A service evaluation of the feasibility of a community-based consultant and stroke navigator review of health and social care needs in stroke survivors 6 weeks after hospital discharge.

The Department of Health Stroke Strategy (2007) recommends that post stroke patients are reviewed within 6 weeks of discharge. Historically, a 6-week outpatient appointment was offered. This was primarily a medical review and not a full assessment of health, social care status and secondary prevention needs. An innovative joint domiciliary clinic was developed in order to meet these recommendations. The joint clinic reviews were conducted by a stroke consultant and an allied health professional. There were no readmissions at 6 weeks and 6 months post stroke. User satisfaction was very high and there were no missed appointments. Patient health and social status was fully captured, reported and acted upon holistically following each review. This form of integrated partnership working seems to promote seamless life after-stroke care, while enhancing patients' understanding. It includes the provision of secondary prevention and self-management strategies. This 'one-stop shop' approach would warrant formal evaluation.

Impact on clinical and cost outcomes of a centralized approach to acute stroke care in London: a comparative effectiveness before and after model.

BACKGROUND: In July 2010 a new multiple hub-and-spoke model for acute stroke care was implemented across the whole of London, UK, with continuous specialist care during the first 72 hours provided at 8 hyper-acute stroke units (HASUs) compared to the previous model of 30 local hospitals receiving acute stroke patients. We investigated differences in clinical outcomes and costs between the new and old models. METHODS: We compared outcomes and costs 'before' (July 2007-July 2008) vs. 'after' (July 2010-June 2011) the introduction of the new model, adjusted for patient characteristics and national time trends in mortality and length of stay. We constructed 90-day and 10-year decision analytic models using data from population based stroke registers, audits and published sources. Mortality and length of stay were modelled using survival analysis. FINDINGS: In a pooled sample of 307 patients 'before' and 3156 patients 'after', survival improved in the 'after' period (age adjusted hazard ratio 0.54; 95% CI 0.41-0.72). The predicted survival rates at 90 days in the deterministic model adjusted for national trends were 87.2% 'before' % (95% CI 86.7%-87.7%) and 88.7% 'after' (95% CI 88.6%-88.8%); a relative reduction in deaths of 12% (95% CI 8%-16%). Based on a cohort of 6,438 stroke patients, the model produces a total cost saving of £5.2 million per year at 90 days (95% CI £4.9-£5.5 million; £811 per patient). CONCLUSION: A centralized model for acute stroke care across an entire metropolitan city appears to have reduced mortality for a reduced cost per patient, predominately as a result of reduced hospital length of stay.

An unexpected Holter monitor result: multiple sinus arrests in a patient with lateral medullary syndrome.

A 52-year-old man presented with vomiting, dysphagia, left-sided ataxia and dissociated sensory loss. Diffusion-weighted MRI showed evidence of acute infarct in the left lateral medulla and left medial cerebellar hemisphere, probably secondary to thromboembolism from left vertebral artery dissection. While making an uneventful recovery as an inpatient, a routine 24 h ECG was performed 2 weeks after the stroke to investigate possible paroxysmal atrial fibrillation. The recording instead revealed 56 asymptomatic episodes of sinus arrest, necessitating implantation of a permanent pacemaker to prevent sudden cardiac death. The medulla contains key structures involved in autonomic regulation, including the dorsal vagal nucleus and the nucleus tractus solitarius. Acute infarction may disrupt cardiac autonomic regulation pathways, resulting in altered parasympathetic and sympathetic outflow to the sinoatrial and atrioventricular nodes, with potentially life-threatening effects.