Developing and testing a patient information booklet for thrombolysis used in acute stroke.

Objective Thrombolysis decreases the chance of post-stroke dependence, although its use carries significant risk, notably of intra-cerebral haemorrhage. Patients (and families) face an important risk/benefit decision before consenting. We drafted a patient information booklet for this purpose, and applied performance-based readability testing with the aim that the most important information in the booklet could be found and understood. Methods The booklet was developed with reference to best practice in information writing and design. We User-Tested its performance on 56 people without prior experience of stroke. After reading the booklet they were asked to find and explain 15 pieces of information. The booklet was revised according to its performance and re-tested, until each item was found and understood by at least 80% of participants. Key findings The four-page information booklet contained approximately 900 words, organised into six sections. A risk-palette graphic showed the chance of positive and negative outcomes. The booklet was tested on four participant cohorts and revised, including more bold text, re-wording, changing the title and changing the graphic to a coloured bar chart. Testing the final version on the fourth cohort of 20 people showed that each of the 15 tested items of information met the target of at least 80% participants being able to find and understand it. Conclusions The use of information design and User Testing produced a booklet that is understandable by people with no prior experience of stroke. User Testing is an inexpensive and quick method to ensure that information intended for patients is usable.

Structured re-assessment system at 6 months after a disabling stroke: a randomised controlled trial with resource use and cost study.

BACKGROUND: national policy recommends routine re-assessment of disabled patients and their carers at 6 months after stroke onset. The clinical and resource outcomes of this policy were investigated. DESIGN: prospective, single-blind, randomised controlled trial in two centres. PARTICIPANTS: a total of 265 patients with a disabling stroke and their carers. INTERVENTIONS: a structured re-assessment system for patients and their carers at 6 months post-stroke or existing care. OUTCOME MEASURES: primary: patient independence (Frenchay activities index) and carer stress (general health questionnaire 28). Secondary: activities of daily living, mood state, satisfaction with services, carer strain index, health and social service resource use and costs. RESULTS: independence at 12 months post-stroke was similar in both groups (Frenchay activities index, adjusted mean difference 0.64; 95% confidence interval -0.74-2.02). Emotional distress in carers was similar in both groups (general health questionnaire 28, mean difference 0.02; 95% confidence interval -0.95-1.00). Results for the secondary outcome measures and total mean costs were similar for both groups. The intervention group patients used 301 fewer hospital bed days and 1,631 fewer care home bed days. CONCLUSIONS: the structured, systematic re-assessment for patients and their carers was not associated with any clinically significant evidence of benefit at 12 months. Health and social care resource use and mean cost per patient were broadly similar in both groups. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Register; number: ISRCTN55412871.

Acceptance, effectiveness and safety of continuous positive airway pressure in acute stroke: a pilot study.

OBJECTIVES: To evaluate the acceptance, effectiveness in preventing upper airways obstruction, and haemodynamic effects of continuous positive airway pressure (CPAP) in acute stroke. METHODS: Twelve patients (4 M, and 8 F; mean (SD), 75.2 (5.5) years) within 48 h of acute stroke onset underwent: (1) sleep studies (1st night: auto-CPAP mode; 2nd night: diagnostic); (2) nocturnal non-invasive blood pressure studies (1st night during CPAP; 2nd night during spontaneous breathing (SB)); and (3) daytime cerebral blood flow velocity measurement in middle cerebral artery (FV) with transcranial Doppler during SB and with CPAP (5, 10, 15 cm H(2)O). RESULTS: Ninety percent, 60% and 50% of stroke patients had a respiratory disturbance index (RDI) of >or=5, >or=10 and >or=15 events per hour, respectively (18.2 (11.3)). CPAP acceptance was 84%; 42% used CPAP more than 6h and 42% between 1-3h with a mean use of CPAP of 5.2h (4.0). Compared to SB, CPAP reduced, though not significantly, RDI, time with SaO(2)<90%, mean blood pressure and mean blood pressure dips (10 mm Hg)/h. Compared with SB, any level of CPAP progressively and significantly reduced systolic and mean FV; drop in diastolic FV was significant at CPAP10 and CPAP15. The partial pressure of end-tidal CO(2) was significantly lowered by all levels of CPAP. CONCLUSIONS: According to this pilot study, CPAP is reasonably well tolerated by patients with acute stroke for at least one night. Despite its possible beneficial effect on obstructive sleep-disordered breathing and blood pressure variability, CPAP use in acute stroke should be still considered with caution due to possible harmful haemodynamic effects at higher pressures.

Effect of upper airway obstruction on blood pressure variability after stroke.

Approx. 60% of acute stroke patients have periods of significant UAO (upper airway obstruction) and this is associated with a worse outcome. UAO is associated with repeated fluctuation in BP (blood pressure) and increased BP variability is also associated with a poor outcome in patients with acute stroke. UAO-induced changes in BP, at a time when regional cerebral perfusion is pressure-dependent in areas of critically ischaemic brain, could explain the detrimental effect of UAO on outcome in these patients. The aim of the present study was to examine the relationship between UAO and BP variability in patients with acute stroke. Twelve acute stroke patients and 12 age-, sex- and BMI (body mass index)-matched controls underwent a sleep study with non-invasive continuous monitoring of BP to assess the impact of UAO on BP control after stroke. Stroke patients had significantly more 15 mmHg dips in BP/h than the controls (51 compared with 6.7 respectively; P<0.004). Stroke patients also demonstrated significantly higher BP variability than the controls (26.8 compared with 14.4 mmHg; P<0.001). There were significantly more 15 mmHg dips in BP/h in stroke patients who had significant UAO than those who did not (85.7 compared with 29.5 respectively; P<0.032). Furthermore, stroke patients without UAO (RDI <10, where RDI is respiratory disturbance index) had significantly more 15 mmHg dips in BP/h than the controls (29.5 compared with 6.7 respectively; P<0.037). There was a positive correlation between the severity of UAO (RDI) and 15 mmHg dips in BP/h (r=0.574, P<0.005) in stroke patients. Our results suggest that UAO alone does not explain BP variation post-stroke, but it does play an important role, particularly in determining the severity of the BP fluctuation.