Acute clinical outcomes predict both generic and specific health-related quality of life six and 12 months after stroke: A one-year prospective study developed in a middle-income country.

OBJECTIVE: To identify acute predictors of generic and specific health-related quality of life (HRQoL) six and 12 months after stroke in individuals from a middle-income country. MATERIAL AND METHODS: This was a prospective study. The dependent outcomes assessed during six and 12 months after stroke included both generic and specific HRQoL (Short Form Health Survey-36 [SF-36] and stroke-specific quality of life [SSQOL]). The predictors were age, sex, education level, length of hospital stay, current living arrangement, stroke severity, functional independence, and motor impairment. RESULTS: 122 (59.9±14 years) and 103 (59.8±14.71 years) individuals were evaluated six and 12 months after stroke, respectively. Functional independence and sex were significant acute predictors of both generic and specific HRQoL. Functional independence was the strongest predictor (0.149≤R2≤0.262; 20.01≤F≤43.96, p<0.001), except for generic HRQoL at 12 months, where sex was the strongest predictor (R2=0.14; F=17.97, p<0.001). CONCLUSION: Generic and specific HRQoL in chronic individuals six and 12 months after stroke, from a middle-income country, can be predicted based on functional independence, the strongest predictor, assessed in the acute phase, except for generic HRQoL at 12 months. Functional independence can be modified by rehabilitation strategies and thus should be considered for HRQoL prognoses at chronic phase.

Determinants of access to rehabilitation professionals by individuals with stroke in the first six months after hospital discharge in Brazil: a study based on the Andersen model.

BACKGROUND: determinants of access to rehabilitation professionals after stroke in middle-income countries, where the burden of this disease is higher, are little known. OBJECTIVES: To identify the determinants of access to rehabilitation professionals by individuals with stroke at one, three, and six months after hospital discharge in Brazil and compare referral and access rates after discharge. METHODS: Longitudinal and prospective study, with individuals with primary stroke, without previous disabilities. At hospital discharge, the number of rehabilitation professionals referred by the multidisciplinary team was recorded. The possible determinants of access, according to Andersen's model, were: a) predisposing factors: age, sex, education levels, and belief that they could improve with treatment; b) need factors: stroke severity, levels of disability; c) enabling factors: socioeconomic status, disposable income for health care, and quality of care provided by rehabilitation professionals. One, three, and six months after hospital discharge, individuals were contacted to identify which rehabilitation professionals were accessed. Multiple linear regression model and Wilcoxon tests were used (α=5%). RESULTS: 201 individuals were included. Disability levels and stroke severity explained 31%, 34%, and 39% (p<0.01) of access at one, three, and six months after hospital discharge, respectively. In all periods, there was less access than that recommended at the time of hospital discharge (p<0.01). CONCLUSION: Need factors (disability levels and stroke severity) were determinants of access in all assessed periods. In addition, in all periods, the comprehensiveness of care for individuals with stroke was compromised.

R3-Walk and R6-Walk, Simple Clinical Equations to Accurately Predict Independent Walking at 3 and 6 Months After Stroke: A Prospective, Cohort Study.

OBJECTIVE: To investigate if independent walking at 3 and 6 months poststroke can be accurately predicted within the first 72 hours, based on simple clinical bedside tests. DESIGN: Prospective observational cohort study with 3-time measurements: immediately after stroke, and 3 and 6 months poststroke. SETTING: Public hospital. PARTICIPANTS: Adults with first-ever stroke evaluated at 3 (N=263) and 6 (N=212) months poststroke. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: The outcome of interest was independent walking at 3 and 6 months after stroke. Predictors were age, walking ability, lower limb strength, motor recovery, spatial neglect, continence, and independence in activities of daily living. RESULTS: The equation for predicting walking 3 months poststroke was 3.040 + (0.283 × FAC baseline) + (0.021 × Modified Barthel Index), and for predicting walking 6 months poststroke was 3.644 + (-0.014 × age) + (0.014 × Modified Barthel Index). For walking ability 3 months after stroke, sensitivity was classified as high (91%; 95% CI: 81-96), specificity was moderate (57%; 95% CI: 45-69), positive predictive value was high (76%; 95% CI: 64-86), and negative predictive value was high (80%; 95% CI: 60-93). For walking ability 6 months after stroke, sensitivity was classified as moderate (54%; 95% CI: 47-61), specificity was high (81%; 95% CI: 61-92), positive predictive value was high (87%; 95% CI: 70-96), and negative predictive value was low (42%; 95% CI: 50-73). CONCLUSIONS: This study provided 2 simple equations that predict walking ability 3 and 6 months after stroke. This represents an important step to accurately identify individuals, who are at high risk of walking dependence early after stroke.

Relative contributions of positive, negative, and adaptive features to limitations in upper-limb function three months after stroke.

PURPOSE: To investigate the contributions of motor impairments to limitations in upper-limb function three months after stroke. DESIGN: Cross-sectional, exploratory study. METHODS: Dependent variable was upper-limb function, measured by the Motor Assessment Scale (MAS), which scores range from 0 to 18. Independent variables included measures of strength, dexterity, spasticity, and contracture of the paretic upper limb. Multiple linear regression analysis was employed to identify which of the independent variables could explain the MAS scores (p<0.05). Analysis was performed with the whole sample and with a sub-group of participants, who had high function (MAS≥12). RESULTS: Sixty-nine individuals participated. Out of them, 63 had high upper-limb function. Regression analysis with the whole sample revealed that strength and dexterity were retained in the models. Together they explained 64% of the variance of the MAS scores (p<0.001), being strength the greater relative contributor. When the regression analysis included only participants with high upper-limb function, dexterity had a greater relative contribution, than strength. Together they explained 52 % of the variance (p< 0.001). CONCLUSIONS: Strength was the main contributor to upper-limb function in individuals three months after stroke. However, in individuals, who already had higher upper-limb function, dexterity showed to be the major contributor.

Changes in the clinico-functional characteristics of stroke patients in the acute phase during the COVID-19 pandemic.

OBJECTIVE: To compare the sociodemographic and clinico-functional characteristics of patients admitted to a stroke unit immediately before and during two different COVID-19 pandemic phases. METHODS: This exploratory study was conducted in the stroke unit of a public hospital in Brazil. Patients consecutively admitted to a stroke unit for 18 months with primary stroke aged ≥20 years were included and divided into three groups: G1: Pre-pandemic; G2: Early pandemic; and G3: Late pandemic. The sociodemographic and clinico-functional characteristics of the groups were compared (α=0.05). RESULTS: The study included 383 individuals (G1=124; G2=151; G3=108). The number of risk factors (higher in G2; p≤0.001), smoking (more common in G2; p≤0.01), type of stroke (ischemic more common in G3; p=0.002), stroke severity (more severe in G2; p=0.02), and level of disability (more severe in G2: p≤0.01) were significantly different among the groups. CONCLUSION: A greater number of serious events and risk factors including smoking and higher level of disability was observed in patients in the beginning of the pandemic than in the late phases. Only the occurrence of ischemic stroke increased in the late phase. Therefore, these individuals may have an increased need for rehabilitation services monitoring and care during their lifespan. Additionally, these results indicate that health promotion and prevention services should be strengthened for future health emergencies.

Access to rehabilitation professionals by individuals with stroke one month after hospital discharge from a stroke unit in Brazil is insufficient regardless of the pandemic.

OBJECTIVE: To compare access to rehabilitation professionals by individuals with stroke one month after hospital discharge from a stroke unit in Brazil, before and during the COVID-19 pandemic. MATERIALS AND METHODS: This longitudinal and prospective study included individuals aged 20 years or older without previous disabilities admitted into a stroke unit due to a first stroke. Individuals were divided into two groups: before (G1) and during (G2) the COVID-19 pandemic. Groups were matched for age, sex, education level, socioeconomic status, and stroke severity. One month after hospital discharge, individuals were contacted via telephone to collect data regarding their access to rehabilitation services based on the number of referred rehabilitation professionals. Then, between-group comparisons were conducted (α = 5%). RESULTS: The access to rehabilitation professionals was similar between groups. Rehabilitation professionals accessed included medical doctors, occupational therapists, physical therapists, and speech therapists. The first consultation after hospital discharge was mainly provided by public services. Despite the pandemic, telehealth was not frequent in any period evaluated. In both groups, the number of accessed professionals (G1 = 110 and G2 = 90) was significantly lower than the number of referrals (G1 = 212 and G2 = 194; p < 0.001). CONCLUSIONS: Access to rehabilitation professionals was similar between groups. However, the number of accessed rehabilitation professionals was lower than that of referred ones during both periods. This finding indicates a compromised comprehensiveness of care for individuals with stroke, regardless of the pandemic.

Functional independence measured in the acute phase of stroke predicts both generic and specific health-related quality of life: a 3-month prospective study in a middle-income country.

PURPOSE: To identify acute predictors of both generic and specific health-related quality of life (HRQoL) 3 months after stroke in individuals from a middle-income country. MATERIALS AND METHODS: A 3-month prospective study with individuals who had suffered their first stroke, without previous disability, discharged from a stroke unit. The dependent outcomes, assessed 3 months after stroke, were generic and specific HRQoL (SF-36 and SSQOL total scores, respectively). The predictors assessed in the stroke unit were age, sex, education level, duration of hospital stay, current living arrangement, stroke severity (National Institutes of Health Stroke Scale-NIHSS), functional independence (Modified Barthel Index-MBI), motor impairment (Fugl-Meyer Assessment), and lower- and upper-limb residual muscle strength deficits. Linear multiple regression analyses were employed to identify predictors of both generic (model-1) and specific (model-2) HRQoL (α = 5%). RESULTS: One hundred twenty-six individuals were assessed at 3-month post-stroke (61.3 ± 13.6 years). Regression analysis showed that functional independence was the best predictor of both generic (R2 = 21%; F = 34.82; p < 0.001) and specific (R2 = 29%; F = 51.71; p < 0.001) HRQoL at 3-month post-stroke. CONCLUSION: Both generic and specific HRQoL at 3-month post-stroke can be predicted by functional independence assessed in the acute phase with the MBI.

Health-related quality of life (HRQoL), a patient-centered outcome, is essential for healthcare, mainly in stroke, a chronic disease with a broad spectrum of disabilities.Functional independence is a key outcome and should always be a part of characterizing patients before the rehabilitation process.Functional independence assessed with the Modified Barthel Index in the acute phase of stroke predicts both generic and specific HRQoL at 3-month post-stroke.Patients post-stroke with lower functional independence at hospital discharge may be at risk of having lower HRQoL at 3-month post-stroke.

Clinical evolution of dysphagic patients after malignant infarction and decompressive craniectomy: a case series / Evolução clínica de pacientes disfágicos pós-AVCi maligno e craniectomia descompressiva: série de casos

ABSTRACT This study aimed to characterize clinical-neurological factors and the functional swallowing capacity of patients with malignant infarction submitted to decompressive craniectomy during the hospital stay. This retrospective, descriptive, observational study was conducted between January 2020 and December 2021. The following data regarding up to eight stages were extracted for descriptive analysis: age, location of the lesion, level of awareness according to the Glasgow Coma Scale, neurological impairment according to the National Institutes of Health Stroke Scale, and the functional swallowing capacity according to the Functional Oral Intake Scale. Data on five patients were collected, with a mean of 0.2 days for the first neurological assessment. Decompressive craniectomy was performed in a mean of 2 days after admission. The speech-language-hearing assessment occurred in a mean of 8.2 days, and the speech-language-hearing discharge took a mean of 35.4 days. The neurological impairment score remained the same as in the first neurological assessment after decompressive craniectomy, with a mean score of 16.6. The functional swallowing capacity was the same in the first assessment after decompressive craniectomy, on FOIS level 1, improving considerably by the discharge, with a mean level of 4.8. It is concluded that clinical-neurological factors can interfere with the functional swallowing capacity, although they did not hinder either speech-language-hearing treatment or their evolution to a full oral diet during the hospital stay.

RESUMO O objetivo do presente trabalho é caracterizar fatores clínicos-neurológicos e capacidade funcional de deglutição de pacientes com Acidente Vascular Cerebral Isquêmico Maligno submetidos a craniectomia descompressiva durante internação hospitalar. Trata-se de um estudo observacional, descritivo e retrospectivo, realizado de janeiro de 2020 a dezembro de 2021. Os dados foram extraídos em até oito momentos, incluindo idade, local da lesão, nível de consciência de acordo com Glasgow, comprometimento neurológico pelo National Institutes of Health Stroke Scale e capacidade funcional de deglutição pela Escala Funcional de Ingestão por Via Oral. Realizou-se análise descritiva. Foram coletados dados de 5 pacientes sendo a média de tempo para primeira avaliação neurológica de 0,2 dias. A realização da craniectomia descompressiva levou em média 2 dias após admissão. Avaliação fonoaudiológica ocorreu, em média, 8,2 dias e alta fonoaudiológica levou, em média, 35,4 dias. O comprometimento neurológico manteve-se na pontuação da primeira avaliação neurológica pós-craniectomia descompressiva, média de 16,6. A capacidade funcional de deglutição foi a mesma na primeira avaliação pós-craniectomia descompressiva, com nível 1 na FOIS, melhorando consideravelmente, com média de nível 4,8, na alta. Concluiu-se que fatores clínicos-neurológicos podem interferir na capacidade funcional de deglutição, contudo não limitaram a atuação fonoaudiológica e evolução com dieta oral exclusiva na internação hospitalar.

Incidence and potential predictors of early onset of upper-limb contractures after stroke.

OBJECTIVES: To investigate the incidence and potential predictors of upper-limb contractures, three months after stroke. DESIGN: Prospective cohort study. METHODS: Consecutive sample of individuals with hemiparesis due to stroke, admitted to a public hospital in Brazil. Contractures were measured by passive range of motion of lateral shoulder rotation, elbow extension, and wrist extension with a gravity inclinometer. Potential predictors included measures of muscle strength, spasticity of the upper-limb muscles, upper-limb function, dexterity, and pain. Measurements were obtained within four weeks and at three months after the stroke. A binomial regression analysis was employed. RESULTS: Out of the 76 individuals with hemiparesis, 28% developed at least one contracture on their paretic upper limb. The incidence of contracture varied across the joints from 6% to 16% and the wrist was the most affected joint. Individuals with moderate stroke showed higher incidence of contracture, compared with those with mild stroke. Dexterity (OR 0.009, 95% confidence intervals (95% CI) 0.00-0.19) and pain (OR 6.417, 95% CI 1.22-33.83) were significant predictors of shoulder, elbow, and wrist contractures. CONCLUSIONS: Individuals with mild and moderate stroke developed upper-limb contractures three months after the onset of the stroke, with an incidence of 28%. The predictors were the presence of pain and loss of dexterity. These impairments should be earlier targeted during rehabilitation interventions.Implications for rehabilitationThe incidence of upper limb contracture 3 months after the stroke is high after mild to moderate stroke.Wrist contractures are the most common upper limb contracture.The presence of pain and loss of dexterity significantly contribute to the development of upper limb contractures.Health professionals should target on the control of pain and improvement of upper-limb dexterity to prevent contractures.

Clinical and molecular correlates of the ASPECTS in the acute phase of stroke.

BACKGROUND: The Alberta Stroke Program Early CT Score (ASPECTS) scale was developed for monitoring early ischemic changes on CT, being associated with clinical outcomes. The ASPECTS can also associate with peripheral biomarkers that reflect the pathophysiological response of the brain to the ischemic stroke. OBJECTIVE: To investigate the association between peripheral biomarkers with the Alberta Stroke Program Early CT Score (ASPECTS) in individuals after ischemic stroke. METHODS: Patients over 18 years old with acute ischemic stroke were enrolled in this study. No patient was eligible for thrombolysis. The patients were submitted to non-contrast CT in the first 24 hours of admission, being the Alberta Stroke Program Early CT Score and clinical and molecular evaluations applied on the same day. The National Institutes of Health Stroke Scale (NIHSS), modified Rankin scale and the Mini-Mental State Examination for clinical evaluation were also applied to all subjects. Plasma levels of BDNF, VCAM-1, VEGF, IL-1ß, sTNFRs and adiponectin were determined by ELISA. RESULTS: Worse neurological impairment (NIHSS), cognitive (MEEM) and functional (Rankin) performance was observed in the group with changes in the NCTT. Patients with NCTT changes also exhibited higher levels of IL-1ß and adiponectin. In the linear multivariate regression, an adjusted R coefficient of 0.515 was found, indicating adiponectin and NIHSS as independent predictors of ASPECTS. CONCLUSION: Plasma levels of adiponectin are associated with the ASPECTS scores.

Plasma Levels of Brain-Derived Neurotrophic Factor are Associated with Prognosis in the Acute Phase of Ischemic Stroke.

CONTEXT: Brain-derived neurotrophic factor (BDNF) is a neurotrophin involved in neuronal survival, differentiation, and maturation. PURPOSE: To evaluate the levels of BDNF in the acute phase of stroke and their potential association with neurological impairment. METHODS: Patients in the acute phase of ischemic stroke were evaluated with the following clinical tools: National Institutes of Health Stroke Scale, modified Rankin scale, Gugging Swallowing Screen and Alberta Stroke Program Early CT Score. Blood samples were collected at 3 different moments of hospital stay. BDNF was measured through enzyme-linked immunosorbent assay. RESULTS: Patients who were discharged after 10 days had worse clinical outcomes and higher levels of BDNF since admission. There was correlation between BDNF levels and clinical parameters. CONCLUSION: BDNF levels were associated with clinical prognosis in the acute phase of ischemic stroke.

Association between executive and food functions in the acute phase after stroke.

Purpose To investigate potential associations among executive, physical and food functions in the acute phase after stroke. Methods This is a cross-sectional study that evaluated 63 patients admitted to the stroke unit of a public hospital. The exclusion criteria were other neurological and/or psychiatric diagnoses. The tools for evaluation were: Mini-Mental State Examination and Frontal Assessment Battery for cognitive functions; Alberta Stroke Program Early CT Score for quantification of brain injury; National Institutes of Health Stroke Scale for neurological impairment; Modified Rankin Scale for functionality, and the Functional Oral Intake Scale for food function. Results The sample comprised 34 men (54%) and 29 women with a mean age of 63.6 years. The Frontal Assessment Battery was significantly associated with the other scales. In multivariate analysis, executive function was independently associated with the Functional Oral Intake Scale. Conclusion Most patients exhibited executive dysfunction that significantly compromised oral intake.

Association between executive and food functions in the acute phase after stroke / Associações entre função executiva e habilidade de alimentação pós-AVC na fase aguda

ABSTRACT Purpose To investigate potential associations among executive, physical and food functions in the acute phase after stroke. Methods This is a cross-sectional study that evaluated 63 patients admitted to the stroke unit of a public hospital. The exclusion criteria were other neurological and/or psychiatric diagnoses. The tools for evaluation were: Mini-Mental State Examination and Frontal Assessment Battery for cognitive functions; Alberta Stroke Program Early CT Score for quantification of brain injury; National Institutes of Health Stroke Scale for neurological impairment; Modified Rankin Scale for functionality, and the Functional Oral Intake Scale for food function. Results The sample comprised 34 men (54%) and 29 women with a mean age of 63.6 years. The Frontal Assessment Battery was significantly associated with the other scales. In multivariate analysis, executive function was independently associated with the Functional Oral Intake Scale. Conclusion Most patients exhibited executive dysfunction that significantly compromised oral intake.

RESUMO Objetivo Investigar potenciais associações entre funções executiva, física global e de alimentação na fase aguda do acidente vascular cerebral (AVC). Métodos Trata-se de estudo transversal envolvendo 63 pacientes admitidos em unidade de AVC de um hospital público. Os critérios de exclusão foram outros diagnósticos neurológicos e/ou psiquiátricos. Os instrumentos utilizados foram: Mini-Exame do Estado Mental e Bateria de Avaliação Frontal para avaliar funções cognitivas; Alberta Stroke Program Early CT Score para quantificação da lesão cerebral; National Institutes of Health Stroke Scale para comprometimento neurológico; Escala Modificada de Rankin para funcionalidade e Functional Oral Intake Scale para função alimentar. Resultados A amostra compreendeu 34 homens e 29 mulheres, sendo a idade média de 63,6 anos. A Bateria de Avaliação Frontal correlacionou significativamente com as demais escalas. Na análise multivariada, a variável independentemente associada com a função executiva foi a Functional Oral Intake Scale. Conclusão A maioria dos pacientes com AVC apresenta alterações das funções executivas que comprometem significativamente a alimentação oral.

Perfil dos pacientes com diagnóstico de AVC atendidos em um hospital de Minas Gerais credenciado na linha de cuidados / Profile of patients with a diagnosis of stroke attended at a hospital in Minas Gerais accredited in the care line

Introdução: Acidente Vascular Cerebral é um problema de saúde pública em que estudos epidemiológicos evidenciam a importância da prevenção, promoção e tratamento da doença no Brasil. Objetivo: descrever a distribuição de pacientes com Acidente Vascular Cerebral nos diferentes setores de internação de um hospital da rede pública credenciado pelo Ministério da Saúde na linha de cuidados. Métodos: Estudo transversal em que foram avaliados pacientes com Acidente Vascular Cerebral admitidos no Hospital Risoleta Tolentino Neves de Belo Horizonte no período de janeiro a junho de 2015. Dados sócio-demográficos e clínicos foram extraídos dos prontuários e/ ou por meio de entrevistas, sendo analisadas as informações: sexo; idade; mecanismo fisiopatológico; tempo de ictus; fatores de risco para o AVC; setor de internação; tempo de internação e complicações clínicas. Resultados: Dos 223 pacientes internados, 55% eram sexo masculino e idade média de 64,3 anos. Em relação aos setores hospitalares, 169 foram alocados para a Unidade de Acidente Vascular Cerebral (82% isquêmico), 24 no Centro de Tratamento Intensivo (79% hemorrágico), 23 no Pronto Atendimento (74% Ataque Isquêmico Transitório) e sete na Enfermaria Geral. A média do tempo de ictus foi de 13,2 horas. O tempo médio de internação foi de 12,4 ± 9,8 dias, entretanto a Enfermaria Geral e o Centro de Tratamento Intensivo apresentaram maiores tempos de internação e número de complicações clínicas. Conclusão: A linha de cuidado em Acidente Vascular Cerebral nos hospitais pode reduzir complicações clínicas, mortalidade e tempo de internação, contribuindo para organização de setores de internação e utilização de recursos hospitalares.(AU)

Background: Stroke is a public health problem in which epidemiological studies evidence the importance of the prevention, promotion and treatment of the disease in Brazil. Purpose: To describe the distribution of patients with Stroke in different hospital sectors of a public hospital accredited by the Ministry of Health in care line. Methods: Cross-sectional study which evaluated patients with Stroke admitted to the Hospital Risoleta Tolentino Neves Belo Horizonte in the period January-June 2015. socio-demographic and clinical data were extracted from medical records and / or through interviews, and analyzed information: gender; age; Pathophysiological mechanism; Stroke time; Risk factors for stroke; Hospitalization; Length of hospital stay and clinical complications. Results: Of the 223 hospitalized patients, 55% were male and mean age was 64.3 years. In the hospital sectors, 169 were allocated to the Stroke Unit (82% ischemic), 24 in the Intensive Care Center (79% hemorrhagic), 23 in the Emergency Care Unit (74% Transient Ischemic Attack) and 7 in the General Nursing. The mean stroke time was 13.2 hours. The mean length of hospital stay was 12.4 ± 9.8 days, although the General Nursing and Intensive Care had longer hospitalization times and number of clinical complications. Conclusion: The line of care in stroke in hospitals can reduce clinical complications, mortality and length of stay, contributing to the organization of hospitalization sectors and use of hospital resources. (AU)