Remote specialist assessment for intravenous thrombolysis of acute ischaemic stroke by telephone.

OBJECTIVE: To describe the process, efficacy and safety of intravenous thrombolysis for acute ischaemic stroke in an emergency department (ED) setting with remote specialist support through structured telephone consultation. DESIGN: Retrospective case series. SETTING: Three EDs within a single stroke service in northern England. PARTICIPANTS: Patients with acute stroke given intravenous thrombolytic therapy between 6 September 2007 and 1 October 2010. OUTCOME MEASURES: Combined death and dependency at 90 days (0-2 on the modified Rankin Scale for a good outcome vs 3-6 for a poor outcome), door-to-needle time, neurological impairment and presence of treatment related haemorrhage. RESULTS: 192 patients received intravenous thrombolysis. 94/178 (53%) were treated after remote specialist assessment. Data available from 178 patients showed similar proportions with a good outcome after each mode of assessment (56% in person and 48% by telephone). The median door-to-needle time was 8 min faster in the group assessed in person (65 vs 73 min by telephone) but there was no difference in neurological outcome or symptomatic haemorrhage. After review in person, the stroke specialist tended to treat patients with a higher median modified Rankin Scale (1 vs 0 by telephone). CONCLUSION: In a single stroke service the clinical outcomes of treatment with intravenous thrombolysis were similar whether assessment was performed after specialist review in person or via a telemedicine service consisting of ED staff training, telephone consultation and remote review of brain imaging by a stroke specialist.

Rehabilitation of older patients: day hospital compared with rehabilitation at home. Clinical outcomes.

OBJECTIVES: to test the hypothesis that older people and their informal carers are not disadvantaged by home-based rehabilitation (HBR) relative to day hospital rehabilitation (DHR). DESIGN: pragmatic randomised controlled trial. SETTING: four geriatric day hospitals and four home rehabilitation teams in England. PARTICIPANTS: eighty-nine patients referred for multidisciplinary rehabilitation. The target sample size was 460. INTERVENTION: multidisciplinary rehabilitation either in the home or in the day hospital. MEASUREMENTS: the primary outcome measure was the Nottingham extended activities of daily living scale (NEADL). Secondary outcome measures included EQ-5D, hospital anxiety and depression scale, therapy outcome measures, hospital admissions and the General Health Questionnaire for carers. RESULTS: at the primary end point of 6 months NEADL scores were not significantly in favour of HBR cf. DHR; mean difference -2.139 (95% confidence interval -6.87 to 2.59, P = 0.37). A post hoc analysis suggested non-inferiority for HBR for NEADL but there was considerable statistical uncertainty. CONCLUSION: taken together the statistical analyses and lack of power of the trial outcomes do not provide sufficient evidence to conclude that patients in receipt of HBR are disadvantaged compared with those receiving DHR.

Randomized controlled trial to evaluate the effect of surface neuromuscular electrical stimulation to the shoulder after acute stroke.

BACKGROUND AND PURPOSE: Surface neuromuscular electrical stimulation (sNMES) after stroke aims to improve upper limb function and reduce shoulder pain, but current evidence of effectiveness is inconclusive. We have undertaken a randomized controlled trial to evaluate sNMES to the shoulder after acute stroke. METHODS: One hundred seventy-six patients, within 10 days of stroke onset, were randomized to receive sNMES or placebo in addition to stroke unit care. The primary outcome measure was upper limb function measured by the Action Research Arm Test (ARAT) 3 months after stroke. Secondary outcome measures included other measures of upper limb function, upper limb impairment, pain, disability, and global health status. Outcome assessments were blinded. RESULTS: There was no difference in arm function between groups in terms of the primary outcome measure. The median ARAT at 3 months was 50 in the intervention group and 55.5 in the control group (P=0.068). Significant differences were seen at 3 months in favor of the control group for other measures of arm function and impairment: grasp and gross movement subsections of the ARAT, Frenchay Arm Test, and the arm subsection of the Motricity Index. Secondary analysis suggested that these differences were most marked in subjects with severe initial upper limb weakness. CONCLUSIONS: A 4-week program of sNMES to the shoulder after acute stroke does not improve functional outcome and may worsen arm function in severely impaired stroke patients. "Routine" use of sNMES to the proximal affected upper limb after acute stroke cannot be recommended.

Does an early increased-intensity interdisciplinary upper limb therapy programme following acute stroke improve outcome?

OBJECTIVE: To determine whether an early increased-intensity upper limb therapy programme following acute stroke improves outcome. DESIGN: A randomized controlled trial. SETTING: A stroke unit which provides acute care and rehabilitation for all stroke admissions. SUBJECTS: One hundred and twenty-three patients who had had a stroke causing upper limb impairment within the previous 10 days. INTERVENTION: The intervention group received stroke unit care plus enhanced upper limb rehabilitation provided jointly by a physiotherapist and occupational therapist, commencing within 10 days of stroke, and available up to 30 minutes/day, five days/week for six weeks. The control group received stroke unit care. MAIN OUTCOME MEASURES: The primary outcome measure was the Action Research Arm Test (ARAT) three months after stroke. SECONDARY OUTCOME MEASURES: Motricity Index; Frenchay Arm Test; upper limb pain; Barthel ADL Index; Nottingham E-ADL Scale; and costs to health and social services at three and six months after stroke. RESULTS: There were no differences in outcomes between the intervention and control groups three and six months after stroke. During the intervention period the intervention group received a median of 29 minutes of enhanced upper limb therapy per working day as inpatients. The total amount of inpatient physiotherapy and occupational therapy received by the intervention group was a median of 52 minutes per working day during the intervention period and 38 minutes per working day for the control group (p = 0.001). There were no differences in service costs. CONCLUSIONS: An early increased-intensity interdisciplinary upper limb therapy programme jointly provided by a physiotherapist and occupational therapist did not improve outcome after stroke. The actual difference in the amount of therapy received by intervention and control groups was less than planned due to a competitive therapy bias.

Magnetic resonance spectroscopy in childhood brainstem tumors.

Five children with brainstem tumors and two control patients had magnetic resonance spectroscopy studies of the brainstem. Two of the malignant tumor patients had magnetic resonance spectroscopy studies before and after radiation therapy. The third was irradiated 14 years earlier but developed new symptoms and a new brainstem lesion on MRI. Magnetic resonance spectroscopy demonstrated a different degree of malignancy between the old and new lesion. The fourth patient had magnetic resonance spectroscopy of a chronic, large pontine lesion 6 years after diagnosis and radiation. The spectral pattern suggested a low degree of malignancy. The fifth patient had neurofibromatosis type 1 with brainstem lesions. Magnetic resonance spectroscopy suggested neoplastic tissue of low malignancy. These results suggest that magnetic resonance spectroscopy offers additional information for anticipating the degree of anaplasia in children with brainstem tumors.

Hematogenous brain metastasis in children.

Hematogenous brain metastases are uncommon in childhood. Three patients and a literature review that includes centers reporting up to 36 years of experience are presented in this study. The total of 2,040 patients includes our three examples of one neuroblastoma, one hepatoblastoma, and one adrenal carcinoma. Cerebral hematogenous metastases were reported in 4.4% of 429 patients with neuroblastoma, 1.9% of 574 rhabdomyosarcoma patients, 6.5% of 386 patients with osteosarcoma, 3.3% of 487 Ewing sarcoma patients, 3.6% of 44 melanoma patients, 13.5% of 37 patients with germ cell tumors, and 1.3% of the 78 patients with Wilms tumor. Five miscellaneous patients included three with a hepatoblastoma and one each with adrenal carcinoma and nephroma. All of the large series reports have been published in oncology journals.