Stroke service: how can we improve and measure outcomes? Consensus summary from a global stroke forum.

The success of acute stroke treatment is first and foremost time-dependent, and the need for improvement in acute stroke management is demonstrated by the fact that only a minority of patients gain access to treatment - in particular, intravenous recombinant tissue plasminogen activator (IV tPA) - within the necessary time window. Standards of acute stroke care vary widely both regionally and nationally; consequently, various healthcare organizations have undertaken initiatives to measure and improve quality of care. To date, most quality measures have been process-based, focusing primarily on metrics of patient care in the acute hospital-based setting (e.g., time to recombinant tPA administration). Therefore, there remains a need for metrics designed to assess how improvements in process translate into patient outcomes. A global forum was convened to share best practice and provide consensus recommendations on core metrics for measuring improvements in access to care and patient outcomes. Recommendations for core metrics of patient outcomes include hospital-based outcomes (e.g., neurological status at 24 h, ambulatory status at discharge) and post-discharge outcomes (e.g., modified Rankin Scale score at 30 and/or 90 days). Recommendations for best practice relating to aspects of people, process, and technology involved in the stroke treatment pathway that may help provide improvements in these core outcome measures are also outlined.

Endovascular mechanical thrombectomy for the treatment of acute ischemic stroke due to arterial dissection.

Arterial dissections account for 2% of strokes in all age groups, and up to 25% in patients aged 45 years or younger. The safety of endovascular intervention in this patient population is not well characterized. We identified all patients in the Merci registry - a prospective, multi-center post-market database enrolling patients treated with the Merci Retriever thrombectomy device - with arterial dissection as the most likely stroke etiology. Stroke presentation and procedural details were obtained prospectively; data regarding procedural complications, intracerebral hemorrhage (ICH), and the use of stenting of the dissected artery were obtained retrospectively. Of 980 patients in the registry, ten were identified with arterial dissection (8/10 ICA; 2/10 vertebrobasilar). The median age was 48 years with a baseline NIH stroke scale score of 16 and median time to treatment of 4.9 h. The procedure resulted in thrombolysis in cerebral ischemia (TICI) scores of 2a or better in eight out of ten and TICI 2b or better in six out of ten patients. Stenting of the dissection was performed in four of nine (44%). The single complication (1/9; 11%) - extension of a dissected carotid artery - was treated effectively with stenting. No symptomatic ICH or stroke in a previously unaffected territory occurred. A favorable functional outcome was observed in eight out of ten patients. Despite severe strokes on presentation, high rates of recanalization (8/10) and favorable functional outcomes (8/10) were observed. These results suggest that mechanical thrombectomy in patients with acute stroke resulting from arterial dissection is feasible, safe, and may be associated with favorable functional outcomes.

Is mechanical embolectomy performed in nonanesthetized patients effective?

BACKGROUND AND PURPOSE: In centers performing endovascular treatment for patients with AIS, there is variability in placing patients under general anesthesia. Nonanesthetized patients might move during the procedure leading to complications and prolonging the time to revascularization due to lack of cooperation. However, general anesthesia can lead to a delay of the procedure, an inability to assess the patient during the procedure, and fluctuations of blood pressure. Our center does not routinely either use general anesthesia or sedate patients. We report our experience with nonanesthetized patients undergoing emergent mechanical embolectomy. MATERIALS AND METHODS: We performed a retrospective analysis of 66 consecutive patients enrolled in the MERCI Registry at our center from June 2007 to June 2009. A univariate statistical analysis was performed by using the Fisher exact test for categoric variables and the Student t test for continuous variables in comparing use of general anesthesia with nonanesthetized patient demographics, procedural times, procedural complications, good outcome, and mortality. RESULTS: Nine patients (13.6%) were placed under general anesthesia, and 57 (86.4%) were awake. Higher baseline NIHSS scores and older age were statistically associated with general anesthesia. No significant difference occurred between groups in the time to groin puncture or procedural times. Revascularization rates were 77% for general anesthesia patients and 70% for nonanesthetized patients (P = .331). The nonanesthetized group had better outcomes, but we did not control these outcomes for other factors. Complications were much more frequent in the general anesthesia patients (22%) than in the nonanesthetized patients (3.5%) (P = .0288). CONCLUSIONS: Performing mechanical embolectomy in nonanesthetized patients at our institution does not prolong procedure time, decrease revascularization rates, increase complication rates, or decrease good outcome. Mechanical embolectomy in nonanesthetized patients is effective and should be considered an option in the treatment of the patient with AIS.

Abdominal vault suspension with rectus sheath strips: a case series.

This is a retrospective case series conducted in Worthing General Hospital to evaluate the clinical outcome of abdominal vault suspension (AVS) using rectus sheath strips to treat vaginal vault prolapse. Thirty-four patients had suspension of the vaginal vault using this procedure. Patients were followed up at 3-6 months and by questionnaire for up to 90 months. Incidence of intraoperative and postoperative complications, improvement of prolapsed symptoms and recurrence of vault prolapsed were the main outcome measures. There were no serious intraoperative complications. Ninety four percent of patients had subjective resolution of their prolapsed symptoms whereas 6% had further symptoms. Hospital stay ranged from 2 to 8 days. There were no cases of bowel problems in the postoperative period or in the long term. Hospital stay ranged from 2 to 8 days. AVS using rectus sheath strips appears to be a safer and easier alternative to other abdominal suspension procedures. The use of patients' own tissue eliminates the risk of mesh erosion.

Mechanical thrombo-embolectomy in acute ischaemic stroke: a local experience.

Large-vessel ischaemic strokes have a very poor natural history. Thombolysis is indicated for the treatment of ischaemic stroke but in practice is given to less than 10% of stroke sufferers, and its efficacy in large-vessel occlusion is poor. Mechanical embolectomy is a new therapy that allows attempted revascularisation up to eight hours after stroke onset. With its improved efficacy, it therefore offers some hope to patients admitted with this devastating condition.

Steep-dip seismic imaging of the shallow San Andreas fault near Parkfield.

Seismic reflection and refraction images illuminate the San Andreas Fault to a depth of 1 kilometer. The prestack depth-migrated reflection image contains near-vertical reflections aligned with the active fault trace. The fault is vertical in the upper 0.5 kilometer, then dips about 70 degrees to the southwest to at least 1 kilometer subsurface. This dip reconciles the difference between the computed locations of earthquakes and the surface fault trace. The seismic velocity cross section shows strong lateral variations. Relatively low velocity (10 to 30%), high electrical conductivity, and low density indicate a 1-kilometer-wide vertical wedge of porous sediment or fractured rock immediately southwest of the active fault trace.

Predicting stroke recovery: three- and six-month rates of patient-centered functional outcomes based on the orpington prognostic scale.

OBJECTIVE: To provide recovery rates after stroke for specific functions using the Orpington Prognostic Scale (OPS). DESIGN: Prospective cohort. SETTING: Hospital and community. PARTICIPANTS: 413 stroke survivors entered the study 3 to 14 days after suffering a stroke. MEASUREMENTS: A cohort of hospitalized stroke survivors were recruited 3 to 14 days after stroke and assessed at 1, 3, and 6 months poststroke for neurological, functional, and health status. Baseline OPS score was used to predict five functional outcomes at 3 and 6 months using development and validation datasets and receiver operating characteristic (ROC) curves. RESULTS: In 413 stroke survivors, functional recovery rates at 3 and 6 months were similar. Baseline OPS predicted significant differences in recovery rates for all five outcomes (P < .0001 for all five outcomes at 3 and 6 months). Personal care dependence was present at 3 months in only 3% of persons with baseline OPS scores of 3.2 or less compared with over 50% with OPS of 4.8 or higher. Independent personal care, meal preparation, and self-administration of medication were achieved by 80% who had baseline OPS scores of 2.4 or lower compared with less than 20% when OPS scores were 4.4 or higher. Independent community mobility was achieved in 50% of those who had OPS scores of 2.4 or lower but only 3% of those with OPS scores of 4.4 or higher. The area under ROC curves assessing OPS scores against each of the five outcomes ranged from 0.805 to 0.863 at 3 months and 0.74 to 0.806 at 6 months. CONCLUSION: OPS scores can predict widely differing rates of functional recovery in five important functional abilities. These estimates can be useful to survivors, families, providers, and healthcare systems who need to plan for the future.

Development of clinical pathways for stroke management: an example from Saint Luke's Hospital, Kansas City.

Clinical pathways for stroke are important tools for improved case management and outcome assessment. The clinical path created at St. Luke's Hospital in Kansas City is described here. It evolved through the collaboration of a multidisciplinary team of clinical experts and is still evolving. Ideally, a clinical path should be used as a guide rather than a standard of care, which is to be individualized for each patient. This article describes the methods for writing the pathways and how they are used for documentation. It also summarizes how the pathway data support stroke outcome assessment.

Medicaid Tape-to-Tape findings: California, New York, and Michigan, 1981.

Presented in this report is an overview of Medicaid enrollment, utilization, and expenditures in California during 1981. The California Medicaid program, called Medi-Cal, is the largest in the Nation in terms of program beneficiaries. During 1981, California had one of the most generous Medicaid programs in the country in terms of eligibility and covered services. At the same time, there were benefit limitations and reimbursement restrictions in place that were designed to restrict program expenditures. The data in this report were provided by the State to the Health Care Financing Administration as part of the Medicaid Tape-to-Tape Project. Data from Michigan and New York are also included for comparison purposes.

Medicaid expenditures for the disabled under a work incentive program.

Congress enacted Section 1619 of the Social Security Act to enable the disabled receiving Supplemental Security Income (SSI) to obtain jobs and still retain Medicaid health benefits. Congress intended this work incentive to remove the fear of the severely disabled that by obtaining employment they would lose Medicaid benefits. Based on data from 11 States, our analysis found that Medicaid expenditures for Section 1619 enrollees were relatively small and only one-half the average Medicaid expenditure for the disabled. Retaining Medicaid appears to provide a significant work incentive because Medicaid expenditures represent 13 percent of Section 1619 enrollees' earnings.

Children and Medicaid: the experience in four states.

Medicaid coverage of children is analyzed in this article, using data from uniform Medicaid files (Tape-to-Tape) for California, Georgia, Michigan, and New York. Results show that Medicaid is a different program to children of different enrollment groups and ages. For children receiving cash assistance through either Aid to Families with Dependent Children or Supplemental Security Income, Medicaid represents a source of ongoing health coverage. However, for children in families not receiving cash assistance, coverage is more episodic and disproportionately related to acute care and hospitalization. Across all child enrollment groups, infants had higher than expected utilization and expenditures.

Survey of disabled children under SSI program.

The Office of Research and Statistics, under a contract with Urban Systems Research and Engineering, Inc., performed a national personal survey of blind and disabled children receiving supplemental security income (SSI) benefits. The purpose of the survey was to provide descriptive characteristics of the children and their families as well as assess SSI's effect on them. The survey has provided the research community with some interesting results. Not all children in the program live in families. Almost 15 percent of the children surveyed were not living with their parents; many of them were in foster care families or group homes. SSI children live in low-income families. Almost two-thirds of them live in families with annual income (including the child's benefit) of less than $7,000. Not only are the children handicapped, but a sizable number of children are in households where another person is also disabled and/or receiving SSI payments. Three-fourths of the families have had exposure to the welfare systems. Many of them have received or are receiving benefits from one or more of the following programs-- AFDC, Medicaid, and food stamps. Many families report that they are satisfied with SSI because in many instances the amount of the benefit meets the needs of the child and the program is administered with few forms and by staff who treat them courteously. A summary of the survey report is presented in the article that follows.

[Renal pelvis stones made of glafenic acid in two patients under prolonged treatment with analgesics (author's transl)]. / Calculs pyéliques d'acide glafénique chez deux patientes traitées de façon prolongée par des analgésiques.

Two women aged 62 and 69 years who had been taking glafenine at normal dosage over a period of 4 years developed a renal calculus. In the first case, 6 small slightly radioopaque stones were extracted by pyelotomy, presenting a crystalline surface and yellow, soft, and amorphous section. They consisted of 50% calcium oxalate, 33% glafenic acid, and 10% proteins. In the second case, pyelography showed a sizable round and radiotransparent defect in the renal pelvis. At pyelotomy, a large, soft, and greenish stone was extracted, presenting a yellow and amorphous section, without calcium, but consisting of 75% glafenic acid, and 25% proteins. Through IR spectrography, glafenine metabolites found in the stones represented 33% in our first case and 75% in our second case. Through other methods, such as UV spectrophotometry and chromatography, 26% and 61% are respectively found. The metabolites are glafenic acid and hydroglafenic acid, in an identical proportion of 9 to 1 in both cases.