer measurements of hip abductor and knee extensor muscle strength, the Five-times Sit to Stand test (FTSTST), assessment using the Berg Balance Scale (BBS), activities-specific balance confidence scale (ABC) assessment, the 10-meter walk test, and the Timed “Up and Go” (TUG) test.
Results: The 12-step ascend and descend test showed excellent intra-rater, inter-rater and test-retest reliability. The test was positively correlated with FTSTS times, gait velocity, and TUG times, and negatively correlated with FMA-LE scores and BBS scores.
Conclusion: The 12-step ascend and descend test is a reliable clinical test which is easy to implement and inexpensive, and is useful for assessing the stair walking ability of patients with chronic stroke.
The Figure of Eight Walk (F8W) test: its reliability and correlations with stroke-specific impairments in patients with chronic stroke
S Ng,1 S Wong,2 M Yam3
1Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China, 2Department of Physiotherapy, Haven of Hope Hospital, Hong Kong, China, 3Department of Physiotherapy, Haven of Hope Community Rehabilitation Day Centre, Haven of Hope Christian Service, Hong Kong, China
Background: Beyond straight-ahead walking, turning ability is required in many situations in daily living such as walking around a table, avoiding obstacles and navigating in the street. 2 The gait characteristics of straight and curved path walking are different. 2, 3 In order to reflect changes in patients' advanced walking performance during the rehabilitation process, a reliable, valid and comprehensive measurement tools involving both straight-path and curved path walking are definitely needed.
Aims: The aims of the study was to investigate: (1) the intra-rater, inter-rater and test-retest reliability of the F8W test times; (2) its correlation with other stroke-specific impairments.
Methods: It was a cross-sectional study with 35 subjects with chronic stroke. The Main outcome measured included: F8W test time times, Fugl-Meyer Motor Assessment for the lower extremities (FMA-LE), hand-held dynamometer measurements of bilateral hip abductor and knee extensor isometric muscle strength, Five-times Sit to Stand test (FTSTST) times, 10-meter walk test (10MWT), Timed up and go test (TUGT) times, Berg Balance Scale (BBS) and Activities-specific balance confidence scale (ABC) scores.
Results: Excellent intra-rater, inter-rater and test-retest reliability (ICC range .944–.999) of F8W test times were found. The F8W test times were also found to be significantly associated with FMA-LE, BBS, FTSTST, TUG scores, and 10MWT. No significant correlation was found between F8W test times and either leg strength or ABC results.
Conclusions: The F8W test time is a reliable and valid measurement tool for assessing the advanced walking performance of subjects with chronic stroke.
How many trials are needed to achieve stable timed up and go test results with chronic stroke patients?
S Ng, K Ng, J Shu
Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong (SAR), China
Background: Although the timed up and go (TUG) test is commonly used as an outcome measure in stroke rehabilitation, the number of trials attempted by the subjects has not been documented clearly. Different numbers of practice trials and timed trials in the TUG test have been adopted in different studies. These procedural differences call for a systematic investigation of the number of trials needed to achieve performance stability in the TUG test when applied to subjects with chronic stroke.
Objectives: To determine the number of trials stroke survivors need to achieve performance stability in the walking unaided and walking with an aid.
Methods: it was a cross-sectional study with 35 community-dwelling elderly with chronic stroke. Six timed trials of the timed up and go test were performed on each subject after a demonstration by the rater. The Wilcoxon Signed Ranks test was used to examine the significance of the differences between times of the six TUG trials, and to determine the number of trails needed to achieve performance stability.
Results: The performance of TUG test has been shown to improve up to and including the 3rd trial.
Conclusion: In order to get valid timed up and go data without putting unnecessary stress to the subjects, particularly subjects with decreased exercise endurance, it is recommended to perform three trials with community-dwelling stroke patients in clinical testing.
Rehabilitation Awareness Week as a tool to assess the awareness of rehabilitation in a developing country
Department of Rehabilitation, John Flynn Private Hospital, Qld, Australia
Background: Rehabilitation is a relatively ‘new’ field in a developing country with limited resources. The first step is to create the awareness amongst healthcare workers for efficient resource allocation and service delivery.
Aim: To assess the level of awareness and knowledge in various aspects of rehabilitation amongst healthcare workers in Malaysia.
Method: A 1-day workshop entitled ‘Rehabilitation Awareness Week’ was organized by the Department of Rehabilitation Medicine, Hospital Sultanah Aminah, Malaysia for five consecutive days. Participants were given 18 true/false statements on stroke rehabilitation, followed by a series of lectures, video presentations and hands-on demonstrations by a multidisciplinary team. Comparisons of the answers were made at the end of the workshop. Suggestions for future topics in rehabilitation were also collated.
Results: A total of 389 healthcare workers attended the workshop. Participants comprised nurses (54.7%), doctors (8.1%), pharmacists (5.0%), therapists (9.0%) and other allied health staff (22.5%). Most participants (97.9%) were aware of general rehabilitation, but few participants understood the ‘signs and symptoms of dysphagia’ (pre test 18.6%, post test 10.0%) and ‘signs of silent aspiration’ (pre test 24.5%, post test 41.2%). Suggestions for further improvement included: similar workshops to be conducted biannually across Malaysia, longer duration of training and more bedside teachings on stroke rehabilitation.
Conclusions: Rehabilitation Awareness Week may be used as a tool to create awareness in rehabilitation and to identify issues least understood by healthcare workers. More education and training should be given to healthcare workers to improve their level of understanding and knowledge in stroke rehabilitation.
Knowledge of dysphagia amongst healthcare workers in Malaysia
I Sabrina,1 R Raphidah,2 M Fatimah2
1Department of Rehabilitation, John Flynn Private Hospital, Qld, Australia, and 2Speech Therapy Unit, Department of Otorhinolaryngology, Hospital Sultanah Aminah, Johor Bahru, Malaysia
Background: Dysphagia is a common complication following a stroke, which could lead to aspiration pneumonia and death.
Aim: To assess the knowledge of dysphagia amongst healthcare workers in Malaysia.
Method: A survey was conducted during a ‘Rehabilitation Awareness Week’ workshop. Participants were given six true/false statements related to dysphagia and aspiration prior to and after a series of lectures, video presentations by speech therapists and a dietician. Comparisons of the answers were made at the end of the workshop.
Results: A total of 389 participants completed the survey. Participants comprised nurses (54.7%), doctors (8.1%), pharmacists (5.0%), therapists (9.0%) and other allied health staff (22.5%). Two-thirds of the participants (pre test 60.3%, post test 63.2%) believed that patients should be allowed to consume food orally as soon as possible. Not many were aware that the absence of coughing or choking while eating did not preclude aspiration (pre test 24.4%, post test 41.2%). Only half knew that recurrent chest infections may be related to dysphagia (pre test 49.9%, post test 87.7%). Although participants were more aware of the signs and symptoms of dysphagia after the workshop (pre test 29.8%, post test 90.0%), some still believed that nasogastric tube feeding can be given in a supine position (pre test 42.0%, post test 54.0%). Most participants were aware of diet modifications in dysphagia (pre test 93.1%, post test 93.9%).
Conclusions: More emphasis and training should be given to heathcare workers in Malaysia to improve their level of understanding and management of dysphagia.
Postural stability affects eye–hand coordination in stroke survivors
W Tsang, S Ng
Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China
Background: Stroke often induces lingering sensory input and motor output (sensori-motor) impairments such as muscle weakness, poor proprioception and impaired upper extremity function. Often, eye–hand coordination and postural stability are also degraded. A better understanding of the relationships among all these sequela promises to help in the design of rehabilitation interventions.
Aims: To investigate eye–hand coordination in stroke survivors while sitting and standing and its relationship with sensori-motor performance.
Methods: A cross-sectional study at university-based rehabilitation center. Fifteen stroke survivors performed a fast finger-pointing task towards a visual target moving at 10 cms-1 from the contra-lateral side towards the moving arm in sitting and standing positions. Reaction time, movement time and pointing accuracy were measured. Antero-posterior, medial-lateral and total sway were also measured during the standing trials. Several sensori-motor impairments were also measured to correlate with the eye–hand coordination performance.
Results: A significantly shorter reaction time was found in the non-paretic than paretic sides in standing, but not in sitting. The movement time of the paretic side was significantly faster in standing when compared to sitting. Fast pointing with the paretic arm significantly increased the total sway path and antero-posterior displacement while standing compared with pointing with the non-paretic arm. Movement time of the paretic arm was negatively correlated with handgrip strength and the strength of the elbow flexors and wrist extensors.
Conclusion: The movement time of eye–hand coordination of stroke survivors was affected by the postural stability. Correlations were found between pointing performance and several sensori-motor impairments.
Hemiplegic shoulder pain incidence in acute stroke
L Marr, L Werner, A Gorelik
Royal Melbourne Hospital, Melbourne, Vic., Australia
Background: Hemiplegic shoulder pain can occur in up to 60% of stroke survivors. Pain can negatively influence outcomes for stroke survivors including decreased function and increased length of stay. The Management Tool for Acute Hemiplegic Shoulder (MTAHS) is an easy to administer risk assessment and management tool for hemiplegic upper limbs.
Aims: Identify the incidence of hemiplegic shoulder pain in acute stroke patients; investigate if a risk assessment score (MTAHS) was predictive for the development of pain; and investigate factors associated with presence of shoulder pain.
Methods: A prospective observational study was conducted for 100 consecutively admitted stroke patients at the Royal Melbourne Hospital's acute stroke unit. The MTAHS risk assessment was completed on admission and discharge as well as other standard outcome measures.
Results: 6% of patients developed pain during their acute admission. Patients who were assessed as high risk on admission using the MTAHS had a significant chance of developing pain, compared to those assessed as low and no risk (p < 0.001). There was a significant association between severity of stroke on the Mobility Scale for Acute Stroke and shoulder pain on discharge (p < 0.001). Length of stay was significantly associated (p < 0.001) with incidence of pain on discharge.
Conclusion: The use of the MTAHS risk assessment tool could assist in identifying which patients need to be targeted by physiotherapists and occupational therapists for ongoing management strategies to prevent development of hemiplegic shoulder pain to minimise the consequences of this as time progresses.
F.A.S.T. notification for stroke thrombolysis
Ambulance Service of New South Wales 1, Rozelle, NSW, Australia
Background: A key element for early thrombolysis for ischaemic stroke patients is the ability to pre notify the thrombolytic centre so the stroke team can be activated and ready to receive the patient on ambulance arrival at the emergency department. Paramedics are being trained in the Face. Arms. Speech. Time (F.A.S.T.), stroke assessment tool inclusive of a pre-notification methodology and it is anticipated that the rate of pre notification will increase as the number of paramedics receive training.
Aims: The aim of this analysis is to establish if the pre notification rate for Stroke (FAST) positive patients has increased in line with an increase of Paramedics trained.
Methods: From July to December 2012, Stroke cases will be identified from Ambulance clinical records and reviewed to determine whether pre – notification of identified Stroke (FAST) positive patients has occurred and in fact increased as the number Paramedics have been completed training.
Results: The data will be compared with the same period in the previous year that has been used as a baseline. The results will be monitored to detect trends in the use of a pre notification methodology.
Conclusion: It is expected that this analysis will demonstrate an improvement in the pre notification rate relative to progressive numbers of paramedics trained in the pre notification methodology and awareness of the stroke reperfusion program comparative to the preceding period and year.
Performance on fast finger-pointing toward a moving target and its correlation with sensori-motor impairment in stroke survivors
K Gao, S Ng, W Tsang
Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China
Background: In daily living, reaching and grasping movements involve moving visual targets. Little is known about the performance of stroke survivors in tasks which involve fast finger-pointing toward a moving target and its relationship with sensori-motor control.
Aims: To investigate eye-hand coordination in stroke survivors and its relationship with sensori-motor impairments and hand functioning in daily life.
Methods: A cross-sectional study at university-based rehabilitation center. Fifteen subjects with stroke (mean age: 62.5 ± 7.1; years post-stroke: 5.2 ± 3.0) recruited by convenience sampling. A fast finger-pointing task towards a moving visual target was employed to investigate the differences between the subjects' affected and unaffected hands in terms of reaction time, movement time and accuracy. Their sensori-motor impairments in tactile sensation, handgrip strength, Fugl-Meyer scores and Jebsen Taylor Hand Function Test scores were measured.
Results: Significant differences were found between the affected and unaffected hands in terms of movement time and accuracy in finger pointing. Movement time was significantly correlated with tactile sensitivity, handgrip strength and total Fugl-Meyer score, while accuracy correlated with tactile sensitivity and total Fugl-Meyer score. Total scores on the hand function test also significantly correlated with reaction time and movement time.
Conclusion: The stroke survivors had poorer eye-hand coordination in terms of slower movement and reduced accuracy when using their affected hand. These performance measures were significantly correlated with several sensori-motor impairments. A significant correlation was also found between the eye-hand coordination performance and hand function test scores.
Outcome comparisons between people with trauma versus non-trauma–related ABI on the MPAI-4 and resource availability and utilisation
R Quinn, M Kendall
Acquired Brain Injury Outreach Service, Metro South Hospital and Health Service, Brisbane, QLD, Australia
Background: Outcome assessment is a core activity which informs the process of assisting people with acquired brain injury across the rehabilitation continuum. The service system for people with traumatic versus non-traumatic brain injury, such as stroke, can be variable.
Aims: To evaluate service system issues and possible improvements through measuring environmental factors such as “resource availability” and “resource utilisation” integrated with a traditional measure of individual function – the MPAI-4.
Method: The sample, clients of the Acquired Brain Injury Rehabilitation Service (ABIOS), included 351 individuals with traumatic and 259 individuals with non-traumatic injuries who completed pre and post MPAI-4 and resource availability/utilisation outcome measures.
Results: There were demographic differences between the two groups and significantly the non-trauma group were less likely to have had specialist inpatient rehabilitation (χ2 = 7.841, p = 0.005). The non-trauma group initially had poorer formal supports to support overall ability, unpaid employment and paid employment but there were no differences at the end of the ABIOS program. The non-trauma group had greater improvements in informal resource availability to support social contacts (p = 0.009) and leisure participation (p = 0.002) over the course of their ABIOS program. There were no other significant differences between non trauma and trauma groups.
Conclusions: Despite demographic differences, individuals with traumatic and non-traumatic brain injury experience improvements during community rehabilitation. However, because individuals with non-traumatic injuries such as stroke are less likely to receive specialist in-patient rehabilitation, this group may be at risk of not receiving step-down community case management services.
Peroneal electrical stimulation: application early following stroke
SS Kuys,1,2 J Clarke,3 C Dilworth,4 M Lynch5
1Griffith Health Institute, Griffith University, Gold Coast, 2Allied Health Research Collaborative, The Prince Charles Hospital, 3St. Andrew's War Memorial Hospital, 4Rural Stroke Outreach Service, 5Australian Catholic University, Brisbane, Qld, Australia
Background: Peroneal nerve electrical stimulation for foot drop following stroke is effective in chronic stroke survivors. New portable devices allowing for early and long duration application are now available. Application early following stroke and clinical utility has received little investigation.
Aims: This study investigated the application of a portable peroneal device early following stroke.
Methods: A comparative pre-post intervention study was conducted of stroke survivors with foot drop following acute onset of stroke. The peroneal electrical stimulation device was applied as early as clinically possible and used at the discretion of the treating physiotherapist. Gait speed, balance and endurance were measured on discharge from hospital.
Results: Fifty-three stroke survivors (58% male, aged 64 SD 12 years) participated in this study. By discharge, participants who used the device walked faster, 0.69 m/s (SD 0.4) compared to 0.49 m/s (SD 0.3), though this was not statistically significant (p = 0.13) and had better balance, Balance Outcome Measure for Elder Rehabilitation score 12 (SD3) versus 9 (SD 4) (p = 0.027). There was no difference in distance walked in 6 minutes, though approximately half of the participants did not complete this.
Conclusion: Peroneal nerve electrical stimulation looks promising early following stroke; though clinicians reported time constraints a limiting factor. Further investigation is required to explore those most likely to benefit, optimal dose and effect on falls.
Electrocardiograph abnormalities in acute stroke patients
S Coote,1 PS Loh,1 A Gilligan,1,2 CF Bladin1,2,3
1Eastern Health, 2The Florey Institute of Neuroscience and Mental Health, 3Monash University, Melbourne, Vic., Australia
Background: Electrocardiography (ECG) is useful for identifying atrial fibrillation (AF) in acute stroke patients, but may also herald previously unknown cardiac disease.
Hypothesis: ECG's, in acute stroke patients, are more commonly abnormal as compared to general neurology patients, and are suggestive of undiagnosed cardiac disease. We sought to explore the rates and types of ECG abnormalities in acute stroke patients compared to general neurology patients, and the cardiac follow up stroke patients received during their admission.
Methods: A retrospective analysis was performed on 114 stroke and 114 general neurology patients for cardiac history, ECG abnormalities and vascular risk factors. Stroke patients were analysed for cardiac follow up, defined as at least one repeat ECG (or echocardiogram) and repeat cardiac enzymes (CE's) during admission. Partial follow up was defined as only one investigation performed.
Results: Stroke patients are older (79 vs. 53 years, p = <0.001,) have more vascular risk factors (hypertension and diabetes, p = <0.05,) and more commonly had ECG abnormalities compared to general neurology patients (67% vs. 27%, p = <0.001.) Of the stroke patients, 37% (n = 28) had an abnormal ECG but no known cardiac history; 89% (n = 102) had partial or no cardiac follow up (including 88% (n = 14) of thrombolysed patients;) and 32% (n = 36) had partial or no follow up, despite raised CE's or ST-elevation on admission.
Discussion: Most of our acute stroke patients had ECG abnormalities on presentation to hospital, and these were much more common than general neurology patients. Despite protocols, many stroke patients, including thrombolysed patients, received incomplete cardiac follow up.
Improving cognitive testing within stroke rehabilitation: what can patient narratives tell us about the experience?
L Baglow, L Davis, C Shapter
Caloundra Hospital, Caloundra, Qld, Australia
Background: This research arose from clinical observations of stroke survivors during treatment by a community rehabilitation team. During the social work assessment interview a significant number of patients mentioned stress caused by the administration of standard cognitive testing during rehabilitation. A comprehensive search of the literature could find no research studies that directly addressed the question of adverse emotional reactions by stroke survivors to standard cognitive testing.
Aim: The aim of this research is to better understand stroke patients' emotional reactions to cognitive testing during rehabilitation so as to improve rehabilitation practice.
Methods: Ten patients with left sided strokes who attended the Community Rehabilitation Team program and who in the course of their therapy were assessed by an Occupational Therapist using the Cognitive Assessment of Minnesota or by a Speech Pathologist using the Mt Wilga screening test were assessed within 72 hours by a Social Worker using the standard initial social work assessment/therapy interview, embedded in which was a mini interview which drew out particular reactions to the earlier cognitive testing. The interviews were audio taped, transcribed and the data assessed using a qualitative descriptive method.
Discussion: Every patient reported stress during the testing, some a little and some a great deal. The relationship with the therapist ameliorated the level of stress, as did prior experience of cognitive testing. The patient explanations for the testing were not consistent with the reasons given by the therapists. The importance of patients having some power/control came across strongly in a number of interviews.
Using FAST-Mag protocol with or without mild hypothermia (35°C) does not improve outcome after permanent MCAO In rats
BP Meloni, JL Cross, LM Brookes, VW Clark, K Campbell, NW Knuckey
Centre for Neuromuscular and Neurological Disorders/University of Western Australia, Australian Neuro-Muscular Research Institute and Department of Neurosurgery, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
Background and Aim: We aimed to determine the post-stroke neuroprotective efficacy of magnesium using a FAST-Mag trial treatment protocol alone and in combination with mild hypothermia in a rat permanent focal cerebral ischaemia stroke model.
Methods: Sprague Dawley rats were subjected to permanent intraluminal thread middle cerebral artery occlusion (MCAO). Treatment with magnesium (MgSO4.7H2O) consisted of an intravenous loading dose (LD: 360 μmol/kg) and a 24 hour infusion (120 μmol/kg/h), while mild hypothermia at 35°C was maintained for 24 hours. Treatment groups consisted of animals receiving: (i) saline; (ii) magnesium LD/infusion at 1.5 h/2.5 h post-MCAO; (iii) magnesium LD/infusion at 1.5 h/2.5 h post-MCAO and hypothermia commencing at 2.5 h post-MCAO; (iv) magnesium LD and hypothermia at 1.5 h and magnesium infusion at 2.5 h post-MCAO; (v) hypothermia commencing at 1.5 h post-MCAO and magnesium LD/infusion at 2.5 h post-MCAO; (vi) hypothermia commencing at 1.5 h post-MCAO; and (vii) hypothermia commencing at 2.5 h post-MCAO. Infarct volume was measured 48 hours after MCAO.
Results and conclusion: No treatment significantly reduced infarct volume. These findings indicate that magnesium treatment using FAST-Mag conditions alone and with mild hypothermia is unlikely to benefit ischaemic stroke caused by permanent occlusion.
A pilot study to improve the management of oral medications when patients have restrictions on oral intake
TP To, K Owen, MC Holmes, DA Matalanis, A Story, A Hardidge, H Dewey
Austin Health, Heidelberg, Vic., Australia
Background: Evidence suggests that patients with restrictions on oral intake are more susceptible to having their medications inappropriately interrupted and to medication-related errors.
Aims: To develop and pilot a policy for the management of oral medications when patients have restrictions on oral intake.
Methods: The ‘Medications & Oral Restrictions’ policy was developed in consultation with stakeholders. Key messages included the:
- Harm associated with interrupting patients‘ regular medications – this should be avoided where possible
- Consideration of alternative routes of medication administration when patients are nil by mouth
- Consideration of other preparations of medications when patients have dysphagia
The pilot was implemented on the stroke ward in October 2012 and included discussions of the policy at unit/departmental meetings, nursing in services and at handover. Medication administration data was collected retrospectively on 40 consecutive stroke patients, per month, for December/January 2011/12 (pre-intervention) and December/January 2012/13 (post-intervention). Feedback from staff was also sought.
Results: Thirty-five of 40 patients were taking medications in December 2011 and of these, 12 (34%) missed medications due to oral intake restrictions. In January 2012, eight of 38 (21%) patients missed medications. Post intervention, eight (22%) of 37 patients and four (11%) of 38 patients missed medications in December 2012 and January 2013, respectively. Feedback indicates the policy is well received.
Discussion: There appears to be a trend towards the reduction in patients missing medications due to oral intake restrictions. The pilot shows that the policy is applicable in an area where many patients have restrictions on oral intake.
From sitting to running: how active are stroke survivors across the activity continuum? A systematic review
C English,1,2 P Manns,3 C Tucak,4 J Bernhardt2
1University of South Australia, Adelaide, SA, 2Florey Institute of Neuroscience and Mental Health, Melbourne, Vic., 4Hollywood Private Hospital, Perth, WA, Australia, and 3University of Alberta, Edmonton, Alberta, Canada
Background: People who sit for long periods each day have a greater risk of cardiovascular disease – and this appears to be independent of the time they spend in moderate to vigorous activities such as brisk walking. What do we know about activity levels of stroke survivors across the activity continuum from sitting to running?
Aim: To review the evidence regarding sedentary behaviors and physical activity levels of community-dwelling stroke survivors.
Method: A comprehensive search was undertaken using relevant databases. Studies including any measures of free-living physical activity or sedentary behaviors of community-dwelling stroke survivors were included.
Results: A total of 23 studies were included with a combined total sample of 1,160 participants. Sedentary time as a proportion of walking hours was reported as 63 and 66% in two studies. By far the most commonly reported outcome was steps per day – an indicator of light intensity physical activity, reported in 19 studies. Step counts were consistently reported as half or less of those taken by age matched peers. Based on heart rate monitoring, one study reported 7% of waking hours was spent in at least moderate intensity activity.
Conclusion: Stroke survivors take far fewer steps per day than their age matched healthy peers, but almost nothing is known about the amount of time they are sitting for each day, or the pattern in which sedentary time is accumulated. Prolonged sitting time may be a modifiable risk factor for cardiovascular disease and recurrent stroke. Further research in this area is needed.
The death of early supported discharge: best practice ignored?
Osborne Park Hospital Stroke Rehabilitation Unit, Perth, WA, Australia
Background: The development of stroke early supported discharge (ESD) schemes should be embraced enthusiastically by health services, as it is by stroke survivors, carers and stroke clinicians. Few other rehabilitation pathways offer such overwhelming high-level evidence in terms of improved clinical outcome, reduced hospital stay, and reduction in costs. This paper examines why the current funding and administrative climate in Australia fails to support ESD in accordance with national and international best practice guidelines.
Aims: To examine the place of ESD in the Australian stroke landscape.
Methods: Consultation with Australian stroke clinical leads and networks; reference to national clinical audit results.
Results: In 2012, 83% of Australian sites participating in the National Stroke Foundation (NSF) audit did not have access to true ESD services. Those sites not participating in the audit are even less likely to have access to ESD. The number of sites with ESD has fallen by 23% between 2008 and 2012.
Discussion: Access to ESD has been a Grade A recommendation in the NSF Guidelines since 2005. ESD service provision is best practice and guideline supported because of consistent high-level evidence of superior clinical outcomes, cost savings, and the support of stroke survivors and carers. In WA, as across Australia, the decline of ESD services can be explained by its inability to fit neatly within ‘inpatient’ or ‘outpatient’ funding streams, and the inflexibility of Activity Based Funding models.
Variation in regional brain temperature as measured by MR thermography in healthy volunteers
T Lillicrap,1,2,3 P Stanwell,3 T Neeman,4 M Parsons,3 N Spratt,3 CR Levi,3 C Lueck1
1The Canberra Hospital and Australian National University, 2The University of New South Wales @ Canberra, 4Statistical Consulting Unit, Australian National University, Canberra, ACT, 3John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
Background: MR thermography has the potential to inform clinical trials of therapeutic hypothermia but typically requires specialist software and MR-physicist support. We have previously developed a simplified method of MR thermography which can be used with standard MR scanner software and minimal training. The current study applied this technique to healthy volunteers to assess temperature variation within the brain and to examine any systematic differences in temperature or spectral quality.
Aims: To examine:
- baseline brain temperature using this MR thermography technique.
- whether there is any consistent spatial variation in temperature and/or quality of MR spectra within the brain.
- whether this information impacts on how MR thermography might be used in clinical practice.
Methods: Ten healthy volunteers were examined. Each examination consisted of MR thermography scans of five regions-of-interest (ROIs) in each hemisphere (frontal lobe, parietal lobe, occipital lobe, cerebellum and basal ganglia). The temperature data were examined in order to detect any systematic variability in temperature between different areas of brain. The line-width of key metabolites for each spectrum were compared the same way to determine the effects of ROI location on signal quality.
Results: There was no statistically significant effect of ROI on temperature. Cerebellum and basal ganglia tended to produce poor quality spectra.
Discussion: MR thermography appears to be a useful tool for in vivo measurement of brain temperature in the context of acute ischaemic stroke (and therefore hypothermia), but this is dependent to some extent on which part of the brain is being investigated.
A pilot investigation of the effect of cathodal transcranial direct current stimulation (ctDCS) plus standard upper limb rehabilitation to augment motor recovery post acute stroke
J Garcia-Vega,1,2 G Bowater,1 C Lind,1,2 DJ Blacker,1,2 S Ghosh,1,2 G Thickbroom,2,3 I Cooper,1 BJ Singer2
1Sir Charles Gairdner Hospital, 2The University of Western Australia, 3Australian Neuro-Muscular Research Institute, Perth, WA, Australia
Background: Interhemispheric balance (IHB) is disrupted after stroke. The contralesional hemisphere can exert an excessive inhibitory influence on the lesioned side, reducing activity in the damaged motor cortex and interfering with motor recovery. Non-invasive brain stimulation (NIBS) may ameliorate this imbalance. One form of NIBS is transcranial direct current stimulation (tDCS). tDCS can modulate cortical excitability in three ways: (1) excitatory (anodal) tDCS to the affected hemisphere; (2) inhibitory (cathodal) tDCS (ctDCS) can dampen overactivity in the contralesional hemisphere; and (3) bihemispheric tDCS which produces a combined effect. Although some data exist for the efficacy of tDCS in chronic stroke cohorts, the application in acute stroke (<1 month), in particular of cathodal tDCS, has not been previously reported.
This randomized, double-blind, sham-controlled pilot study will explore the effect of ctDCS plus therapy in the early stages (commencing 7–10) days post stroke on upper limb motor recovery and cortical excitability (motor evoked potentials in the first dorsal interosseus muscle).
Protocol: Forty acute stroke survivors with moderate to severe upper limb impairment will be randomised to receive 10 sessions of ctDCS (1 mA) or sham tDCS to the contralesional primary motor cortex (M1) and concurrent upper limb therapy for 30 minutes over a 2-week period. TMS will be used to explore IHB early after stroke and to screen for suitable participants. The primary outcomes are changes in Fugl-Meyer Upper Extremity scores and TMS evoked motor evoked potentials at 1 day, 2 weeks and 3 months post intervention period.
 Optimizing recovery potential through simultaneous occupational therapy and non-invasive brain-stimulation using tDCS. Restor Neurol Neuroscience. 2011; 29: 411–420., , , , .
 Transcranial direct current stimulation (tDCS) for improving function and activities of daily living in patients after stroke. The Cochrane Library. 2012; (2): 1–8., , .
Implementation of an ambulance-based stroke early notification system
H Grantham,1 R Larsen,2 K Goldsmith,3 J Leyden,4 T Kleinig,5 A Lee,6 J Jannes3
1Flinders University, 2SA Ambulance Service, 3The Queen Elizabeth Hospital, 4The Lyell McEwin Hospital, 5The Royal Adelaide Hospital, 6Flinders Medical Centre, Adelaide, SA, Australia
Background: Early delivery of thrombolysis to appropriate stroke patients is associated with better clinical outcomes1 and systems that improve the efficiency of assessment and management are therefore directly linked to improved patient care. Ambulance responses to stroke events in the past has tended to be treat, transport to closest hospital (even if stroke expertise was not available) and handover to hospital staff. The stroke early notification system was implemented to transport stroke patients identified in the field directly to a stroke unit hospital, by-passing non-stroke unit hosptials. The system includes a paramedic screening tool ROSIER (Recognition of Stroke in Emergency Departments), statewide education and training and a pre-notification system directly to the destination stroke unit.
Aim: To present a retrospective review of the establishment of a rapid acces, specialist stroke assessment and management program in Adelaide.
Methods: We compared 163 patients who received thrombolysis over a 2-year period prior to implementation of the new service with 144 patients who receive thrombolysis over 1 year following implementation of the new service.
Results: Following implementation of the stroke early notification system the paramedics spent around the same time on the scene assessing, treating, packaging and loading of the patient, with no real change in time to hospital from scene. There was a statistically significant reduction in door to thromboylsis time of 20 minutes.
Conculsion: We have demonstrated that implementation of a statewide early notification and triage system for people with stroke is feasible and is associated with a statistically significant reduction in door to treatment time without adverse impact on paramedic management time.
1. Early stroke treatment associated with better outcomes: the NINDS rt-PA Stroke Study, Neurology. 2000;55: 1649–1655., , , , , , , , , , , , .
Stroke survivors with severe upper limb disability: how much and what do they do during inpatient rehabilitation?
KS Hayward,1 RN Barker,2,3 AH Wiseman,1 SG Brauer1
1The University of Queensland, Brisbane, 2James Cook University, 3Townsville Mackay Medicare Local, Townsville, Qld, Australia
Background: To retrain upper limb function after stroke, a high dose of activity-related therapy is recommended. However, observational studies indicate that the actual dose undertaken is minimal. While it is speculated that those with severe motor disability will undertake an even smaller dose of such therapy, it remains to be explored.
Aim: Quantify the dose and content of upper limb therapy performed by stroke survivors with severe upper limb disability during routine inpatient rehabilitation.
Methods: Therapy provided by physiotherapists and occupational therapists to 32 stroke survivors over 20 weekdays was recorded. Dose of individual and group therapy was analysed by discipline and severity of upper and lower limb disability. Dose and content of individual therapy was also analysed by functional domain.
Results: On average, 46 minutes of individual and 11 minutes of group upper limb therapy was provided per participant, per day. Occupational therapists provided a higher dose of both individual and group therapy compared to physiotherapists (p < 0.0005). Findings indicated that greater residual upper and lower limb movement was associated with more therapy. Within individual therapy, a higher dose (29 versus 17 minutes, p < 0.002) and greater number (1218 versus 549) of impairment-than activity-related interventions were administered.
Conclusions: These findings highlight the need to identify interventions and models of service delivery that can increase the intensity and appropriateness of therapy stroke survivors with severe disability undertake during inpatient rehabilitation.
Factors influencing the consultants' decision to admit a stroke survivor to and then continue or cease inpatient stroke rehabilitation: a statewide survey
KS Hayward,1 PD Aitkin,2 RN Barker,3,4 SG Brauer1
1The University of Queensland, 2Princess Alexandra Hospital, Brisbane, 3James Cook University, 4Townsville Mackay Medicare Local, Townsville, Qld, Australia
Background: Access to inpatient rehabilitation is a critical element to functional recovery after stroke. Few studies have explored the factors that influence the opinion of the primary decision-maker, that is, the consultant medical officer, with regards to admission to and continuation or cessation of inpatient stroke rehabilitation.
Aim: To (1) identify factors that favour or disfavour admission of a stroke survivor to inpatient rehabilitation; and (2) identify factors that favour continuation or cessation of inpatient rehabilitation.
Methods: A cross-sectional survey of consultant medical officers in Queensland Australia, who could lead the decision-making process with regards to inpatient stroke rehabilitation was undertaken. A mix of open and closed questions were used.
Results: Twenty-one consultants completed the survey. Factors related to the stroke survivor's physical function, along with the presence of social support networks favoured admission. The presence of behavioural and cognitive impairments disfavoured admission. Continued functional gains favoured continuation of inpatient rehabilitation, while a lack of functional gain favoured cessation.
Conclusion: These findings indicate that stroke survivors who demonstrate early and continued return of movement may be more likely to gain access to and continue with inpatient rehabilitation than those with little to no residual movement. To ensure access to inpatient rehabilitation is equitable, future research needs to explore ways to identify ideal candidates for inpatient rehabilitation.
Creating a systematic process of early identification of barriers to discharge and the need for early planning meetings using a “Planning Meeting Indicators” (PMI) tool at Caulfield hospital
B Anthonisz, K O'Meara, S Bynon, R Prosser, S Leech, K Gledhill
Caulfield Hospital, Melbourne, Vic., Australia
Background: Neurological inpatient rehabilitation is complex and multifaceted. A number of processes are undertaken to determine length of stay, timing of family meetings, and effective discharge planning in order to provide excellent care for all our patients.
Caulfield Hospital's neurological rehabilitation unit developed and implemented a tool called the Planning Meeting Indicator (PMI) to systematically identify patients' barriers for discharge at the initial case conference.
The PMI tool prompts the treating team to facilitate early planning meetings as required involving the clinicians, patients and their families, thus reducing the time lapse between a patient's admission and a planning meeting.
Aims: This tool aimed to identify potential discharge barriers earlier in a patient's admission, and formalise the process of identifying the need for an early planning meeting with patients and their families, thus allowing more timely discharge planning discussions between all relevant parties.
Methods: The PMI tool was implemented into all inpatient neurological rehabilitation initial case conferences and completed for all new patients admitted after 23/07/2012.
A retrospective audit will be conducted to compare timeliness of planning meetings and length of stay (days) pre and post implementation of the PMI.
Data will be extracted from existing data collected within Scheduling for allied health interventions and health information databases.
Staff Feedback on the clinical application of this tool was also obtained via a survey using survey monkey.
Results: Data collection and analysis is currently being performed for the pre and post implementation of the PMI tool. This will be completed by the March 31st 2013. Data will be available for presentation by mid April.
Discussion: Discussion will relate to the data from pre and post implementation of the PMI tool and its impact on length of stay, timeliness of patient & family meetings and staff satisfaction for neurological rehabilitation clients.
Stroke Regional Outreach and Knowledge Exchange: towards consistency and the sustainability of evidence-based stroke service delivery in regional Victoria
P Groot,1,2 RP Gerraty,1,3 H Dewey,1,4 L Weir,1,5 J Devereux1
1Victorian Stroke Clinical Network, 2South West Healthcare, 3Epworth Healthcare, 4Austin Health, 5Melbourne Health, Vic., Australia
Background: The activities of the Victorian Stroke Clinical Network (VSCN), including the placement of stroke clinical network facilitators at strategic regional health services has resulted in enhanced stroke service delivery across regional Victoria. With the tenure of the last facilitators about to conclude there is a perceived risk that recently enhanced stroke service delivery capacity may not be sustained.
Aim: A sub-committee of the VSCN, the STroke Regional Outreach & Knowledge Exchange (STROKE) Project Team, was convened to develop an education delivery platform that would reduce this risk.
Methods: Experts in stroke management have been engaged to present case reviews on various aspects of evidence-based stroke care. Topics have covered points along the entire stroke care continuum. Regional clinicians have dialled into a teleconference facility to listen to the presenter deliver a pre-disseminated power point case review.
Results: Nine STROKE sessions have been held since April 2012 engaging almost 700 participants from over 40 sites (average participation rate is 76). A broad range of clinicians involved in stroke care have participated. Feedback has been consistently positive with almost all sites revisiting the sessions each month.
Conclusion: Indications are that the ‘outreach and knowledge exchange’ features of the STROKE Project may enhance the consistency and sustainability of evidence-based stroke service delivery in regional Victoria.
A drop in the average age of stroke patients
D Anderlini,1,2 G Wallis,1 R Henderson,2 A Wong2
1School of Human Movement Studies, University of Queensland, 2Neurology Department, Royal Brisbane and Women's Hospital Herston, Qld. Australia
Background: According to many studies from Europe and the USA, the average age of stroke patients is falling. Give that stroke is one of the major causes of death and permanent disability, it is important for us to understand if the same is true in Australia.
Aims: Is Australia, and in particular the Brisbane area, seeing an increased number of younger stroke patients?
Methods: This retrospective study included patients who were admitted to the Stroke Unit of the Royal Brisbane Women's Hospital, between 2002 and 2011. We analyzed the patient data on the basis of age range (0–10, 11–20, etc.) and year of admission (2002–2006 or 2007–2011).
Results: Data from 1993 patients were analysed. They had a mean age of 67.4 and median 70 (6 years younger than the median for Australia). Patients admitted from 2002 to 2006 had a mean age of 69.2 and those from 2007 to 2011, a mean age of 65.4. Hence, during the last 5 years, stroke patients are on average, 4 years younger than during the previous 5 years (t(1991) = 5.128, p < 0.001). All age ranges have seen an increase in the rate of stroke except ages 70–79 and 80–89 where the incidence has dropped considerably.
Conclusion: Our study suggests that stroke is becoming more frequent in younger Australians. The fact that stroke numbers have dropped in older people, implies that primary and secondary prevention techniques are effective, but that they need to be carried over to younger at-risk groups too.
EXtending the time for Thombolysis in Emergency Neurological Deficits: the EXTEND trial progress
GA Donnan,1 SM Davis,2 H Ma,1,3 BC Campbell,2 S Christensen,4 A Connelly,5 L Churilov,1 DW Howells,1 L Carey,1 E Cowley,1 B Yan,2 M Parsons6
1Florey Institute of Neuroscience and Mental Health, 2Melbourne Brain Centre, 4Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, 3Department of Neurology, Monash Medical Centre, Clayton, 5Brain Research Institute, Heidelberg, Vic., 6Priority Research Centre for Brain and Mental Health Research, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
Background: Thrombolysis in stroke is limited by the 4.5 hr time window. Patient selection using physiologic imaging criteria may extend the therapeutic window.
Aim: To test the hypothesis that perfusion-diffusion mismatch identifies patients with favourable response to thrombolysis beyond 4.5 hrs.
Methods: EXTEND is a randomised, double-blind, placebo controlled trial of intravenous alteplase vs placebo in patients with ischemic stroke 4.5–9 hrs from onset. Patients with “wake-up stroke” are eligible if the midpoint of the time they went to sleep and awoke with the stroke symptoms is <9 hrs. Inclusion criteria include penumbral mismatch using CT or MRI using a perfusion threshold of Tmax > 6 sec and infarct core defined using CT-relative cerebral blood flow or diffusion MRI lesion, assessed using fully automated software (RAPID, Stanford University). Infarct core lesion volume must be <70 mL. Patients will be assessed for reperfusion/recanalization at 24 hrs. The primary endpoint is mRS 0–1 at 90 days. Secondary endpoints include mRS shift analysis, reperfusion, recanalization, quality of life and depression scales. The trial is also investigating diet and lifestyle factors in stroke and depression.
Results: Site recruitment commenced June 2010. There are now 20 active sites in Australia and New Zealand with additional sites in Taiwan and Singapore being initiated. The European ECASS-IV/EXTEND trial using the same protocol will commence this year.
Conclusions: EXTEND will provide the first randomized evidence regarding the efficacy of tPA in mismatch-selected patients beyond 4.5 hours.
EXtending the time for Thombolysis in Emergency Neurological Deficits – intra-arterial: the EXTEND-IA trial rationale and protocol
BC Campbell,1,2 P Mitchell,2 B Yan,1 L Churilov,3 H Ma,3 M Parsons,4 GA Donnan,3 SM Davis1 for the EXTEND-IA Investigators
1Melbourne Brain Centre, 2Department of Radiology, Royal Melbourne Hospital University of Melbourne, 3Florey Institute of Neuroscience and Mental Health, Parkville, Vic., 4Priority Research Centre for Brain and Mental Health Research, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
Background: The proven benefits of tPA within 4.5 h of stroke onset are limited by modest reperfusion rates in patients with major vessel occlusion. Endovascular mechanical clot retrieval may increase reperfusion rates in these patients.
Aim: EXTEND-IA will test the hypothesis that dual target vessel occlusion and penumbral mismatch can select patients with favourable response to reperfusion using mechanical clot retrieval after standard IV tPA < 4.5 h from stroke onset.
Methods: EXTEND-IA is a prospective, randomised, open-label, blinded-endpoint (PROBE) phase 2 trial of mechanical clot retrieval (Solitaire device) after IV tPA vs tPA alone in 100 patients with ischemic stroke <4.5 h from onset. Eligibility for the trial requires vessel occlusion of the ICA or MCA (M1/M2) and CT or MR “mismatch” using a perfusion threshold of Tmax >6 sec and a perfusion:infarct core lesion volume ratio of >1.2. Infarct core volume, assessed using MR-DWI or CT-relative cerebral blood flow, must be <70 mL. This is assessed using a fully automated software package (RAPID, Stanford University). The co-primary endpoint is reperfusion at 24 h and favourable clinical response (≥8 point reduction in National Institutes of Health Stroke Scale or reaching 0–1) at 3 days with secondary endpoints including recanalization, symptomatic hemorrhage and functional outcome (modified Rankin score at 90 days).
Results: Recruitment has commenced at eight centres in Australia and New Zealand with a further six sites planned to open in 2013.
Conclusions: EXTEND-IA will provide much needed randomized evidence about the effectiveness of clot retrieval in a responder population defined by CT or MR mismatch.
Early intensive mobilisation is possible in the bariatric (250 kg) stroke patient: a case study
G Bowater, L Cormack
Physiotherapy Department, Sir Charles Gairdner Hospital, Perth, WA, Australia
Background: Early activity and rehabilitation is considered to be a key element in effective stroke unit care, and may positively influence outcomes following stroke. Obesity is a growing consideration in the health care setting, with 24% of the Australian adult population now considered obese (BMI ≥ 30).
Aim: To present a case study of a young woman with severe stroke, who weighed 250 kg and had a BMI of 81 at presentation, highlighting the innovative physiotherapy approach that enabled early intensive mobilisation and activity.
Method: Prospective data collection, prospective video and photography; retrospective note audit.
Results: The patient had 125 hours of physiotherapy over 32 sessions, delivered mostly by four physiotherapists at a time. Utilisation of the SWAT Physiotherapy team contributed significantly to the effective delivery of care. Initial MSAS was 6, discharge MSAS was 24. Physiotherapy sessions utilised all available bariatric equipment, often in combination, including tilt table, standing frame, ceiling hoist and walking aids. A considered approach was required to maintain staff and patient safety, whilst also allowing active contribution from the patient. Important aspects of this approach will be discussed.
Conclusions: This case highlights that early, intensive rehabilitation is possible despite the challenges of the bariatric patient, and that excellent outcomes can be achieved in this population.
Early activity following stroke: are Australian stroke units still the same?
L Cormack,1 M Firth2
1Physiotherapy Department, Sir Charles Gairdner Hospital, 2School of Physiotherapy, Curtin University, Perth, WA, Australia
Background: Stroke Unit care improves outcome after stroke and an important component of this care may include early mobilisation and rehabilitation.
Aim: To assess current practice of early mobility and activity in a tertiary hospital Stroke Unit, adding to the growing data in this area, and to compare levels of activity with previous studies.
Method: Eighteen consenting patients with acute stroke (days since stroke 1–22) were monitored every 10 minutes from 8am until 5pm for 2 consecutive days between May and July, 2012. Their levels of activity and people present were recorded.
Results: Overall, patients on average spent 50.7% of the day in bed, 29.0% sitting, and 13.4% in higher level activities. Patients with severe stroke spent 55.7% in bed, 31.9% sitting out and 6.8% in higher level activities.
Levels of activity in patients with severe stroke were shown to be higher than previous Australian studies and a recent study completed in Trondheim, Norway. Significant correlations were found between levels of activity and severity of stroke, patient age and days since stroke.
Patients spent on average 34.4% of their day alone, well below that recorded in previous studies (60.4%, 51.3%).
Conclusions: This study demonstrates that higher levels of activity and less time alone are possible in patients with acute, severe stroke in an Australian setting. Further studies to identify contributing factors to early mobilisation are warranted.
Referral of ‘high risk’ registrants in the KYN program
MF Kilkenny,1,2,3 R Johnson,4 T Purvis,1,2 B Wilkinson,4 E Lalor,4 DA Cadilhac1,2,3
1Translational Public Health Unit, Stroke & Ageing Research Centre, Southern Clinical School, Monash University, 2National Stroke Research Institute, Florey Neuroscience Institutes, 3University of Melbourne, 4National Stroke Foundation, Melbourne, Vic., Australia
Background: Since 2011, diabetes risk assessments have been included as part of the National Stroke Foundation ‘Know Your Numbers (KYN)’ Program which also includes measurement of blood pressure (BP) as part of the health check. Pharmacists should refer all ‘high risk’ registrants (BP ≥ 140/90 mmhg and diabetes risk [AUSDRISK] score 12+) to their local doctor.
Aims: To determine the proportion of ‘high risk’ KYN registrants referred to their doctor and the factors that determine whether a registrant is referred.
Methods: Community pharmacies provided standardised BP and diabetes risk assessments and record participant information on a registration log. Data from registrants with a complete BP and diabetes assessment were included. Definition of ‘high risk’ registrants: recorded a BP reading ≥140/90 mmhg and AUSDRISK score 12+. Repeat customers were excluded. Bivariate analyses and multivariate logistic regression were used.
Results: Among 25,702 registrants (61% female; 51% aged 55+ years), one-third were referred to their doctor. ‘High risk’ registrants (64% vs ‘low-moderate’ 25% p < 0.001) were more likely to be referred. Pharmacists were more likely to provide advice eg: weight loss, reduce salt to ‘high risk’ registrants (87% vs ‘low-moderate’ 73% p < 0.001). Factors associated with registrants being referred on day of event included being at ‘high’ risk (OR; 4.8 95% CI: 4.4–5.1), being female (OR; 1.3 95% CI: 1.2,1.4) and reporting a history of high BP (OR; 1.05 95% CI: 1.04,1.06).
Conclusions: The KYN Program provides evidence that the appropriate ‘high risk’ people are being referred to their doctor. Education programs are required in order to improve the proportion of ‘high risk’ people being referred.
Outpatient transient ischaemic attack (TIA) care using the Monash TIA triaging treatment (M3T) model is cost-effective compared with routine hospital admission
LM Sanders,1,2 DA Cadilhac,1 VK Srikanth,1,2 CP Chong,2 TG Phan1,2
1Stroke and Ageing Research Centre, Monash University, 2Southern Health, Clayton, Vic., Australia
Background: Rapid non-admission based management of TIA effectively reduces stroke risk and may be cost-effective compared with admission-based (inpatient) care. We have previously established the safety of the outpatient-based M3T model compared with routine admission with respect to 90-day stroke recurrence.
Aim: to assess cost-effectiveness of M3T with the previous admission-based model.
Methods: Pre-post, micro-costing cohort design. Cost data for each patient for all hospital presentations, investigations and clinic appointments associated with M3T (2004–2007) and the previous admission-based model (2003) were collected. Primary outcome: difference in average episode costs per patient. Multivariable uncertainty analyses were performed by varying hospital bed and clinic costs over 10,000 Monte Carlo simulations. Costs presented in 2012 Australian dollars (AUD). Incremental cost-effectiveness for strokes averted per 100 patients was estimated and uncertainty assessed by varying hospital admission rates, length of stay, and number of investigations.
Results: Average cost per episode was less for M3T (AUD1927.38 95% uncertainty interval [UI]: AUD1827.80–AUD2036.92) compared with the admission-based model (AUD4841.49 95% UI: AUD4178.40–AUD5590.03). Annual clinic costs were double in M3T compared with the admission-based model, but this was offset by the reduction in hospital bed-day costs of the former model. Recurrent stroke at 90 days in M3T was 1.50% (95% Confidence Interval [CI]: 0.73%–3.05%) compared with 4.67% (95% CI: 2.28%–9.32%) in the admission-based model. Cost-effectiveness analyses demonstrated M3T was cost-saving with a median 3 (95% UI: 0.7–6.0) stroke averted per 100 patients treated.
Conclusion: The outpatient-based M3T model of TIA care is cost-saving in preventing stroke within 90 days when compared with routine hospital admission.
Exercise reduces infarct volume and facilitates neurobehavioural recovery: systematic review and meta-analysis of exercise in animal models of stroke
KJ Egan,1 H Janssen,2 ES Sena,1,3 J Bernhardt,3 L Longley,1 S Speare,3 DW Howells,3 NJ Spratt,2 MR Macleod,1 GE Mead1
1Department of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom, and2Faculty of Health, University of Newcastle, Hunter New England Health and Hunter Medical Research Institute, Newcastle, NSW,3Florey Institute for Neuroscience and Mental Health, Melbourne, Vic., Australia
Background: Regular exercise reduces the risk of stroke and is associated with smaller infarcts. Therapeutic exercise following stroke facilitates functional recovery. The mechanisms underlying these exercise-induced benefits remain unclear. Animal models provide a means by which to explore the effect of exercise on stroke.
Objective: To determine the efficacy of exercise on the outcomes of infarct volume, neurobehavioural score and neurogenesis in animal models of ischaemic stroke. We also sought evidence of publication bias.
Methods: Sytematic review with meta-analysis. DerSimonian and Laird normalised random effects meta-analysis and meta-regression were used to determine the impact of study quality and design on the efficacy of exercise.
Results: Reported study quality was moderate (median score 5/10) and there was evidence of publication bias for the outcome of neurobehavioural score. Insufficient data prevented analysis of the efficacy of exercise on neurogenesis. Overall, exercise reduced infarct volume by 25% (95% confidence interval (CI) 19–31%, 65 experiments, n = 986 animals) and improved neurobehavioural score by 38% (-329 to 47%, 42 experiments, n = 771). Larger effects were seen on infarct volume and neurobehavioural score following pre- compared to post-ischaemic stroke exercise. Reported outcomes were influenced by both model and exercise specific characteristics.
Conclusion: Both pre- and post-ischaemic stroke exercise had favourable effects on infarct volume and neurobehavioural score. These results are in accord with the limited available clinical evidence indicating that physical activity reduces stroke severity. Our findings support the need for more studies investigating the efficacy of post-stroke exercise in stroke survivors.
Brain attacks in children: a prospective study of stroke and stroke mimics presenting to the emergency department
MT Mackay,1,2,3,4 ZK Chua,3 M Lee,3 A Yock-Corrales,2 L Churilov,3,4 GA Donnan,3,4 F Babl,2,3,5 P Monagle2,3,6
Departments of 1Neurology and 6Haematology, 5Emergency Department, Royal Children's Hospital, 2Murdoch Children's Research Institute, 3University of Melbourne, 4Florey Neurosciences Institute, Melbourne, Vic., Australia
Background: Determining causes of brain attacks is a key step for developing paediatric brain attack protocols to allow children with stroke access to time critical interventions.
Objectives: To determine symptoms, signs and aetiology of brain attacks in children presenting to the Emergency Department (ED).
Methods: Prospective study of children from 1 month to 18 years with symptoms or signs of a brain attack (focal brain dysfunction of apparently abrupt onset). Exclusion criteria included epilepsy, hydrocephalus, head trauma and isolated headache.
Results: Two hundred eighty-seven children with 301 consecutive presentations were seen over 18 months. Median age was 9.4 years. One hundred four (35%) arrived by ambulance. Median symptom duration prior to arrival was 6 hrs (IQR 2–28 hrs). Median time from triage to medical assessment was 22 mins (IQR 6–55 mins). Symptoms included headache (56%), vomiting (36%), focal weakness (35%) or numbness (24%), visual disturbance (23%), seizures (21%), altered consciousness (21%), dizziness (20%), speech disturbance (17%), ataxia (14%), loss of consciousness and syncope (both 11%). Signs included focal weakness (31%), numbness (13%), ataxia (10%), speech (8%) or visual disturbance (7%). Investigations included CT imaging (30%; abnormal in 26%), MR imaging (31%; abnormal in 61%), lumbar puncture (13%) and EEG in (13%). Specialty consultation was sought in 62%. Diagnoses included migraine (28%), seizures (15%), Bell's Palsy (10%), cerebrovascular disorders (7%), conversion disorders (6%), syncope (5%), non-specific headache (4%), methotrexate/other encephalopathies, demyelination, post-infectious cerebellitis and neuropathy (all 3%).
Conclusions: Aetiology, presentation and EMS utilization in children with brain attacks differ from adults. Stroke was the fourth most common diagnosis.
A clinical audit of the transfer of stroke patients from a non-tertiary hospital to a tertiary hospital: who, why, and how?
D Do-Nguyen,1,2 A Granger1,2
1Osborne Park Hospital, 2Sir Charles Gairdner Hospital, Perth, WA, Australia
Background: The National Stroke Foundation (NSF) recommends “all patients with stroke should be treated in a stroke unit (level-A)”. Non-tertiary hospitals such as Joondalup Health Campus (JHC) do not have a dedicated stroke unit or neurosurgical services; therefore patients may be transferred to the nearest tertiary hospital, Sir Charles Gairdner Hospital (SCGH). There are no formal patient selection guidelines or transfer protocols to guide this process.
Aims: To review the transfer of stroke patients from JHC to SCGH and formulate a transfer protocol.
Methods: A retrospective case note audit reviewed patients with an ICD-10 diagnosis of stroke who were transferred from JHC to SCGH between June 2010 and July 2011.
Results: Of 183 stroke patients identified at JHC, nine were transferred to SCGH. The most common indication was for stroke unit management, followed by neurosurgical review. All cases were discussed with the accepting neurology team with neurosurgery consulted when indicated.
Discussion: Although it is recommended all stroke patients be managed in a stroke unit, it is not feasible to transfer all stroke patients from JHC to SCGH. In keeping with NSF recommendations that hospitals admitting >100 stroke patients per year have a dedicated stroke unit, guidelines would suggest a stroke unit be established at JHC . This requires further feasibility analysis. Our interim solution involves developing guidelines to rationalise stroke patient selection for transfer. Transfer indications are based on existing protocols and reviewing the evidence for each indication. Formalising transfer guidelines also included developing communication and transfer process protocols.
 National Stroke Foundation. Clinical Guidelines for Stroke Management 2010. Melbourne Australia.
Interventions to improve cardiorespiratory fitness after stroke: a systematic review with meta-analysis
DL Marsden,1,2,3 A Dunn,1,3 R Callister,1,3 CR Levi,1,2,3 NJ Spratt1,2,3
1University of Newcastle, 2Hunter Stroke Service, Hunter New England Local Health District 3Hunter Medical Research Institute, Newcastle, NSW, Australia
Background: Most stroke survivors are sedentary and have low cardiorespiratory fitness levels. Improving fitness may result in better function and reduced risk of subsequent cardiovascular events.
Aim: To determine the effectiveness of interventions to improve cardiorespiratory fitness after stroke and identify their characteristics.
Methods: A systematic search and review with meta-analysis was undertaken. Key inclusion criteria were: peer-reviewed articles published in English, adult stroke survivors, intervention with potential to improve cardiorespiratory fitness, and peak oxygen consumption (VO2peak) assessed pre and post-intervention via a progressive aerobic exercise test.
Results: From 3208 citations identified, 12 randomised controlled trials were included in the meta-analysis, reporting results for 310 intervention and 266 control participants. Mean(SD) age ranged from 53.2(8.3) to 70.2(11.4) years. Study intervention typically were conducted with one-to-one supervision in a research centre or hospital and used an aerobic (treadmill = 4, cycle ergometer = 2, water exercise = 1) or mixed (aerobic component plus usual care, strength, balance and/or endurance activities = 5) intervention. Baseline VO2peak values were low (8–23 ml/kg/min). Overall improvement in VO2peak was 2.27 (95% CI: 1.58, 2.95) ml/kg/min, with a similar improvement (10–15%) for both aerobic and mixed interventions. No intervention met the recommended 30 minutes of moderate intensity physical activity most days of the week.
Conclusions: The results demonstrate even modest dose interventions with an aerobic component can improve cardiorespiratory fitness post-stroke. The key factor appears to be “aerobic” with the type being less important. Most interventions trialled to date are resource-intensive, centre-based with no post-programme follow-up to determine effect maintenance or identify subsequent cardiovascular events.
The Enhanced Control of Hypertension ANd Thrombolysis strokE StuDy (ENCHANTED): complexity of set-up large international clinical trial
X Chen,1 CS Anderson,1 T Robinson,2 P Lavados,3 S Fuentes,1 R Lindley,1 H Arima,1 JS Kim,4 T Lee,5 J Chalmers1 for the ENCHANTED Investigators
1The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, Australia, and 2Department of Cardiovascular Sciences, University of Leicester, Leicester Royal Infirmary, United Kingdom, and 3Department of Neurology, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile, and 4Department of Neurology, Asan Medical Center, Seoul, Korea, and 5Department of Neurology, Chang Gung Memorial Hospital, Taipei, Taiwan
Background: Controversy exists over the optimal dose (0.6 vs 0.9 mg/kg) of i.v. rtPA and level of blood pressure (BP) control in acute ischaemic stroke (AIS). Studies indicate low dose rtPA to be efficacious, and hypertension (>150 mmhg systolic) both ‘before’ and ‘after’ rtPA predicts poor outcomes.
Aims: ENCHANTED aims to address whether (i) 0.6 mg/kg rtPA is non-inferior to standard 0.9 mg/kg rtPA, and (ii) early intensive BP lowering (target systolic 140–150 mmhg) is superior to guideline-based recommended BP control (systolic <180 mmHg) on 90-day poor outcome in patients requiring rtPA for AIS.
Methods: The trial is being conducted across an expanding global network (>100 sites) to achieve the required sample size (5000; 3300 per treatment arm; >90% power) to achieve its objectives.
Results: In the first year (March 2012 to February 2013), 391 randomised patients from 44 sites have been included, which slightly below the projected target (n = 425). However, average site recruitment at 12 patients is far above the expected number of six patients/site/year. Complex ethics committee, regulatory and contractural approvals for setting up regional/national coordinating centers and hospital sites, and unexpectedly high central infrastructure costs, have adversely impacted on the study, the details of which are to be elaborated upon in the presentation. Additional sites are required to accelerate recruitment towards the desired target.
Conclusions: Academic researchers are faced with increasing administrative and regulatory complexities, and associated high costs, in their efforts to set-up and conduct international multicenter clinical trials. These issues require recognition by researchers, and importantly the funding bodies, who support high quality high impact research.
Ambient temperature on severity and haematoma volume in acute intracerebral haemorrhage: the INTERACT 1 study
D Zheng,1 H Arima,1 E Heeley,1 A Karpin,2 G Heller,2 J Chalmers,1 CS Anderson1 for the INTERACT 1 investigators
1The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, 2Department of Statistics, Macquarie University, Sydney, NSW, Australia
Background: Evidence links ambient temperature with intracerebral haemorrhage (ICH), but there is less evidence of such association between either the severity or haematoma volume in ICH.
Aims: To examine associations of ambient temperature with clinical severity and haematoma size in acute ICH patients within the pilot INTERACT 1 study dataset.
Methods: In INTERACT 1, a randomised controlled trial of intensive compared to guideline-recommended blood pressure (BP) lowering in acute ICH, we linked Chinese participants' (n = 304) data with information on ambient temperature (average, minimum, maximum and range) on the day of ICH onset from China Meteorological Data Sharing Service System. Stroke severity outcomes – elevated National Institute of Health Stroke scale (NIHSS) score (≥14) and low GCS score (<9) were evaluated in logistic regression models adjusted for baseline prognostic variables (age, sex, city, hypertension history, diabetes, previous ICH, antithrombotic medication, systolic BP, time from onset to CT scan, and location and volume of haematoma). Data of log transformed haematoma with and without intraventircular haemorrhage (IVH) follows a normal distribution and therefore was evaluated in multivariate regression models also adjusted for the same prognostic variables.
Results: There are no association between the temperature parameters and elevated NIHSS score (all p > 0.2). Although maximum and minimum temperature (both p = 0.4) were associated with low GCS score, no clear associations were observed for mean temperature or range (both p > 0.05). There were no clear associations between each temperature parameter and haematoma volume (with and without IVH) at hospital presentation.
Conclusion: There was no clear evidence of a relationship between ambient temperature and the clinical or topographical severity of the haematoma in acute ICH.
The Enhanced Control of Hypertension ANd Thrombolysis strokE StuDy (ENCHANTED): first year experience regarding possible selection bias
S Fuentes,1 V Sharma,2 Y Huang,3 P Lavados,4 R Lindley,1 J Pandian,6 C Stapf,7 H Arima,1 M Parsons,8 CR Levi,8 T Robinson,9 C Delcourt,1 J Kim,10 T Lee,11 J Chalmers,1 CS Anderson1 for the ENCHANTED Investigators
1The George Institute for Global Health, Sydney, 8John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia, and 2Dept. of Neurology, National University Hospital, Singapore, and 3Dept. of Neurology, Peking University First Hospital, Beijing, China, and 4Dept. of Neurology, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile, and 5Stroke Unit, 115 Hospital, Ho Chi Minh City, Vietnam, and 6Department of Neurology, Christian Medical College, Ludhiana, India, and 7Dept. of Neurology, Lariboisière Hospital, Paris, France, and 9Department of Cardiovasc. Sci., University of Leicester, Leicester Royal Infirmary, UK, and 10Dept. of Neurology, Asan Medical Center, Seoul, Korea, and 11Dept. of Neurology, Chang Gung Memorial Hospital, Taipei, Taiwan
Background: Controversy exists over the optimal dose of i.v. rtPA and level of blood pressure (BP) control in acute ischaemic stroke (AIS). ENCHANTED aims to determine in rtPA-eligible patients whether: (i) 0.6 mg/kg is non-inferior to 0.9 mg/kg rtPA, and (ii) early intensive BP lowering (target systolic 140–150 mmhg) is superior to guideline recommended BP control (systolic <180–185 mmhg) on 90-day poor outcome.
Aims: Due to potential selection bias in the recruitment of patients (e.g. older patients preferentially included into the dosing arm), we assessed the blinded baseline characteristics of participants in the first 12 months of the trial.
Methods: ENCHANTED is a quasi-factorial, active-comparative, open, blinded endpoint trial evaluating ‘rtPA dose’ and/or ‘BP control’ in AIS patients fulfilling eligibility criteria for rtPA. An estimated 5000 patients (3300 per treatment arm) are required to provide >90% power to achieve the study aims.
Results: Overall, the baseline characteristics of patients (n = 273) were similar between the rtPA arm (av. age 66 yr; male 56%; median [iqr] NIHSS 15 [13–15]) versus BP arm (av. age 65 yr; male 60%; NIHSS 14 [12–15]). Characteristics were also well balanced between treatment arms by ethnic group, but non-Asian patients tended to be older (av. age 75 vs 66 yr) with milder strokes (NIHSS 7 [5–16] vs 12 [7–16]) than Asian patients.
Discussion: No major recruitment selection bias is evident overall in early trial participants. However, a trend is emerging for the inclusion of milder AIS non-Asian patients with a lower likelihood of underlying proximal artery occlusion. However, the role of endovascular clot retrieval therapy in AIS remains uncertain.
Challenges to international academic clinical trials: the INTERACT2 experience
M Leroux, E Heeley, CS Anderson for the INTERACT2 Investigators
The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW, Australia
Background: INTERACT2 was a large-scale academic, multi-centre, open, blinded endpoint, randomised controlled trial to establish the effectiveness of early intensive blood pressure (BP) lowering in spontaneous intracerebral haemorrhage (ICH).
Methods: Patients with acute ICH (N = 2839), elevated systolic BP (150–220 mmhg) and capacity to receive intensive BP lowering within 6 hours of onset, were centrally randomised to intensive (target systolic <140 mmhg) or conservative (systolic <180 mmhg) BP management using routine i.v. BP lowering agents. Vital and disability status were assessed at 28 and 90 days.
Results: From October 2008 to August 2013, a total of 2839 patients were randomised from an international network of 144 hospitals in 21 countries across five continents: Asia (57); Australia (10); Europe (64); North America (1); and South America (12). A total of 73 patients were recruited from the 10 Australian hospitals. Information will be presented regarding the interdependency of managing three key factors (quality, time and cost) within the context of international academic clinical trials. Trial milestones will be compared across countries, including the time from ethics submission to first participant recruited in comparison to overall recruitment rate. Important lessons learned regarding selection of sites and research staff, and cost-effectiveness comparisons across countries will be presented.
Conclusions: Recruitment strategies and quality control parameters utilised in INTERACT2 were required on both a global and a country-specific level to ensure that the study objectives were achieved.
Can lacunar infarction be diagnosed using CT perfusion?
W Cao, N Yassi, G Sharma, B Yan, SM Davis, BC Campbell
Melbourne Brain Centre at Royal Melbourne Hospital, Parkville, Vic., Australia
Background and purpose: The value of CT perfusion (CTP) in detecting acute lacunar (small vessel) infarcts has not been well established.
Aim: We tested the sensitivity of CTP images for identification of lacunar infarcts in the acute phase.
Methods: CTP of consecutive acute ischemic stroke patients admitted to Royal Melbourne Hospital between 2009–2013 was examined to identify those with MRI-confirmed lacunar infarction (single perforating vessel territory). Two stroke neurologists, blinded to the MRI, independently evaluated the CTP maps. Cerebral Blood Volume (CBV), Cerebral Blood Flow (CBF), Mean Transit Time (MTT) and Time to maximum (Tmax) maps were first examined in isolation and then in combination. Interobserver agreement was measured using Cohen kappa. Raters then reached consensus. The lesions identified were later confirmed against MRI by consensus of 3 raters. The sensitivity of CTP maps using DWI as the reference standard was calculated. Fisher exact test was performed to compare map types.
Results: There were 30 patients with MRI-confirmed lacunar stroke within the coverage of CTP, 17 in the basal ganglia, nine thalamic, four in the corona radiata. Interater agreement was substantial (kappa = 0.65). Sensitivity (blinded consensus) was highest for MTT (40%) compared to Tmax (16.7%, p = 0.006). CBV (3%) and CBF (3%) performed poorly. There were no false positives. Sensitivity was higher for striatal lesions than thalamic lesions (53% vs 11%, p = 0.037).
Conclusions: MTT maps enable detection of a significant proportion of lacunar infarcts using CTP. Further study is required to determine whether CTP positive versus negative lacunes have different clinical outcomes.
Hospital admission for stroke encourages inactivity
R Sheedy,1,2 N Shields,2 DA Cadilhac,3,4 J Bernhardt2,3
1Barwon Health, Geelong, 2La Trobe University, Melbourne, 3The Florey Institute of Neuroscience and Mental Health, Heidelberg, 4Translational Public Health Unit, Stroke and Ageing Research, Southern Clinical School, Monash University, Clayton, Vic., Australia.
Background: Measurement of physical activity in patients with acute stroke is challenging, but potentially worthwhile. Early observational studies suggesting patients are ‘inactive and alone’ stimulated trials of early and frequent mobilisation. Higher resolution (instrumented) measurement may help us refine our practices.
Aim: To prospectively measure the physical activity patterns of patients with acute stroke during hospitalisation.
Method: Cross-sectional study of consecutive patients admitted to an acute stroke unit and recruited within 48 hours of admission. Physical activity was recorded using an activPALTM accelerometer device over 14 days or the duration of admission (if shorter). Activity was categorised as: time spent inactive (lying or sitting), standing or stepping. Number of steps per day was also recorded.
Results: Eighty patients were included: mean age 76 (SD 13) years; 48% female; 90% ischaemic stroke, average length of stay 7 days (SD 6). Initial mobilisation occurred within 24 hours of admission for 51% of patients. On average patients spent 96% [SD 3.6] of their admission inactive, 3.3% [SD 3.2] of their admission standing and 0.6% [SD 0.6] of their admission stepping. Patients who were independent on admission (modified Rankin Score <2, n = 17), were less likely to be inactive (Z = –3.205, p < 0.05) and more likely to spend time standing (Z = 3.364, p < 0.05) and stepping (Z = 1.993, p < 0.05). Daily average number of steps per patient was 372 (SD 555).
Conclusion: Although half the patients were mobilised within 24 hours of admission, little physical activity occurred thereafter, highlighting the ongoing challenge of promoting activity in the acute stroke period.
Stroke123: overview of a national initiative to monitor and improve stroke care
DA Cadilhac,1,2 NA Lannin,3 CS Anderson,4 R Grimly,5 S Middleton,6 NE Andrew,1 AG Thrift,1 MF Kilkenny,1,2 B Grabsch,2 V Sundararajan,7 CR Levi,8 S Faux,9 E Lalor,10 K Hill,10 M Page,10 GA Donnan2
1Stroke & Ageing Research Centre, Southern Clinical School, 7Department of Medicine, Monash University, Clayton, 2Florey Institute of Neuroscience and Mental Health, Heidelberg, 3Alfred Clinical School, Faculty of Health Sciences, La Trobe University, 10National Stroke Foundation, Melbourne, Vic., 4The George Institute for Global Health, University of Sydney and Royal Prince Alfred Hospital, 6Nursing Research Institute, Australian Catholic University, 9Faculty of Medicine, The University of NSW, St. Vincent's Hospital, Darlinghurst, Sydney, 8Priority Research Centre for Translational Neurosciences Mental Health Research, University of Newcastle and Hunter Research Unit, Newcastle, 5Statewide Stroke Clinical Network, Queensland Health, Brisbane, Qld, Australia
On behalf of the Stroke123 investigators and partner organisations
Background: In 2011, a National Health and Medical Research Council Partnerships for Better Health grant was awarded for Stroke123, a collaborative, national effort to monitor, promote and improve the quality of stroke care in Australia.
Aim: To demonstrate that integrated quality of care data, coupled with facilitated quality improvement programs, is effective in changing clinician behaviour and improving patient outcomes.
Methods: A multicentre historical controlled, prospective healthcare intervention study to be conducted in Queensland. Patient-level Australian Stroke Clinical Registry (AuSCR) data, including 3-month patient outcomes, will be integrated with (i) National Stroke Foundation (NSF) audit data and (ii) hospital and death registry data. Feedback to clinicians is provided by the NSF StrokeLink quality improvement program and State Clinical Network activities. The effectiveness of the 2013 integrated data for changing clinician behaviour will be compared to the baseline 2011 NSF audit results. Primary outcome: a composite score of adherence to selected clinical performance measures. Process evaluation will be used to describe the critical success factors in achieving the outcomes.
Results: As of February 2013, 36 Australian hospitals (n = 17 Queensland) were using AuSCR (epiosdes of care: 9,149; 87% followed-up between 90–180 days). Eight additional Ethics Committee approvals are ‘in-progress’. Integration trials of linking hospital data with AuSCR are underway. Harmonisation of the NSF 2013 National Clinical Audit with AuSCR is ongoing and data collection has commenced.
Conclusion: Stroke123 will provide a platform for testing the national roll-out of enhanced systems to monitor the quality of stroke care with embedded facilitated quality improvement.
Aspirin in Reducing Events in the Elderly (ASPREE)
J McNeil,1 GA Donnan2 on behalf of ASPREE Investigators
1Department of Epidemiology and Preventive Medicine, Monash University, 2Florey Institute of Neuroscience and Mental Health, Melbourne, Vic., Australia
Background: Cardiovascular disease (CVD), dementia and cancer are major causes of mortality, chronic disease and disability in the elderly. Given the rapidly ageing population, identifying therapies and interventions that may prolong disability-free life is crucial.
Aspirin is an over-the-counter medication with well-known adverse effects. It confers a net benefit in secondary prevention for CVD, yet <10% of participants in major primary prevention aspirin trials were aged >65, despite their higher risk of developing the disease.
Aims: ASPREE will determine whether low-dose aspirin prolongs disability-free and dementia-free survival and weighs the overall benefit/risk balance, including ischaemic and haemorrhagic strokes in the healthy elderly.
Methods: ASPREE is a primary prevention double-blinded, placebo-controlled trial of daily 100 mg aspirin, in 19,000 elderly people (16,000 in Australia, 3000 in the USA). Healthy Australians aged 70+ are primarily recruited through general practitioner co-investigators. Exclusion criteria include clinical evidence of CVD, dementia, disability, atrial fibrillation, and a serious illness likely to cause death within 5 years. Participants undergo assessments of cognitive and physical function at baseline and annually (average 5-year follow-up).
Progress: Recruitment began March 2010; nearly 11,000 Australians and 1,600 USA participants have been randomised to date.
Conclusions: The ASPREE study is the largest primary prevention trial of aspirin in healthy older adults, and the first to use a composite endpoint of disability-free and dementia-free years, and total mortality. The ASPREE results will be pivotal in assessing the risk/benefit of aspirin in this older group who are at higher risk for serious bleeding due to aspirin.
A prospective study of diagnostic accuracy and outcomes in cerebellar infarction
Z Calic, C Cappelen-Smith, V Patel, S Djekic, D Cordato
Department of Neurology and Neurophysiology, Liverpool Hospital, Liverpool, NSW, Australia
Background: Early and accurate diagnosis of cerebellar infarction (CI) is challenging because of non-specific symptoms and absence of localizing neurological signs. Delayed or misdiagnosis may result in increased morbidity and mortality.
Aims: A prospective study to determine factors associated with delayed diagnosis of CI.
Methods: Thirty-two consecutive patients with CI (CT/MRI confirmed), admitted to Liverpool Hospital, January 2012–January 2013.
Results: Mean age was 66 years, M:F = 19:13. Five patients had prior ED (Emergency Department) presentation. Fifteen (47%) presented within 4.5–hrs, three between 4.5–24 hrs and 14 (44%) >24 hrs after symptom onset. TIA/stroke was not the principal diagnosis in 13 (40%) during ED evaluation. Two received thrombolysis. The most common presenting symptoms in patients presenting <4.5 hrs were dizziness, nausea/vomiting and gait disturbance compared to dizziness, gait disturbance and vertigo in those presenting >4.5 hrs. The most common sign was limb ataxia. Seven patients had no signs on ED assessment. Atrial fibrillation was found in 11 patients (34%); two patients had vertebral artery dissection. The most common CI site was in the posterior inferior cerebellar artery territory (72%). Isolated CI was present in 15 patients (47%). Additional territories affected 17 patients (posterior circulation 59%; anterior 41%). Complications occurred in 10 patients, of whom 8 had multiple arterial territory strokes. Eight (25%) died within 3 months.
Conclusions: Late presentation (>24 hrs from symptom onset) with CI was common. CI frequently occurred with infarction in other vascular territories. Although involvement of additional arterial territories did not predict earlier hospital presentation, such patients were more likely to experience complications.
Independent stroke quality measures review is needed to maintain stroke centre stroke care standards
Mayo Clinic Arizona, Phoenix, AZ, USA
Background: Stroke Center (SC) certification identifies hospitals which are capable of providing care to stroke patients (SP) in a stroke system (SS). Collecting stroke quality measures (SQM) data is required for SCs to monitor their stroke care processes. However, SSs do not independently review SQM data from individual SCs, which could lead to underperforming SCs not being detected.
Aims: This study was conducted to determine if self-monitoring of SQMs is associated with maintenance of stroke care standards in a metropolitan SS.
Methods: The Phoenix SC Matrix was created in 2003, and for the first 4 years, SQM data was collected, and self-reviewed by every SC. In 2008, the 10 SCs in the Matrix to were required to submit SQM data, including door-to-needle times, for independent review.
Results: Seven of the 10 SCs had satisfactory SQM data consistent with good quality SP care. However, three of the SCs had average door-to-needle times greater than 90 minutes compared to prior times less than 70 minutes. These hospitals were required to develop a corrective action plan, and then resubmit new SQM data. After the action plans were implemented, all three hospitals had significant, satisfactory, reductions in their door-to-needle times.
Conclusion: Self monitoring of SQM data by certified SCs is not always associated with the identification, and correction, of problems which develop in the delivery of acute stroke care. This study demonstrates the importance of having an independent reveiew process of SQM data from hospitals participating as SCs in an integrated SS.
‘Drive your own recovery’ after stroke: a multidisciplinary upper limb group training program
KS Hayward,1 C Robertson,2 E Satake,2 J Mitchell,2 E Ninnes,2 RN Barker3,4
1The University of Queensland, 2Princess Alexandra Hospital, Brisbane, 3James Cook University, 4Townsville Mackay Medicare Local, Townsville, Qld, Australia
Background: Increasing the dose of activity-related upper limb training is necessary, but stroke survivors also need to be equipped with skills and knowledge to drive their own recovery. A group setting offers one approach to achieve this.
Aim: Develop and refine a ‘Drive your own recovery’ group for stroke survivors with upper limb disability who are participating in rehabilitation.
Methods: A prospective observational study using an action research approach was undertaken. A weekly group, facilitated by a physiotherapist and occupational therapist, was conducted focussing on (1) goal-oriented, activity-related training and (2) education on how to ‘Drive Your Own Recovery’. To refine the group, therapists completed post-group reflection logs, which were evaluated and actioned at a monthly meeting. Participants recorded repetitions within and outside the group on a weekly training log.
Results: Thirty-two stroke survivors (mean 64 years old, 38% female) attended the group for on average 5 weeks. On average 422 (SD 658) part goal-oriented practice repetitions were completed per week during and outside of the group. Part goal-oriented practice outside of the group was completed approximately 2 days per week (range 0–6), while whole goal-oriented practice occurred 1 day per week (range 0–5). Program refinements included altering the ratio of part to whole goal-oriented practice performed, conducting the group for a longer duration and in the ward dining room.
Conclusion: This group led to and encouraged repetitive upper limb practice during and outside of the group. It remains to be explored if this approach leads to long-term benefits.
Establishing an effective and efficient early supported discharge (ESD) rehabilitation program for stroke clients in Perth WA
R Jones,1 G Allison,2 J Ancliffe3
1SMHS RITH, 2Curtin University, 3Royal Perth Hospital, Perth, WA, Australia
Background: There is strong evidence for early supported discharge (ESD) following stroke (1, 2, 3) and in Perth, WA, Rehabilitation in the Home (RITH) had been providing ESD rehabilitation to stroke and other conditions since 2006. Compared with the literature and ‘gold’ standard stroke care (4,5) such as Trodheim in Norway, the access, predicted efficiencies and benefits to the healthcare system had not yet been fully optimised.
Aims: This project sort to optimise the stroke clinical pathway through developing closer relationships between the acute stroke unit and ESD program to deliver effective clinical outcomes in a cost effective way.
Methods: Several strategies were implemented over an 18 month period aimed at linking the acute stroke unit and the RITH program including creating specialist stroke therapist positions within RITH, facilitated discharge planning between the inpatient and RITH teams, joint professional development sessions and improved clinical pathways through the continuum of care for stroke patients.
Results: The implemented project strategies were able to demonstrate better articulation of the RITH program with the acute stroke services to produce systems change resulting in a decrease in LOS in the Stroke unit, reduced waiting periods for inpatient rehabilitation units and increased referrals to the program with earlier discharge to the home rehabilitation program.
Conclusion: The gains achieved through these clinical redesign strategies are critical for the provision of best practice clinical interventions for stroke patients along with improving the efficiencies of the healthcare system to meet the growing demands of increased activity and funding reforms.
 The National Stroke Foundation. [Homepage on the internet]. Available from: http://www.strokefoundation.com.au
 Early supported discharge after stroke [Review]. J Rehabil Med 2007; 39: 103–108.and
 Early supported discharge services for stroke patients: a meta-analysis of individual patients' data. Lancet 2005; 365: 501–506., , , , et al.
 A consensus on stroke: early supported discharge. Stroke 2011; 42(5): 1392–1397., , , et al.
 Early Supported Discharge Trialists. Services for reducing duration of hospital care for acute stroke patients. Cochrane Database of Systematic Reviews. Published Online: September 12, 2012. Available from: http://summaries.cochrane.org, ,
Thrombolysis in a centenarian: a case report
A Schutz, D Crimmins
Gosford Hospital, Gosford, NSW, Australia
Background: There are not many data on thrombolysis in the very elderly. It is generally accepted that elderly stroke patients have worse outcomes than their younger counterparts. Recent studies have found age over 80 to be an independent predictor of death and of reduced functional outcome at 3 months, and increasing age to be associated with poorer outcomes. Outcomes remain superior to placebo in all age groups, however. Rates of symptomatic haemorrhage seem not to be increased. Many studies have found thrombolysis in the elderly to be safe and effective. Age alone should not be a barrier to treatment.
Case: A 101-year-old lady presented at 60 minutes with a right hemiparesis and a complete aphasia following a witnessed fall in a hostel. Her background is remarkable for an abdominal aortic aneurysm (radiological surveillance), depression and mastectomy for localised breast cancer. Plain CT revealed no acute changes, and CT angiogram revealed complete occlusion at the terminus of the left internal carotid artery. CT perfusion confirmed a large ischaemic penumbra in the region of the left anterior and middle cerebral arteries. Thrombolysis was administered at 102 minutes with good effect. The patient achieved complete symptom resolution within 2 hours, with recanalisation on repeat angiographic imaging, and no evidence of completed stroke on 24-hour MRI.
Conslusion: Thrombolysis can be safe and effective in the very elderly.
Profile and outcome of intracerebral haemorrhage (ICH) in east China: a 1-year prospective follow-up study hospital-based stroke registry study
J Yang, Y Zhang, J Zhou, Y Tian, H Zhao, Y Liu
Department of Neurology, Nanjing Hospital affiliated to Nanjing Medical University, Nanjing, China
Background: In mainland China, there is a higher rate of ICH than in western countries, and the profile and outcome from ICH may vary in different regions.
Aims: To investigate risk factors, management and prognosis of ICH in a large level 3 teaching hospital of East China.
Methods: From September 2004 to September 2005, 132 consecutive ICH patients (23.9% of 552 stroke patients) admitted to the Department of Neurology were consecutively registered. Standardised clinical and imaging information were collected at baseline and all but 5 patients were follow-up prospectively over 12 months.
Results: The average age of patients was 64.7 ± 12.3 (range 39–90) years, 44 (33.3%) were female, 49 (37.1%) were smokers and 32 (24.2%) regularly drank alcohol. Their risk factor profile included: 89 (67.4%) with hypertension, 9 (6.8%) with diabetes, 7 (5.3%) hyperlipidaemia. Only four (3.0%) of patients received minimally invasive aspiration of hematoma surgery, and their outcome did not differ from the medical group. At 12 months, 35 (26.5%) patients had died and 54 (40.9%) were either dead or disabled.
Discussion: ICH affects patients at a younger age than in China compared to the west, but the poor outcome appears comparable across regions and China and in other countries.
Use of the Liverpool care pathway in an acute stroke unit
TY Wu,1 YK Baker,1 A Parker,2 WJ Brownlee,1 A O'Callaghan,2 PA Barber1,3
Departments of 1Neurology and 2Palliative Care Medicine, Auckland City Hospital, 3Department of Medicine, Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
Background: The Liverpool Care Pathway (LCP) provides a structured approach to the management of a patient who is dying. There has been almost no research on the role of the LCP in the palliative care of stroke patients.
Aim: To provide the first descriptive study of the use of the LCP in stroke patients in an Australasian setting.
Methods: The LCP was introduced in the Auckland City Hospital acute stroke unit in October 2010. All stroke unit patients who were commenced on the LCP and/or who died were identified from databases. Patient demographic information, stroke type and severity (NIHSS), indications for the LCP, and time from stroke onset to death, were recorded.
Results: Ninety-eight of 953 (10%) patients admitted to the stroke unit between 1 October 2010 and 31 December 2012 died. Seventy-two (73%) of the patients who died were commenced on the LCP [42 women; mean age 81.1 (SD 9.9) years; median NIHSS 21, 72% ischemic stroke]. The mean (SD) time from admission to starting the LCP was 72 (110) hours, and to death was 140 (130) hours. The mean number of hours on the LCP was 72.2 (2.6) hours. One patient was taken off the LCP when they improved.
Conclusion: The LCP is transferable into stroke care and potentially enhances care for dying stroke patients. A prospective study examining staff, family and carer experience with the use of the LCP in being planned.
Upper limb compartment syndrome: an unusual complication of stoke thrombolysis
WJ Brownlee, TY Wu, B Snow
Department of Neurology, Auckland District Health Board, Auckland, New Zealand
Background: Bleeding is the most important complication of treatment with intravenous tissue plasminogen activator (tPA) for acute ischemic stroke. Neurologists are familiar with intracranial hemorrhage, the most feared site for bleeding following tPA, but extracranial bleeding can also occur resulting in substantial morbidity and mortality.
Aim and Methods: To describe a patient who developed acute upper limb compartment syndrome following stroke thrombolysis with accompanying clinical photography and imaging. A literature search was conducted to identify other reported cases.
Results: An 88-year-old woman presented following the sudden onset of left hemiparesis and slurred speech (NIHSS = 8). There was no history of trauma. Following treatment with tPA she developed pain and swelling in the left arm associated with haemodynamic instability. Compartment pressures were elevated. The patient was not thought to be a candidate for fasciotomy and was managed conservatively. A single other case in the stroke literature describes a patient with compartment syndrome after treatment with tPA who had an occult fracture of the proximal radius.
Discussion: Neurologists should be aware of this unusual complication of stroke thrombolysis.
Burden of untreated atrial fibrillation in the acute setting: an audit of a general medical service at a tertiary level hospital, Wellington, New Zealand
E Jolliffe, I Rosemergy, J Lanford, A Reid
Wellington Regional Hospital, Wellington, New Zealand
Background: Anticoagulation to prevent first and recurrent ischaemic stroke due to atrial fibrillation (AF) remains highly effective.1 A recent audit of New Zealand's stroke care delivery suggested that among patients presenting with an acute ischaemic stroke, the percentage with known AF was high (40%). However, only 24% were on anticoagulants.2 The number of patients not on anticoagulants is high compared to other patient populations with AF.3
Aims: We aimed to determine the burden of untreated AF within patients presenting in the acute care setting.
Methods: An audit of patients presenting with AF, either as their primary diagnosis or secondary diagnosis, to the General Medical Service at Wellington Regional Hospital was performed. 100 presentations during a specified 3-month period were randomly selected.
Results: Ninety-eight percent had a CHA2DS2VASC (congestive heart failure, hypertension, age, diabetes, stroke/transient ischaemic attack, vascular disease, sex) score ≥2, but only 21% had a stroke risk score documented.
19% were already anti-coagulated, a further 7% were commenced on anticoagulation, and 9% were commenced on antiplatelet therapy.
If anticoagulation was not prescribed, most frequently (27%) no reason was documented. Documented reasons included, decision deferred to the General Practitioner (17%), patient deceased (9%), patient considered too frail or a falls risk (8%), previous bleeding problem (8%), or current bleeding problem (2%).
Conclusions: Our audit confirms the underuse of anticoagulation in patients with AF who should receive anticoagulation according to published guidelines. The reasons not to anticoagulate were often not documented or not valid.
 Stroke Prevention in Atrial Fibrillation Investigators, Adjusted-dose warfarin versus low-intensity, fixed-dose warfarin plus aspirin for high-risk patients with atrial fibrillation: Stroke Prevention in Atrial Fibrillation III randomized clinical trial, The Lancet (1996) 348: 633–638.
 New Zealand National Acute Stroke Services Audit: acute stroke care delivery in New Zealand, The New Zealand Medical Journal (2012) 125: 44–51., , , , , ,
 Underuse of Oral Anticoagulants in Atrial Fibrillation: A Systematic Review, The American Journal of Medicine (2010) 123: 638–645., , , , ,
A Very Early Rehabilitation Trial (AVERT): progress
J Bernhardt of behalf of the AVERT Trialists' Collaboration
The Florey Institute of Neuroscience and Mental Health, Melbourne, Vic., Australia
Background: Early and frequent out of bed activity starting within 24 hours of stroke, may be an important component of effective stroke unit care. We hypothesise that early mobilisation will reduce death and disability and be cost effective, compared to standard care.
Aims: To achieve high data quality with ≥90% data completion targets for primary outcomes, and secondary outcomes ≥90%, with cognitive and mood tests ≥80%.
Methods: AVERT is a multi-centre, single blind randomised controlled trial. Randomisation is concealed, with stratification by site and stroke severity. Included: Medically stable patients within 24 hours of stroke. Excluded: patients with severe pre-morbid disability and co-morbidities. Early rehabilitation starts within 24 hours, for 14 days. Control group patients receive standard care. Primary outcome: 3-month modified Rankin Scale. Sample size is 2104 patients (n = 1052 per group). Analyses will be intention to treat.
Results: Fifty-four hospitals are participating in five countries. At February 2013, 31 074 patients have been screened with 1530 patients recruited. Recruited patients: mean (SD) age: 70.5 (12.9) years; male: 62.9%; first stroke: 81.6%; infarct 87.5%; mean (SD) NIHSS: 8.8 (6.4); rtPA: 21.6%. 1422 patients have completed 3-month follow up. Primary outcome completion 99.6%, Secondary outcome completion 92.0–99.9%, cognitive 83.0% and mood 81.4%.
Discussion: The trial data quality is high and is exceeding data completion targets. The Data Monitoring Committee has met nine times and no safety issues have been identified. We aim to complete recruitment in December 2014.
Reasons for non-recruitment to a Very Early Rehabilitation Trial (AVERT)
J Bernhardt,1 S Speare,1 J Collier,1 L Churilov,1 AG Thrift,2 R Lindley,3 GA Donnan,1 H Dewey,1 P Langhorne4 on behalf of the AVERT Trialists' Collaboration
1The Florey Institute of Neuroscience and Mental Health, 2Monash University, Melbourne, Vic., 3University of Sydney, Sydney, NSW, Australia, and 4University of Glasgow, Glasgow, Scotland, United Kingdom
Background: A Very Early Rehabilitation Trial (AVERT) is an ongoing multi-centre international randomised controlled trial testing whether rehabilitation commenced within 24 hours reduces death and disability. We aimed to explore reasons for non-recruitment into AVERT.
Methods: All patients admitted with stroke were screened. Trial exclusion criteria included: hospital attendance >24 hours after stroke, premorbid disability, early deterioration, admission to ICU and participation in other trials. We used binary logistic regression analyses to explore potential reasons for non recruitment.
Results: Twenty thousand stroke patients were screened at 44 hospitals from July 2006 to December 2011, with 1158 recruited, 18,842 not recruited. Characteristics of patients not recruited: mean age (SD): 72.0 yrs (14.0); woman 47.3%; infarct 86.7%; stroke severity (NIHSS); mild 53.1%; mod 26.2%; severe 20.7%. In examining reasons for non recruitment (adjusted), patients with mild stroke had greater odds of admission >24 hours (OR 0.6 CI 95% 0.5–0.6) and women had greater odds of premorbid disability (OR 1.5 CI 95%1.3–1.6). Increasing age (OR 1.1 CI 95% 1.1–1.1), haemorrhagic stroke (OR 2.9 CI 95% 2.5–3.3) and severe stroke (OR 10.4 CI 95% 9.2–11.6) were all associated with deterioration; and patients admitted to ICU had greater odds of having haemorrhagic stroke (OR 2.6 CI 95% 2.2–3.1) or severe stroke (OR 4.3 CI 95% 3.8–4.8). Patients with haemorrhagic stroke had lower odds of recruitment to other trials (OR 0.6 CI 95% 0.5–0.9).
Conclusion: Exclusion criteria are selected to minimise harm and maximise the likelihood of study completion. Results support a typical clinical pattern for non recruited patients.
Perspectives on language, medicine and the human body in a multidisciplinary biomedical research group
VJ Krawczyk,1,2 J Crichton,1 MA Hamilton-Bruce,2,3 SA Koblar2,3
1School of Communication, International Studies and Languages, University of South Australia, Magill, 2Stroke Research Programme, Neurology, Basil Hetzel Institute for Medical Research, The Queen Elizabeth Hospital, Woodville South, 3School of Medicine, University of Adelaide, Adelaide, SA, Australia
Background: The translational research (TR) paradigm, which leads to the development of clinical applications, provides a new way of working in biomedical science and is essential for continued advancement of stroke research. However, little is known about multidisciplinary group-work practices within this paradigm.
Aim: This exploratory qualitative case-study aimed to learn about research group members' perspectives on language, medicine and the human body in their work practices, as these are key components of the work they carry out as researchers.
Methods: Multiple data collection methods were used, i.e., surveys, focus groups, participant observation and organisational documents. Data from 16 researchers, including those with a special interest in stroke, were used to provide a case description. Focus group transcripts were further subjected to template analysis, to generate case-based themes.
Results: Analysis of the data suggested that there was limited consideration about Language (first main theme of research). However, the discipline of Medicine (second main theme) provided some common ground for the project, with medical scientists often acting as brokers between clinicians and basic scientists. Analysis also showed that the group did not seem to have a shared imagination of the Human Body (third main theme), thus what they were learning together for the benefit of their project was not fully optimised.
Conclusion: Drawing on these findings emphasises the need for further research into how language, medicine and conceptions of the human body can influence, craft or shape research groups working under the TR paradigm, in order to maximise outcomes.
Animal assisted therapy (AAT) for stroke victims: the need for objective assessment?
MA Hamilton-Bruce,1 J Gowland,2 S Hazel,2 SA Koblar1
1Stroke Research Programme, Discipline of Medicine, University of Adelaide and Neurology, The Queen Elizabeth Hospital, Adelaide, 2School of Animal and Veterinary Sciences, University of Adelaide, Roseworthy, SA, Australia
Background: AAT research findings have shown some benefits for humans in a range of disorders, including stroke. However, the research area is complex and there are many challenges. Furthermore, although non-human animals are integral to the intervention, there is little concomitant objective reference to the welfare of both.
Aim: To review the literature to identify gaps that we could explore in order to assess AAT objectively, taking the welfare of both human and non-human animals into consideration.
Method: We searched the major databases covering the medical, scientific, social science and veterinary literature and examined these for assessment of AAT on both human and non-human animals, using the same assessment tool at the same time.
Results: We identified a range of AAT treatments and assessment tools in multiple disease groups (including stroke), multiple disciplines (including medicine, allied health and veterinary science) and in multiple organisations, with discipline-specific assessment tools being used. Assessment of both human and non-human animals with the same tool at the same time was limited. Where this had occurred, e.g., in a study of affiliative behaviour in humans and dogs, neurochemicals were assessed on blood samples. While the process was considered reciprocal, it was unclear why there was still some biochemical difference.
Conclusion: Many questions in AAT are unanswered. Given technological advances, objective assessment can now be done less stressfully using a salivary biomarker panel. This could assist in the elucidation of the impact of AAT on both stroke victims and the non-human animals involved.
QEEG may uniquely inform and expedite decisions regarding reperfusion therapies in acute stroke
N Sheikh,1,2,3 A Wong,2,3 S Read,2,3 A Coulthard,4,5 S Finnigan1
1UQ Centre for Clinical Research, 2School of Medicine, 5Discipline of Medical Imaging, The University of Queensland, 3Acute Stroke Unit, Neurology Department, 4Department of Medical Imaging, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia
Background: Numerous studies indicate that quantitative electroencephalography (QEEG) markers, e.g., delta/alpha power ratio (DAR), can uniquely inform ischaemic stroke management. Some outcomes indicate that continuous QEEG can rapidly detect neurological responses to intravenous (IV) alteplase, well before this is apparent clinically .
Aims: To investigate the efficacy of QEEG to inform decision-making regarding thrombectomy.
Methods: Continuous bedside EEG using standard methods commenced as soon as feasible after computed tomography. QEEG analyses were performed using published methods  with each measure computed from 2 minutes of EEG.
Results: In patient 1 DAR substantially worsened (increased) as symptoms deteriorated. Subsequently, DAR improved significantly within minutes of IV alteplase bolus, 50 min before any clinical improvement was apparent. In patient 2 DAR indicated unsuccessful reperfusion therapy. In patient 3 DAR initially indicated that IV alteplase was unsuccessful then promptly indicated that thrombectomy had been successful, despite the patient being sedated (for the procedure) which precluded clinical assessment for 48 hours.
Discussion: These cases indicate that continuous QEEG can rapidly assess cerebral responses to reperfusion (or lack thereof), even well before this is apparent clinically. Importantly, this is distinct from reperfusion revealed by imaging, which does not necessarily equate with tissue salvage or restoration of neurological function. QEEG also accurately indicated favourable response to thrombectomy in a sedated patient. Thus QEEG may uniquely inform and expedite decisions regarding thrombectomy when IV alteplase is unsuccessful, and may inform assessments of the efficacy of thrombectomy (including in sedated patients). This preliminary study is ongoing.
 EEG in ischaemic stroke: Quantitative EEG can uniquely inform (sub-)acute prognoses and clinical management. Clinical Neurophysiology (2013) 124:10–19., ,
Phosphodiesterase 4D (PDE4D) and stroke: heterogeneity of studies
AG Milton,1 MA Hamilton-Bruce,1,2 J Jannes,1 SA Koblar2
1Stroke Research Programme, Neurology Department, Basil Hetzel Institute for Medical Research, The Queen Elizabeth Hospital, Woodville, 2School of Medicine, University of Adelaide, Adelaide, SA, Australia
Background: Large-scale epidemiological studies have shown that genetic factors play an important role in the pathogenesis of stroke, with PDE4D identified as the first gene predisposing to ischaemic stroke. Many single nucleotide polymorphisms (SNPs) within the PDE4D gene have been implicated in the pathogenesis of stroke, although linkage varies considerably.
Aim: To review the literature and assess underlying differences in studies of PDE4D gene-association with ischaemic stroke, to improve future association studies.
Method: We searched major scientific/medical databases for case-controlled studies on PDE4D and stroke. Publications were assessed for critical differences in population and methodologies.
Results: As discussed in our study1 reporting an association with stroke in an Australian population, and in recent publications2, different populations show variable linkage or no variation (monomorphism). Sources of variation in studies include: lack of power to study stroke and subtypes; different stroke-subtype classification criteria and population ethnicity.
Conclusion: Future prospective case-controlled studies must be powered for stroke and stroke subgroup analysis, use standardised classification of ischaemic stroke (e.g. TOAST with pre-defined cut-offs for parameters such as percentage stenosis in large-vessel stroke) with details of population ethnicity collected and defined to avoid some of the variation seen historically. Further exploration of the ethnicity issues for accurate stratification may assist in clarification of the association between PDE4D and ischaemic stroke.
 Association of the PDE4D gene and cardioembolic stroke in an Australian cohort. Int. J. Stroke (2011) 6:480–486.et al.
 Association of PDE4D gene with ischaemic stroke. Int. J. Stroke (2012) 7:E8.et al.
Using data from the Australian Stroke Clinical Registry (AuSCR) for collaborative quality improvement projects at Tamworth Base Hospital
I Wilson,1 R Peake,1 B Grabsch,2 J Lim,3 CS Anderson,3 NA Lannin,4 DA Cadilhac2,5 On behalf of the AuSCR Management Committee
1Tamworth Base Hospital, Tamworth, 3The George Institute for Global Health, Camperdown, NSW, 2Florey Institute of Neuroscience and Mental Health, Heidelberg, 4Alfred Clinical School, La Trobe University, Melbourne, 5Stroke and Ageing Research Centre, Monash University, Clayton, Vic., Australia
Background: The Australian Stroke Clinical Registry (AuSCR) provides opportunities for participating hospitals to monitor and improve care and outcomes for patients with acute stroke. Tamworth Base Hospital, New South Wales (NSW) has been contributing to the registry since January 2010.
Aims: To describe the use of national clinical quality registry data to identify gaps in evidence-based care at an individual hospital level.
Methods: Prospective collection of patient demographics and clinical information enables the generation of reports on processes of care and discharge destination. The comparative data were used by our stroke service to monitor performance and establish collaborative plans for instigating improvements.
Results: By February 2013, Tamworth had data for 380 patients (representing 14% of all patients from nine AuSCR participating sites in NSW). Our reviews of the AuSCR data reports in 2010 and 2011 provided evidence of: (1) poor use of thrombolysis (2010: 5%, Tamworth; Australia, 9%) resulting in new education projects, amendments to the tPA pathway process, and participation in relevant clinical trials; (2) falling patient admissions to the Tamworth stroke unit (86%, 2010; 81% 2011) flagging the need to review processes with our eleven rural feeder hospitals; and (3) the need to communicate more with the discharge planner and ensure greater uptake of patient centred involvement in the development and implementation of discharge care plans (7%, 2010; 11%, 2011) but behind national figures (46%, 2011).
Conclusion: Whilst there is scope for further practice improvements, access to quality of care data has motivated cross-discipline collaboration and quality improvement activities.
Health literacy (HL) mediates the relationship of socioeconomic status (SES) and stroke in a population sample
S Appleton,1 S Biermann,2 MA Hamilton-Bruce,2 C Piantadosi,1 G Tucker,3 SA Koblar,2 R Adams1
1The Health Observatory, 2Stroke Research Programme, Discipline of Medicine, University of Adelaide and Department of Neurology, The Queen Elizabeth Hospital, 3Health Statistics, SA Health Department, Adelaide, SA, Australia
Background: While a link between low or limited HL and adverse health outcomes is well established in a number of conditions, research related to stroke is limited. Furthermore, relatively little is known about the associations of HL and life-style behaviours at a population level.
Aim: To examine the association of functional HL (FHL) with self-reported lifestyle behaviours, cardio-metabolic risk factors and prevalent stroke in a representative Australian population sample.
Method: Data were derived from 2,487 South Australian adults (mean age 58.0 years) participating in Stage 3 (2008–10) of the North West Adelaide Health Study, a population biomedical cohort. Participants underwent clinical assessment and completed questionnaires assessing doctor-diagnosed conditions and demographics. FHL was assessed using the Newest Vital Sign. Structural equation modelling assessed the mediating effect of FHL on the relationship between SES, lifestyle behaviours and stroke.
Results: At-risk and inadequate FHL were present in 16.6% and 9.8% of participants, respectively. After adjustment for age and gender, FHL was significantly associated with hypertension, depression, current smoking, diabetes and insufficient activity, as well as income, education and employment status. There was a statistically significant mediation effect of FHL on the path SES to stroke, with the mediation effect estimated at 8.9 % of the total effect.
Conclusion: Considering health literacy in design and dissemination of health information, with respect to healthy behaviours and stroke risks, should be a priority for clinical service designers and public health policy-makers in order to improve primary and secondary stroke prevention.
Speech pathologists' clinical decision making in the provision of services to people with aphasia
N Ciccone,1,2 D Hersh,1,2 E Armstrong,1,2 E Godecke1,2
1Edith Cowan University, Perth, WA, 2Clinical Centre of Research Excellence in Aphasia Rehabilitation, Brisbane, Qld, Australia
Background: Despite growing evidence for a range of approaches to aphasia therapy, little is known about how speech pathologists (SPs) view their clinical decision making and management choices across clinical settings.
Aims: To explore SPs' accounts and perceptions of management decisions for people with aphasia (PWA) in acute and rehabilitation settings.
Methods: SPs from acute hospitals (n = 8) and rehabilitation contexts (n = 8) recorded their occasions of service for a single PWA. All clinical activities were recorded while the PWA was part of the SPs' caseload. SPs then participated in a semi structured interview at the completion of the data collection period.
Results: Across SP occasions of service, aphasia management accounted for 64% (19–100%) of the identified activities in the acute settings and 75% (57–95%) in the rehabilitation settings. Dysphagia management, treatment of motor speech disorders and overall case management constituted the remainder of the clinical activities. Direct language intervention accounted for 19% (0–37%) of the aphasia related activity in the acute settings and 56% (39–69%) in the rehabilitation settings. Other aphasia related management involved: assessment, counselling, partner training and providing aphasia education. The SPs' perception of factors influencing their clinical decision-making included caseload prioritisation, case-mix and patient specific factors.
Conclusion: Clinical decision making in the management of people with aphasia is complex and multi-faceted. The time spent providing direct language intervention varied across acute and rehabilitation settings. Both the amount, and the balance of direct (assessment and therapy) and indirect intervention requires more debate in the light of best practice guidelines.
Learned communicative non-use is a reality in very early aphasia recovery: preliminary results from an ongoing observational study
E Godecke,1,2 E Armstrong,1,2 D Hersh,1,2 N Ciccone,1,2 J Bernhardt3
1Edith Cowan University, Perth, WA, 2Clinical Centre of Research Excellence in Aphasia Rehabilitation, Brisbane, Qld, 3The Florey Institute of Neuroscience and Mental Health, Melbourne, Vic., Australia
Background: To better understand the interactions that occur in early stroke recovery, this study focuses on observed communicative activities that may underlie the neuroplasticity principles of “use it or lose it,” and “learned non-use.”
Aim: This study aimed to determine if people with aphasia (PWA) had equivalent general and communicative activity as people without aphasia (PwoA) in the acute hospital setting during very early stroke recovery.
Methods: Eight participants with acute aphasia and eight participants without aphasia were observed. Inclusion criteria: acute stroke, acute post-stroke aphasia, medical stability and corrected hearing/vision. Exclusion criteria: previous aphasia, previous head injury, major depression and a progressive neurodegenerative condition. All PWA were assessed with Western Aphasia Battery (Aphasia Quotient) within 3 days of observation.
Participants were video recorded in hospital over a single day (7.5 hours). For each participant observational snapshots were recorded at 10-minute intervals (45 observations over the 7.5 hours). The snapshot activity was defined as the activity within the first minute of each 10 minute interval and included all communication and general activities. Data were collected on weekdays and weekends.
Results: Sixteen people have completed (eight PWA and eight PWoA) the 7.5 hours of observation.The mean observation time post-stroke was 10 days. PWA spent more time alone and less time communicating than PWoA. Nurses and family were the most frequent communication partners for PWA.
Conclusions: Early data suggest that communicative inactivity in early stroke recovery may be a substantial factor in “learned communicative non-use” for people with aphasia.
Barriers faced when discharging a patient with high level of care needs to a remote Aboriginal community in Far Northern Queensland: a successful case study
C Barron, D Clifford
Queensland Health, Cairns, Qld, Australia
Background: Traditionally Aboriginal and Torres Strait Islander clients have been found to have poorer functional outcomes as a result of stroke. This case study discusses the challenges faced and overcome by the newly appointed Aboriginal and Torres Strait Islander Stroke Care Team during the recovery of an Aboriginal man in Cairns Base Hospital.
Aims: To discuss the challenges of a safe, timely and successful discharge to a remote, northern Queensland community.
Methods: Intensive Occupational Therapy and Physiotherapy services were provided for the final 12 weeks of the clients inpatient stay. A number of obstacles were identified and subsequently overcome to allow the client with high level of care needs to return to community.
Results: The patient was able to be successfully discharged home to his community with the support of his family and the local HACC (Home and Community Care) service.
Discussion: The greatest challenges faced by the team were:
- ○ Cultural – Identifiing appropriate carers and completing culturally appropriate carer training. Clients and carers often felt isolated from family.
- ○ Services – Limited services are avaliable in many Indigenous communities to assist family with caring for a loved one at home. Follow up is often limited and provided infrequently via outreach services.
- ○ Environmental – Hospital based staff can have poor awareness of community dynamics, housing availability and conditions. Remote communities are unable to have home visits and greater distances also mean longer time periods to transport equipment. Often inferences on potential level of function and subsequent equipment needs must be made before full rehab potential is reached.
Very Early Rehabilitation in SpEech (VERSE): the development of an Australian randomised controlled trial of aphasia therapy after stroke
E Godecke,1,2 E Armstrong,1,2 J Bernhardt,3 S Middleton,4 T Rai,5 A Holland,6 DA Cadilhac,3 A Whitworth,7 M Rose,8 N Ciccone,1,2 GJ. Hankey9,10
1Edith Cowan University, 7Curtin University of Technology, 9Royal Perth Hospital, 10University of Western Australia, Perth, WA,2Clinical Centre of Research Excellence in Aphasia Rehabilitation, 4St. Vincent's & Mater Health Sydney and Australian Catholic University, Brisbane, Qld,3The Florey Institute of Neuroscience and Mental Health, 8La Trobe University, Melbourne, Vic.,5University of Technology Sydney, Sydney, NSW, Australia, and6University of Arizona, Tucson, Arizona, USA
Background: The Cochrane Review stated that speech-language therapy (SLT) intervention showed some effectiveness for people with aphasia following stroke. The authors stated, however, that there was “insufficient evidence within this review to establish the effectiveness of one SLT approach over another” and that “we still need to establish what is the optimum approach, frequency, duration of allocation and format of SLT provision for specific patient groups.”
Aims: This study aims to test whether intensive prescribed aphasia therapy (VERSE) is more effective and cost saving than non-prescribed usual care training in very early aphasia recovery.
Methods: This 3-arm, prosepective, randomised, open-label, single-blinded controlled trial has an endpoint at 3 months (Aphasia Quotient of Western Aphasia Battery). Participants with acute post-stroke aphasia will be randomised to usual care (UC), usual care-plus (UC-Plus) or VERSE therapy. UC therapy is usual ward based aphasia therapy; UC-Plus is usual ward based therapy but provided daily, and VERSE therapy is a prescribed aphasia therapy intervention provided daily. Therapy will commence before day-14 post-stroke and will be provided for 20 sessions.
Discussion: This NHMRC funded study is the first in Australia, and one of the first in the world to address the research gaps in very early aphasia intervention, using a robust study design. This research will determine if a prescribed type and amount of aphasia therapy will enhance spontaneous communication recovery very early post-stroke recovery and will potentially change the face of post stroke aphasia management. A detailed rationale and trial methodology will be presented.
Nurse practitioner TIA clinic: establishment and patient satisfaction
L Weir,1 A Turner,2 S Middleton,3 M Worcester,2 B Murphy,2 S Stratton,2 SM Davis,1 P Hand1
1Royal Melbourne Hospital, 2Heart Research Centre, Melbourne, Vic., 3National Centre for Clinical Outcomes Research, Australian Catholic University Australia, Brisbane, Qld, Australia
Background: Transient ischaemic attack (TIA) is a warning sign for stroke. Urgent treatment is required to reduce stroke risk. Management generally occurs by specialist stroke services. Stroke Nurse Practitioners (SNP) can help meet increasing service demand.
Aims: To establish a SNP led TIA outpatient clinic at Royal Melbourne Hospital (RMH), and to evaluate patient satisfaction with care.
Methods: We set up a SNP led clinic for assessment and management of TIA outpatients in an autonomous collaborative framework with the RMH Stroke Neurologists. An independent research officer recruited eligible patients (diagnosed with TIA; aged ≥18 years; Modified Rankin Scale score <4; English speaker) immediately following their clinic appointment. Satisfaction with care was assessed using quantitative (questions from the Australian Nurse Practitioner Study Research Toolkit) and qualitative (semi-structured interview) methods.
Results: Twenty-four patients have completed the satisfaction surveys (68% male; mean age 68 years). 79% had not heard of a SNP before. All reported satisfaction with the service (96% highly satisfied). All patients indicated the SNP spent enough time with them and listened to them carefully, and they would see a SNP again and would recommend a SNP to family and friends. Qualitative results indicate patients valued receiving detailed health information from the SNP in an understandable way in a friendly and relaxed environment.
Discussion: An SNP TIA clinic is feasible and associated with high levels of patient satisfaction. Challenges include current limitations in access to Medicare Benefits Scheme when working within a public hospital leading to NP practice inefficiencies.
SA statewide stroke clinical network 2009–2013
K Goldsmith,1 J Jannes2
1SA Health, 2The Queen Elizabeth Hospital, Adelaide, SA, Australia
Background: The National Stroke Foundation (NSF) clinical audit in 2007 prompted the South Australian government to appoint an advisory committee to develop the South Australian Stroke Service Plan 2009–2016 (Plan). The Statewide Stroke Clinical Network (Network) was established in July 2009.
Aims: Provide an overview of Network activity from inception.
Methods: The aim of the Network is to monitor the implementation of the recommendations in the Plan. The Network consists of all people who work in stroke or are affected by stroke and is led by a Steering Committee. The Steering Committed appointed work groups to develop specific pathways, protocols or direction based on the recommendations in the Plan.
Results: Since 2009 the Network has developed a number of tools to assist the health workforce and administrators to provide better stroke care. A rapid assessment and transport system for the SA Ambulance Service has been established since 2011. The Adelaide Stroke Service Report provides direction about where stroke services should be and what infrastructure is required. The Stroke Management Procedures & Protocols provide an implementation tool for the NSF Clinical Guidelines for Stroke Management 2010. A business case for a Centralised Transient Ischemic Attack (TIA) service for metropolitan South Australia has been submitted to SA Health. The Stroke Rehabilitation Pathway provides an assessment tool to ensure appropriate rehabilitation as well as a guide to best practice care.
Discussion: New direction for the Network is around Aboriginal and Torres Strait Islander stroke care, data and information management, and implementing stroke services in country.
Head position in the early phase of acute ischaemic stroke: an international survey of current practice
P Muñoz-Venturelli,1,2 V Olavarría,1 P Vicuña,1 A Brunser,1 P Lavados,1 H Arima,2 CS Anderson2
1Clínica Alemana de Santiago, Santiago, Chile, and 2The George Institute for Global Health, Sydney, NSW, Australia
Background: Tilting down to the flat position the head of patients with an acute ischaemic stroke (AIS) could ameliorate blood flow in the penumbral region and improve outcome. Current guidelines regarding this issue are not evidence–based, and local protocols/policy likely vary across different healthcare settings.
Aims: To assess knowledge and variations on head position for AIS patients among doctors from hospitals in different countries.
Method: We conducted a survey of 91 medical doctors (neurologists and intensive care specialists) at 66 hospitals in South and Central America, the US and Spain during late 2012.
Results: Most (63%) participants considered the elevated (30° upright) head position for AIS patients is preferred at their hospital, 44% claim that no written protocol regarding this issue exists and an additional 9% answered that although there is a protocol at their centre, it is rarely used. Moreover, 65% recognised uncertainty about the correct head position for AIS patients. When only doctors from academic hospitals were analysed, there were non-significant differences: 69% prefer the up-right position, 49% had no protocol, and 65% were uncertain at to the best position. Almost all participants (95%) would be willing to participate in a clinical trial to address the uncertainty.
Conclusion: Although the elevated head position is most popular, most doctors accept uncertainty over the best head position to apply to their patients with AIS. An opportunity exists for a randomised trial to resolve uncertainty and develop evidence-based consensus protocols to improve patient outcomes.
1. Heads down: flat positioning improves blood flow velocity in acute ischemic stroke. Neurology. 2005;64:1354–1357., , , .
2. National Guideline Clearinghouse. Guide to the care of the hospitalized patient with ischemic stroke. 2nd edition. http://guidelines.gov/content.aspx?f=rss&id=13575 (accessed February 28, 2013.
A meta-analysis of brain regions activated during tactile stimulation in healthy individuals: implications for sensory impaired stroke survivors
S Palmer,1 A Barutchu,1 E Low,1,2 L Carey,1,3
1Neurorehabilitation and Recovery, Stroke Division, Florey Institute of Neuroscience and Mental Health, Heidelberg, 2School of Psychological Sciences, 3Department of Occupational Therapy, School of Allied Health, La Trobe University, Bundoora, Vic., Australia
Background: One in two people experience loss in ability to feel everyday objects through touch following stroke.
Aim: We sought to quantitatively summarise the brain areas involved in processing tactile (touch) stimulation (without motor processing) to separate right and left hands in normal healthy controls.
Methods: We reviewed the somatosensory literature from relevant databases and found a total of 283 papers. Studies that involved tactile stimulation alone, of the right or the left hand separately, utilised either PET or functional MRI technology, and involved whole brain analysis were included. This resulted in n = 32 studies for the right hand and n = 20 for the left hand. The analysis involved a published meta-analysis technique, known as Activation Likelihood Estimation (ALE) (www.brainmap.org). This analysis produces a brain map of significant clusters of brain activiation. Using a threshold for false discovery of p < 0.05 and the recommended cluster threshold, we performed ALE meta-analysis on the coordinates of brain activation reported.
Results: Results of the meta-analysis for the right hand tactile stimulation, showed significant clusters in left primary (S1) somatosensory cortex and bilateral secondary (S2) somatosensory cortices as expected. In comparison, left hand tactile stimulation revealed significant clusters of activation in the both the right and left S1, as well as bilateral S2 somatosensory areas.
Conclusions: Differences observed in the pattern of activation for left versus right hand tactile stimulation may have implications for nature of sensory loss and subsequent rehabilitation when infarction is located in the left versus right hemispheric somatosensory areas.
Early access to thrombolysis: implementation of the NSW reperfusion programme
M Tinsley,1 J Dunne,1 M Longworth,1 B Paddock,2 J.M. Worthington3
1Agency for Clinical Innovation, 2Ambulance Service of NSW, Sydney, 3Ingham Institute, Liverpool, NSW, Australia
Background: Although intravenous recombinant tissue plasminogen activator (rt-PA) is the most effective hyperacute stroke treatment it is estimated that only 3% of ischaemic stroke patients receive thrombolysis across Australia. Time to symptom recognition and the service delivery in the onset-to-door and door-to-needle periods determine thrombolysis rates and patient outcomes. Arriving at a non-thrombolysing hospital extends onset-to-needle time, and may exclude thrombolysis treatment.
The NSW Stroke Reperfusion Program: Early access to Thrombolysis is a state-wide pre-hospital and hospital programme designed to improve patient access to newly identified Acute Thrombolytic Centres (ATCs) in NSW.
Aim: Implementation of Early Access aims to shorten the onset-to-needle time in eligible patients with ischaemic stroke and increase thrombolysis rates by ensuring the right patient receives the right care in the right time, by arriving in the right place.
Methods: Design and implementation was a partnership of the Agency for Clinical Innovation with ambulance, emergency and stroke clinicians and Local Health District management. Twenty ATCs were identified; many upgrading services to 24/7 during lead-in. Ambulance crews were trained to identify eligible patients as ‘FAST positive,’ transporting them to ATCs with pre-notification, bypassing hospitals without 24/7 thrombolysis.
Results: Early Access to Thrombolysis went ‘live’ on 21/1/13. We describe the state-wide rural and metropolitan clinical redesign methodology, robust communication processes, defined scope and local project governance as well as early impacts and future development.
Conclusion: The program has been implemented successfully with 20 ATCs and in the first 10 days 41 FAST positive patients were identified in metropolitan areas.
Thai experience on primary-to-tertiary referral pathway under the universal coverage scheme
N Suksiriluksn,1 K Pongpirul,2,3 NC Suwanwela4
1Medical Students for Health Systems and Services (MS-HSS), Thailand Research Center for Health Services System, 2Department of Preventive and Social Medicine, Faculty of Medicine, 4Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand, 3Adjunct Faculty, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
Background: The Universal Coverage (UC) scheme of Thailand has launched new program to support stroke fast track, mainly to improve referral pathway. Although the principle is sound, the program implementation has not been evaluated.
Aims: To present Thai experience in implementing stroke fast track policy, financed under the Thai UC scheme.
Methods: Document review, secondary data analysis, and in-depth interview of national insurer, policymaker, clinical team of a university hospital, as well as referring hospitals were conducted.
Key issues explored included principle and development of the policy, budget allocation, expected outcomes, feasibility, and other concerns. Provider experiences along primary-to-tertiary care pathways were also investigated.
Preliminary Results: The policy was rapidly developed and launched based on mutual agreement between the National Health Security Office (NHSO) and some pilot tertiary hospitals. Approximately … baht was allocated and … cases were treated. While stakeholders agree with the importance of the policy, hospital providers raised a number of concerns about financial and non-financial administrative hurdles.
Conclusion/Discussion: “Best available care” have various meaning. Thailand, however, considers both clinical and financial aspects on the ground of monetary availability limitation.
Universal coverage … but access impaired by “labeling”
H Kim,1 K Pongpirul2,3
1B.A. Johns Hopkins University, Maryland, USA, and 2Lecturer, Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand, and 3Adjunct Faculty, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
Background: Thailand has been studied as a successful example of a low-middle income country that achieved universal health care coverage. Studies in the developed world showed that the publicly insured had higher chances of adverse clinical outcomes than the privately insured (1,2,3). However, little research has been done on how patient's health insurance status influences provider clinical practice in developing countries.
Hypotheses: We hypothesized that stroke patients received different care according to their health insurance status. “Labeling” stroke patients using Universal Coverage (UC) option may influence their clinical care.
Methods: Direct observation and in-depth interview were conducted in a large university hospital. Thematic content analysis was used to analyze the qualitative data.
Results: Stroke patients who used UC had longer waiting time for ward admission and MRI scan than patients who paid “out of pocket.” Emergency Room was a virtual ward for UC patients. Separate ward and waiting list was available for fee-for-service patients.
Conclusion: Labeling does exist in the process of stroke care.
 Effects of health insurance and race on colorectal cancer treatments and outcomes. Am J Public Health (2000) 90: 1746–1754., , , , , &
 Insurance status and access to urgent ambulatory care follow-up appointments. JAMA: J Am Med Assoc (2005) 294: 1248–1254., , , , , et al.
 Drug reimbursement and GPs' prescribing decisions: A randomized case-vignette study about the pharmacotherapy of obesity associated with type 2 diabetes: How GPs react to drug reimbursement. Fundam Clin Pharmac (2010) 24: 509–516., , , , &
Feasibility of an international tele-stroke service: implementation phase
A Ranta,1 C Gunawardana,1 M Whitehead,2 A Reoch3
1MidCentral Health, Palmerston North, New Zealand, and 2NHS Lanarkshire – Wishaw Hospital, Wishaw, 3Scottish Centre for Telehealth and Telecare, NHS24, Aberdeen, Scotland, UK
Background: Stroke thrombolysis can effectively reverse acute stroke symptoms, but treatment rates in New Zealand remain very low especially in the non-tertiary setting. To increase expert access the MidCentral stroke service is engaging in an innovative tele-stroke system with a district of similar size in Scotland taking advantage of the time difference to minimise costly after hour call-outs. If successful this service model can be rolled out to other DHBs of similar or even smaller size and represents an alternative to the traditional ‘hub-and-spoke’ tele-stroke model.
Aims: This study aims to assess the feasibility and implementation barriers of a global tele-stroke service arrangement.
Methods: This pilot consists of two phases. Phase one relates to implementation, which is assessed in the form of qualitative reports from parties involved. Phase two relates to patient outcomes. This paper focuses on phase one reporting feedback from relevant stakeholders.
Results: Overall service implementation was complex and work intensive. However, related additional costs were low and perceived administrative barriers were overcome more readily than had been anticipated by most. Strong project management skills, a good communication plan, and early achievement of cross-departmental clinician by-in were felt to be the most important levers.
Discussion: Implementing novel service models especially involving international collaboration is complex and demanding. However, through a collaborative approach a satisfactory result can be achieved.
Early ipsilesional hippocampal atrophy occurs after both anterior and posterior circulation strokes
A Brodtmann,1 H Pardoe,1,2 Q Li,1 R Lichter,1 E Werden,1 A Raffelt,1 T Cumming1
1The Florey Institute for Neuroscience and Mental Health, Heidelberg, Vic., Australia, and 2NYU Comprehensive Epilepsy Center, New York University, New York, NY, USA
Background: There is evidence that some brain regions, especially the hippocampi, exhibit atrophy after stroke. We have reported changes in a cohort of patients with middle cerebral artery stroke, and sought here to corroborate these findings in a group of prospectively recruited patients with both anterior and posterior circulation stroke.
Hypothesis: That hippocampal atrophy would occur following both anterior and posterior circulation infarction.
Methods: Acute ischemic stroke patients were imaged within 40 days of symptom onset and at 3 months. Healthy control participants were also imaged at baseline and 3 months. 3D MPRAGE images were acquired on a Siemens Trio 3T MRI scanner. Images were processed using Freesurfer V 5.1 with default settings. Patients completed a cognitive assessment at both time points. We compared baseline and 3 month average regional cortical thickness and hippocampal volume, calculating individual percentage change scores. Ipsilesional and contralesional results were analyzed separately. Paired sample t-tests were used to assess significant change.
Results: Sixteen stroke patients were included (14 men; 9 left; mean age = 66.9 ± 8.7, range 53–82 years; years of education 15 ± 4, range 9–24 years; mean NIHSS 3.5 ± 2.5, range 1–10; 3 LACI, 6 PACI, 7 POCI) and 10 healthy controls (5 men, mean age 67.2 ± 3; years of education 11 ± 5). A significant decrease in ipsilesional hippocampal volume was found. No significant changes in memory were identified.
Conclusion: In conclusion, we found that ipsilesional hippocampal atrophy occurs in the subacute post-stroke period in patients with both anterior and posterior circulation stroke, even in the absence of early memory decline.
Probabilistic mapping the location of white matter hyperintensity and subcortical infarcts
Stroke and Aging Research Centre, Monash University, Clayton, VIC, Australia
Background & aims: Differentiating between white matter hyperintensity (WMH) and stroke can be rather difficult if stroke patients are imaged in the chronic phase. We hypothesise that knowledge of the topographic distribution of WMH and subcortical stroke may help with differentiating these two entities.
Methods: The map of the WMH was created from a cohort of community dwelling healthy elderly subjects. Patients with subcortical infarcts on magnetic resonance imaging (MRI) admitted to our institution between 2009 and 2011 were included. These images were aligned to a common stereotactic coordinate to facilitate comparison. The disease frequency at each voxel for each group was calculated using: f1 = m1/n1 for WMH and f2 = m2/n2 for subcortical stroke. Where f is frequency, m is the number of disease samples at a location and n is the total number samples in the group. The intersection, or overlap, of the non-zero components of the frequency map of each group was computed. These frequency images were then nomalized as p1 = f1/(f1+f2) and p2 = f2/(f1+f2).
Results: There were 384 subjects (213 males) in TASCOG group and 57 (33 males) subjects in stroke group. The mean age of TASCOG group is 72.1 (SD 7.0) and of stroke group is 64.3 (SD 14.4). WMH predominate around the poles of the lateral ventricles while lesions adjacent to the body of the lateral ventricles and deep grey matter nuclei have a higher probability of being infarcts.
Conclusion: The probabilistic map can be used to help differentiating between WMH and subcortical strokes.
Quality in Acute Stroke Care (QASC) NSW state-wide implementation project
S Middleton,1,2 D Comerford,3 J Dunne,3 CR Levi,4 C Quinn,5 DA Cadilhac,6 S Dale,1,2 M Longworth,3 S Wutze,3 M Tinsley3
1National Centre for Clinical Outcomes Research, Australian Catholic University, 2Nursing Research Institute, St Vincent's Hospital, 3Agency for Clinical Innovation, Chatswood, 4University of Newcastle Priority Centre for Brain & Mental Health Research, 5Speech Pathology Department, Prince of Wales Hospital, Randwick, NSW, 6National Stroke Research Institute, Vic., Australia
Background: The Quality in Acute Stroke Care (QASC) trial showed significant benefits for patients cared for in stroke units who received assistance to implement evidence-based treatment protocols to manage fever, hyperglycaemia and swallowing (FeSS protocols). Building on these results, our team will implement the Fever, Sugar (hyperglycaemia) and Swallowing (FeSS) protocols across NSW Stroke Services.
Aim: To implement the QASC Fever, Sugar, Swallowing protocols in all NSW Stroke Services and to conduct an evaluation of the same.
Methods: Key clinical champions will be recruited from each of the 36 NSW Stroke Services. We will implement the QASC intervention which consists of: multidisciplinary team building workshops; interactive education program; sustained engagement of stroke unit champions to embed protocols as part of routine clinical care. Evaluation will consist of a pre and post medical record audits to examine quality of care outcomes and implementation efficacy. We will also examine lessons learnt to inform future funded implementation studies.
Conclusion: We will provide evidence for the effectiveness of a practice change intervention across NSW Stroke services, based on rigorous research. This project will be a showcase example on how to implement evidence based results across a wider population.
Human adult stem cells interact with the blood brain barrier
J Winderlich, K Kremer, SA Koblar
Stroke Research Programme, School of Medicine, University of Adelaide, Adelaide, SA, Australia
Background: Stem Cell therapy in ischaemic stroke is an important new strategy to enhance functional outcome following brain damage. Our group has recently published that human adult stem cells derived from the dental pulp (DPSC) of third molar teeth when injected into the rodent brain 24 hours post-stroke enhanced functional recovery. However, this method of delivery resulted in 9% mortality in this animal model that would be unacceptable in a clinical situation. A number of reported studies demonstrate the vascular delivery of stem cells post-stroke improve function.
Aim: To investigate if adult human DPSC interact with the blood-brain-barrier (BBB) in a way, which may allow the entry of stem cells into the ischaemic brain.
Method: To study this interaction we developed an in vitro model of the BBB using a transwell millipore system co-culturing rat-derived astrocytes and human endothelial cells on opposite sides of a porous membrane.
Results: We treated this in vitro BBB with media from DPSC cultures and found that this resulted in an increase in permeability of the BBB demonstrated by diffusion of Evan's blue bovine serum albumin. A tight junction protein, Occludin, was down-regulated in expression with treatment. This appeared not to be mediated by vascular endothelial growth factor.
Conclusion: These results indicate stem cells are able to interact with the BBB in a manner that may increase their access to the brain in ischaemic stroke. This is one of the first studies to our knowledge to investigate a stem cell and BBB interaction.
Supporting carers of people living with vascular dementia
D Jackson,1 C Doyle,1 M Courtney,2 R Ford,1 J Foottitt,2 W Wu2
1Australian Catholic University, Melbourne, Vic., 2Australian Catholic University, Brisbane, Qld, Australia
Background: The vast majority of older adults with dementia (87%) are cared for in the home setting by family carers . While Alzheimer's Disease is the most common cause of dementia, vascular dementia is found in about 20% of people with dementia. Caring for people with dementia and stroke survivors is costly to society, both in dollar terms and in terms of the mental and physical health of family carers . Family carers of people with vascular dementia need support to understand how to prevent further strokes, how to manage symptoms of dementia, and how to look after their own health.
Aims: The project aimed to develop and trial a program of telephone support for family carers of people living with vascular dementia.
Methods: we reviewed the literature on effectiveness of telephone support and on treatment of vascular dementia; then we developed a protocol for a telephone intervention based on evidence based practice; then we trialed the intervention with a pilot sample of carers.
Results: In this paper the intervention protocol will be described, including eight sessions of education and psychological support delivered by a nurse with expertise in stroke, dementia and counseling. Sessions are manualised but flexible enough to be tailored to individual needs. Preliminary results will be provided.
Conclusion: Telehealth or health monitoring delivered over the telephone has great potential to supplement more expensive face-to-face supports and may help to improve outcomes for people receiving community services.
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