A comparison of service organisation and guideline compliance between two adjacent European health services.

INTRODUCTION: Outcomes in stroke patients are improved by a co-ordinated organisation of stroke services and provision of evidence-based care. We studied the organisation of care and application of guidelines in two neighbouring health care systems with similar characteristics. METHODS: Organisational elements of the 2015 National Stroke Audit (NSA) from the Republic of Ireland (ROI) were compared with the Sentinel Stroke National Audit Programme (SSNAP) in Northern Ireland (NI) and the United Kingdom (UK). Compliance was compared with UK and European guidelines. RESULTS: Twenty-one of 28 ROI hospitals (78%) reported having a stroke unit (SU) compared with all 10 in NI. Average SU size was smaller in ROI (6 beds vs. 15 beds) and bed availability per head of population was lower (1:30,633 vs. 1:12,037 p < 0.0001 Chi Sq). Fifty-four percent of ROI patients were admitted to SU care compared with 96% of UK patients (p < 0.0001). Twenty-four-hour physiological monitoring was available in 54% of ROI SUs compared to 91% of UK units (p < 0.0001). There was no significant difference between ROI and NI in access to senior specialist physicians or nurses or in SU nurse staffing (3.9/10 beds weekday mornings) but there was a higher proportion of trained nurses in ROI units (2.9/10 beds vs. 2.3/10 beds (p = 0.02 Chi Sq). CONCLUSION: Whilst the majority of hospitals in both jurisdictions met key criteria for organised stroke care the small size and underdevelopment of the ROI units meant a substantial proportion of patients were unable to access this specialised care.

Troponin-I is a predictor of a delayed diagnosis of atrial fibrillation in acute ischemic stroke and transient ischemic attack.

BACKGROUND: Prolonged cardiac monitoring detects higher rates of atrial fibrillation (AF) in ischemic stroke and transient ischemic attack (TIA) but is costly and has practical implications. The use of admission troponin-I (TnI) level to identify patients at high risk of delayed AF detection was investigated. METHODS: Consecutive ischemic stroke and TIA cases presenting to our institute over a 13-month period were identified from the Irish Stroke and TIA Register. Electronic databases and case notes were examined. "Delayed" AF was diagnosed after a sinus rhythm admission electrocardiogram and no documented history. Group comparisons were made by AF status. The association between TnI and AF was investigated using a multivariate regression model. RESULTS: A total of 185 cases (130 ischemic stroke) were analyzed. Mean age (standard deviation) was 73.3 (13.9) years, 47% female. Sixty-two cases (33.5%) had AF. The first documented presentation of AF was found in 21 cases, on admission electrocardiogram (n = 11) or inpatient telemetry (delayed, n = 10). TnI was higher in those with delayed AF than in those without AF (W = 194; P = .036). A higher proportion of those with an elevated TnI (30%) than those with a normal TnI (6.1%) had delayed diagnosis of AF (χ(2) = 6.41, P = .011). Having an abnormal TnI was a significant independent predictor of delayed AF detection (odds ratio, 5.8; P = .037). CONCLUSIONS: TnI elevation is associated with a higher likelihood of subsequent AF diagnosis. Identification of these higher risk stroke and TIA cases for more intensive cardiac monitoring may improve stroke secondary prevention practices.

Home, please: A conjoint analysis of patient preferences after a bad hip fracture.

AIM: An Australian study of older, community-dwelling women found that 80% would rather be dead than experience loss of independence and nursing home admission after a bad hip fracture. We re-examined this issue using a conjoint analysis approach. METHODS: We asked older hospital patients with a history of falls, fracture or osteoporosis to imagine they had a hip fracture resulting in significant residual disability. Subjects were asked to rank in order of preference an orthogonal array of nine out of 36 potential outcome scenarios reporting risk of falls, life expectancy, discharge home with support or to a nursing home and family agreement or disagreement with discharge location. RESULTS: Of 192 patients satisfying inclusion criteria, 183 agreed to participate and 97 completed the study. Those who failed to complete the study were older and had lower Mini-Mental State Examination scores than those who completed the study. For the group as a whole, averaged importance scores were: discharge residence 31.3%, length of life 27%, fall risk 26.4% and family preference 15.5%. On average, subjects would be willing to sacrifice approximately 9 months of life in order to return home rather than go to a nursing home. CONCLUSIONS: In the present study, older people at high risk for fracture judged that after a bad hip fracture their main priority would be to remain at home.

Thrombolysis delivery by a regional telestroke network--experience from the U.K. National Health Service.

BACKGROUND: The majority of established telestroke services are based on "hub-and-spoke" models for providing acute clinical assessment and thrombolysis. We report results from the first year of the successful implementation of a locally based telemedicine network, without the need of 1 or more hub hospitals, across a largely rural landscape. METHODS AND RESULTS: Following a successful pilot phase that demonstrated safety and feasibility, the East of England telestroke project was rolled out across 7 regional hospitals, covering an area of 7500 square miles and a population of 5.6 million to enable out-of-hours access to thrombolysis. Between November 2010 and November 2011, 142 telemedicine consultations were recorded out-of-hours. Seventy-four (52.11%) cases received thrombolysis. Median (IQR) onset-to-needle and door-to-needle times were 169 (141.5 to 201.5) minutes and 94 (72 to 113.5) minutes, respectively. Symptomatic hemorrhage rate was 7.3% and stroke mimic rate was 10.6%. CONCLUSIONS: We demonstrate the safety and effectiveness of a horizontal networking approach for stroke telemedicine, which may be applicable to areas where traditional "hub-and-spoke" models may not be geographically feasible.

Incidence of atrial fibrillation detected by implantable loop recorders in unexplained stroke.

OBJECTIVES: The usefulness of the implantable loop recorder (ILR) with improved atrial fibrillation (AF) detection capability (Reveal XT) and the factors associated with AF in the setting of unexplained stroke were investigated. METHODS: A cohort study is reported of 51 patients in whom ILRs were implanted for the investigation of ischemic stroke for which no cause had been found (cryptogenic) following appropriate vascular and cardiac imaging and at least 24 hours of cardiac rhythm monitoring. RESULTS: The patients were aged from 17 to 73 (median 52) years. Of the 30 patients with a shunt investigation, 22 had a patent foramen ovale (73.3%; 95% confidence interval [CI] 56.5%-90.1%). AF was identified in 13 (25.5%; 95% CI 13.1%-37.9%) cases. AF was associated with increasing age (p = 0.018), interatrial conduction block (p = 0.02), left atrial volume (p = 0.025), and the occurrence of atrial premature contractions on preceding external monitoring (p = 0.004). The median (range) of monitoring prior to AF detection was 48 (0-154) days. CONCLUSION: In patients with unexplained stroke, AF was detected by ILR in 25.5%. Predictors of AF were identified, which may help to target investigations. ILRs may have a central role in the future in the investigation of patients with unexplained stroke.

Predicting readmissions: poor performance of the LACE index in an older UK population.

INTRODUCTION: interventions to prevent hospital readmission depend on the identification of patients at risk. The LACE index predicts readmission (and death) and is in clinical use internationally. The LACE index was investigated in an older UK population. METHODS: randomly selected alive-discharge episodes were reviewed. A LACE score was calculated for each patient and assessed using receiver operator characteristic (ROC) curves. A logistic regression model was constructed, compared with the LACE and validated in a separate population. RESULTS: a total of 507 patients were included with a mean (SD) age of 85 (6.5) years; 17.8% were readmitted and 4.5% died within 30 days. The median LACE score of those readmitted compared with those who were not was 12.5 versus 12 (P = 0.13). The Lace index was only a fair predictor of both 30-day readmission and death with c-statistics of 0.55 and 0.70, respectively. Only the emergency department visit was an independent predictor of readmission, with a c-statistic of 0.61 for readmission. In a validation cohort of 507 cases, the c-statistic of the regression model was 0.57. CONCLUSION: the LACE index is a poor tool for predicting 30-day readmission in older UK inpatients. The absence of a simple predictive model may limit the benefit of readmission avoidance strategies.

Toward understanding the atrial septum in cryptogenic stroke.

Ischemic stroke in younger people is common, and often remains unexplained. There is a well-documented association between unexplained stroke in younger people, and the presence of a patent foramen ovale. Therefore, in the absence of a clear cause of stroke, the heart is often assessed in detail for such lower risk causes of stroke. This usually involves imaging with a transesophageal echo, and investigation for a right-to-left shunt. An understanding of the anatomy of the atrial septum, and its associated abnormalities, is important for the stroke neurologist charged with decision making regarding appropriate secondary prevention. In this paper, we review the development and anatomy of the right heart with a focus on patent foramen ovale, and other associated abnormalities. We discuss how the heart can be imaged in the case of unexplained stroke, and provide examples. Finally, we suggest a method of investigation, in light of the recent European Association of Echocardiography guidance. Our aim is to provide the neurologist with an understanding on how the heart can be investigated in unexplained stroke, and the significance of abnormalities detected.

Ring chromosome 12 with inverted microduplication of 12p13.3 involving the Von Willebrand Factor gene associated with cryptogenic stroke in a young adult male.

We report a 35-year-old male with a ring chromosome 12 originally diagnosed 20 years prior to presentation with an ischemic stroke. Array CGH analysis revealed a sub-microscopic microdeletion and microduplication within 12p13.3 and a microdeletion in 12q24.33. FISH analysis further revealed that the duplication was in an inverted orientation and included exons 35-52 of the dosage-sensitive Von Willebrand Factor (VWF) gene. Partial duplication of this gene, which has a role in the clotting cascade, suggests a potential mechanism for generating a pro-thrombotic state that may have contributed to a premature cerebrovascular event. Evidence of raised VWF antigen levels and VWF activity levels in the highest quartile provides support for this hypothesis. This case illustrates that when a ring chromosome is identified, the possibility of cryptic genomic rearrangements needs to be considered as these may have implications in predicting natural history.

Restless leg syndrome: is it a real problem?

Restless legs syndrome (RLS) is a common condition that is frequently unrecognized, misdiagnosed and poorly managed. It is characterized by uncomfortable sensations deep in the legs developing at rest that compel the person to move; symptoms are worst at night and sleep disturbance is common. RLS occurs in 7%-11% of the population in Western countries, and many such people experience troublesome symptoms. Primary RLS is familial in up to two thirds of patients. RLS may also be secondary to a number of conditions including iron deficiency, pregnancy and end-stage renal failure and, perhaps, neuropathy. Secondary RLS is most common in those presenting for the first time in later life. The pathogenesis of RLS probably involves the interplay of systemic or brain iron deficiency and impaired dopaminergic neurotransmission in the subcortex of the brain. RLS is very responsive to dopaminergic therapies. Rebound of RLS symptoms during the early morning and development of severe symptoms earlier in the day (augmentation) are problematic in those treated for a prolonged period with levodopa. Consequently, dopamine agonists have become first line treatment. Anti-convulsant medications and opioids are helpful in some patients. Correction of underlying problem wherever possible is important in the management of secondary RLS.