Criteria and Indicators for Centers of Clinical Excellence in Stroke Recovery and Rehabilitation: A Global Consensus Facilitated by ISRRA.

BACKGROUND: The aim of the International Stroke Recovery and Rehabilitation Alliance is to create a world where worldwide collaboration brings major breakthroughs for the millions of people living with stroke. A key pillar of this work is to define globally relevant criteria for centers that aspire to deliver excellent clinical rehabilitation and generate exceptional outcomes for patients. OBJECTIVES: This paper presents consensus work conducted with an international group of expert stroke recovery and rehabilitation researchers, clinicians, and people living with stroke to identify and define criteria and measurable indicators for Centers of Clinical Excellence (CoCE) in stroke recovery and rehabilitation. These were intentionally developed to be ambitious and internationally relevant, regardless of a country's development or income status, to drive global improvement in stroke services. METHODS: Criteria and specific measurable indicators for CoCE were collaboratively developed by an international panel of stroke recovery and rehabilitation experts from 10 countries and consumer groups from 5 countries. RESULTS: The criteria and associated indicators, ranked in order of importance, focused upon (i) optimal outcome, (ii) research culture, (iii) working collaboratively with people living with stroke, (iv) knowledge exchange, (v) leadership, (vi) education, and (vii) advocacy. Work is currently underway to user-test the criteria and indicators in 14 rehabilitation centers in 10 different countries. CONCLUSIONS: We anticipate that use of the criteria and indicators could support individual organizations to further develop their services and, more widely, provide a mechanism by which clinical excellence can be articulated and shared to generate global improvements in stroke care.

The Unmet Needs of Caregiving Skills, Support, Emotions, and Finances of Stroke Caregivers: A Multicenter Study.

​​​​​​Background Informal stroke caregivers in Malaysia play an important role in supporting stroke survivors following acute care. Nevertheless, there is a lack of available data to inform the sufficiency of help and resources available to address the needs of local stroke caregivers. This study aimed to determine the unmet needs in caregiving skills, support, emotions, and finances as well as the associated factors of stroke caregivers in Malaysia. Methodology This multicenter, cross-sectional study used a self-administered survey developed and validated for the Malaysian population. It was prepared in paper-based and web-based formats, and it was distributed via direct contact with the respondents, post, and email. Respondents were recruited from different sites in Malaysia. In this study, unmet needs were defined as "help that was needed more or was not provided to assist caregivers and address their specific needs." This article only presents the quantitative data of this study. Data were analyzed using descriptive analysis and logistic regression to determine factors associated with unmet needs. Results Almost all study respondents (91%) reported having unmet needs. Unmet needs ranged from 1 to 10, while the mean unmet needs was 5. The highest unmet need was related to financial support (72.5%), followed by support from professionals to address their own needs (59.2%), skills to care for stroke survivors, i.e., skills in caring for stroke survivors with their daily activities (57.9%), and skills in supporting stroke survivors to perform rehabilitation at home (53.1%). The lowest unmet need was related to support in transporting stroke survivors from place to place (45.3%). Additionally, this study did not identify an association between the reported unmet needs and gender, age, ethnicity, duration of caregiving, and site of participation. Conclusions This study reported a range of unmet needs perceived by stroke caregivers in Malaysia. Further research is warranted to understand the gaps in supporting local stroke caregivers to inform future post-stroke support and services in the country.

A malnourished post-stroke man with multi-morbidity and sarcopenia risk in a long-term stroke clinic: A case report.

A 78-year-old post-stroke man with multiple comorbidities who was activity of daily living- dependent developed aspiration pneumonia associated with nasogastric tube (NGT) blockage. He presented with malnutrition and risk of sarcopenia with hypoalbuminaemia, small calf circumference (CC), low body mass index and small mid upper arm circumference. He showed symptoms of moderate-to-severe vascular dementia with behavioural psychological stress disorder, resulting in carer stress. Psychoeducation among the carers and referral to a neuro-psychiatrist were ensued after outpatient-based team meeting discussion. Herein, we highlight the importance of screening for sarcopenia and nutritional status in post-stroke patients with the use of the CC and serum albumin level as well as the involvement of a multidisciplinary team in the primary care setting to improve patient outcomes. Percutaneous endoscopic gastrostomy tubes are more suitable than NGTs for post-stroke patients who require enteral feeding to improve the nutritional status.

Neuroprotection by Trans-Resveratrol in Rats With Intracerebral Hemorrhage: Insights into the Role of Adenosine A1 Receptors.

Given the neuroprotective effects of trans-resveratrol (RV), this study aimed to investigate the involvement of the adenosine A1 receptor (A1R) in RV-mediated neuroprotection in a rat intracerebral hemorrhage (ICH) model induced by intrastriatal injection of collagenase. Rats were divided into 5 groups: (1) control, (2) sham-operated, (3) ICH pretreated with vehicle, (4) ICH pretreated with RV, and (5) ICH pretreated with RV and the A1R antagonist DPCPX. At 48 hours after ICH, the rats were subjected to neurological testing. Brain tissues were assessed for neuronal density and morphological features using routine and immunohistochemical staining. Expression of tumor necrosis factor-α (TNF-α), caspase-3, and RIPK3 proteins was examined using ELISA. A1R, MAPK P38, Hsp90, TrkB, and BDNF genes were examined using RT-qPCR. RV protected against neurological deficits and neuronal depletion, restored the expression of TNF-α, CASP3, RIPK3, A1R, and Hsp90, and increased BDNF/TrkB. DPCPX abolished the effects of RV on neurological outcomes, neuronal density, CASP3, RIPK3, A1R, Hsp90, and BDNF. These data indicate that the neuroprotection by RV involves A1R and inhibits CASP3-dependent apoptosis and RIPK3-dependent necroptosis in the perihematoma region; this is likely to be mediated by crosstalk between A1R and the BDNF/TrkB pathway.

Current Update on the Clinical Utility of MMSE and MoCA for Stroke Patients in Asia: A Systematic Review.

OBJECTIVE: Primary care clinicians in Asia employed the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) to aid dementia diagnosis post-stroke. Recent studies questioned their clinical utility in stroke settings for relying on verbal abilities and education level, as well as lack of consideration for aphasia and neglect. We aimed to review the clinical utility of the MMSE and MoCA for stroke patients in Asia and provide recommendations for clinical practice. METHODS: PubMed, Scopus, Web of Science, and Science Direct were searched for relevant articles. Included studies were assessed for risk of bias. RevMan 5.4 was used for data synthesis (sensitivity and specificity) and covariates were identified. RESULTS: Among the 48 full-text articles reviewed, 11 studies were included with 3735 total subjects; of these studies, 7 (77%) were conducted in China, 3 (27%) in Singapore, and 1 (9%) in South Korea. Both the MMSE and MoCA generally showed adequate sensitivity and specificity. Education was identified as a covariate that significantly affected detection accuracy. Due to heterogeneity in cutoff scores, methodologies, and languages, it was not feasible to suggest a single cutoff score. One additional point is recommended for MoCA for patients with <6 years of education. CONCLUSION: Clinicians in Asia are strongly recommended to consider the education level of stroke patients when interpreting the results of the MMSE and MoCA. Further studies in other Asian countries are needed to understand their clinical value in stroke settings.

Internet pornography exposures amongst young people in Malaysia: A cross-sectional study looking into the role of gender and perceived realism versus the actual sexual activities.

Despite the wide accessibility to internet, pornography activities among youths are not well described in conservative countries like Malaysia. This study aimed to determine the prevalence, elicit gender differences and identify associated factors of pornographic exposure including perceived realism among college students. This cross-sectional study was conducted among students aged 18 to 25 years from seven colleges in Penang, Malaysia. A self-administered questionnaire was used to obtain data on socio-demographic characteristics, pornography exposure, pattern of use, sexual exposure and perceived realism. Among 986 participants, the prevalence of lifetime pornography exposure was 74.5%. More males (71.7%) were exposed to pornography, had started at earlier age, were frequent users and using the internet alone at home (p < 0.001). Males had higher odds of having exposure (Adjusted odds ratio, AOR = 20.44, 95% CI: 12.50 - 33.42, p < 0.001), whilst those who perceived pornography as real had lower odds of having pornographic exposure (AOR = 0.64, 95% CI: 0.43-0.94, p = 0.02). There is a high prevalence of pornography exposure among Malaysian college students, especially involving males. Easy access to pornographic materials at home facilitates this activity. Gender and perceived realism determined their pornographic exposure. Thus, parental monitoring of online access and planning structured activities to occupy free time are recommended at an early age.

Neuroprotection by trans-resveratrol against collagenase-induced neurological and neurobehavioural deficits in rats involves adenosine A1 receptors.

Objective: Trans-resveratrol has been shown to have neuroprotective effects and could be a promising therapeutic agent in the treatment of intracerebral haemorrhage (ICH). This study aimed to investigate the involvement of the adenosine A1 receptor (A1R) in trans-resveratrol-induced neuroprotection in rats with collagenase-induced ICH.Methods: Sixty male Sprague-Dawley rats weighing 330-380 g were randomly divided into five groups (n = 12): (i) control, (ii) sham-operated rats, (iii) ICH rats pretreated with vehicle (0.1% DMSO saline, i.c.v.), (iv) ICH rats pretreated with trans-resveratrol (0.9 µg, i.c.v.) and (v) ICH rats pretreated with trans-resveratrol (0.9 µg) and the A1R antagonist, DPCPX (2.5 µg, i.c.v.). Thirty minutes after pretreatment, ICH was induced by intrastriatal injection of collagenase (0.04 U). Forty-eight hours after ICH, the rats were assessed using a variety of neurobehavioural tests. Subsequently, rats were sacrificed and brains were subjected to gross morphological examination of the haematoma area and histological examination of the damaged area.Results: Severe neurobehavioural deficits and haematoma with diffuse oedema were observed after intrastriatal collagenase injection. Pretreatment with trans-resveratrol partially restored general locomotor activity, muscle strength and coordination, which was accompanied with reduction of haematoma volume by 73.22% (P < 0.05) and damaged area by 60.77% (P < 0.05) in comparison to the vehicle-pretreated ICH group. The trans-resveratrol-induced improvement in neurobehavioural outcomes and morphological features of brain tissues was inhibited by DPCPX pretreatment.Conclusion: This study demonstrates that the A1R activation is possibly the mechanism underlying the trans-resveratrol-induced neurological and neurobehavioural protection in rats with ICH.

Barriers in Adopting Healthy Body Weight Among Malaysian Population: A Cross-Sectional Study of Body Weight Perception and Misperception Versus Actual Body Weight.

Perception of body weight has been recognized as an important barrier in the adoption of healthy lifestyles. Several factors affect perception of body weight, but the outcomes have been varied. This study aimed to study the perception and misperception of body weight and its association with the measured body mass index. A clinic-based cross-sectional study was done in the clinic using systematic sampling. Data were collected by using a self-administered questionnaire consisting of the sociodemographic profile, body weight perception question adopted from Weight Management Questionnaire and Youth Risk Behavior Surveillance System (YRBSS) 1991-2017. The prevalence of body weight misperception in the sample population was 58.6%. Most of the respondents were overweight (33.9%) and obese (33.9%). Respondents aged 25 years and older were 2.98 times more likely to have misperception compared with other age groups (95% CI: 1.21-3.19, P = .006). Divorced respondents were 4.70 times more likely to have body misperception compared with married respondents (95% CI 1.44-15.32, P = 0.01). This study showed that misperception of body weight could be influenced by reversible factors and measured body mass index. Hence, the rectification of these misperceptions is important in the clinical setting especially in these vulnerable groups of respondents.

LY294002, a PI3K pathway inhibitor, prevents leptin-induced adverse effects on spermatozoa in Sprague-Dawley rats.

This study examined the effects of PI3K and AMPK signalling pathway inhibitors on leptin-induced adverse effects on rat spermatozoa. Sprague-Dawley rats, aged 14-16 weeks, were randomised into control, leptin-, leptin + dorsomorphin (AMPK inhibitor)-, and leptin+LY294002 (PI3K inhibitor)-treated groups with six rats per group. Leptin was given once daily for 14 days via the intraperitoneal (i.p.) route at a dose of 60 ug kg-1 body weight. Rats in the leptin and inhibitor-treated groups received concurrently either dorsomorphin (5 mg kg-1  day-1 ) or LY294002 (1.2 mg kg-1  day-1 ) i.p. for 14 days. Controls received 0.1 ml of normal saline. Upon completion, sperm count, sperm morphology, seminiferous tubular epithelial height (STEH), seminiferous tubular diameter (STD), 8-hydroxy-2-deoxyguanosine (8-OHdG) and phospho-Akt/total Akt ratio were estimated. Data were analysed using ANOVA. Sperm count, STEH and STD were significantly lower, while the percentage of spermatozoa with abnormal morphology and the level of 8-OHdG were significantly higher in rats treated with leptin and leptin + dorsomorphin when compared to those in controls and LY294002-treated rats. Testicular phospho-Akt/total Akt ratio was significantly higher in leptin and leptin + LY294002-treated rats. In conclusion, LY294002 prevents leptin-induced changes in rat sperm parameters, suggesting the potential role of the PI3K signalling pathway in the adverse effects of leptin on sperm parameters.

Tocotrienol-rich fraction supplementation prevents foetal loss in females mated with corticosterone-treated male Sprague-Dawley rats.

This study examined whether tocotrienol supplementation to corticosterone-treated male rats could prevent foetal loss in females upon their mating. Epididymides of adult male Sprague-Dawley (SD) rats with proven fertility were surgically separated at the testis-caput junction. Twenty-four hours post-surgery, these animals received for 7 days either: tocopherol-stripped corn oil (Control), corticosterone 25 mg/kg s.c. (CORT), CORT 25 mg/kg s.c. and tocotrienol-rich fraction (TRF) 100 mg/kg orally (CORT + TRF) or TRF 100 mg/kg orally (TRF). On day 8, males were cohabited with proestrus females. A spermatozoa-positive vaginal smear indicated pregnancy. Males were euthanised for analysis of testosterone and antioxidant activities. Reproductive organs were weighed. On day 8 of pregnancy, females were laparotomised to count the number of implantation sites. Pregnancy was continued until term. Number of pups delivered and their weights were determined. Data were analysed using ANOVA. Malondialdehyde levels were significantly lower in CORT + TRF group compared with CORT group. Enzymatic antioxidant activities, testosterone level and reproductive organ weights were significantly higher in CORT + TRF group compared with CORT group. Number of implantation sites and live pups delivered, and their birth weights from females mated with CORT + TRF males were significantly higher compared to CORT group. Therefore, TRF prevents foetal loss in females mated with CORT + TRF-treated males.

Correction: Stroke survivors' and informal caregivers' experiences of primary care and community healthcare services - A systematic review and meta-ethnography.

[This corrects the article DOI: 10.1371/journal.pone.0192533.].

Stroke survivors' and informal caregivers' experiences of primary care and community healthcare services - A systematic review and meta-ethnography.

OBJECTIVE: To describe and explain stroke survivors and informal caregivers' experiences of primary care and community healthcare services. To offer potential solutions for how negative experiences could be addressed by healthcare services. DESIGN: Systematic review and meta-ethnography. DATA SOURCES: Medline, CINAHL, Embase and PsycINFO databases (literature searched until May 2015, published studies ranged from 1996 to 2015). ELIGIBILITY CRITERIA: Primary qualitative studies focused on adult community-dwelling stroke survivors' and/or informal caregivers' experiences of primary care and/or community healthcare services. DATA SYNTHESIS: A set of common second order constructs (original authors' interpretations of participants' experiences) were identified across the studies and used to develop a novel integrative account of the data (third order constructs). Study quality was assessed using the Critical Appraisal Skills Programme checklist. Relevance was assessed using Dixon-Woods' criteria. RESULTS: 51 studies (including 168 stroke survivors and 328 caregivers) were synthesised. We developed three inter-dependent third order constructs: (1) marginalisation of stroke survivors and caregivers by healthcare services, (2) passivity versus proactivity in the relationship between health services and the patient/caregiver dyad, and (3) fluidity of stroke related needs for both patient and caregiver. Issues of continuity of care, limitations in access to services and inadequate information provision drove perceptions of marginalisation and passivity of services for both patients and caregivers. Fluidity was apparent through changing information needs and psychological adaptation to living with long-term consequences of stroke. LIMITATIONS: Potential limitations of qualitative research such as limited generalisability and inability to provide firm answers are offset by the consistency of the findings across a range of countries and healthcare systems. CONCLUSIONS: Stroke survivors and caregivers feel abandoned because they have become marginalised by services and they do not have the knowledge or skills to re-engage. This can be addressed by: (1) increasing stroke specific health literacy by targeted and timely information provision, and (2) improving continuity of care between specialist and generalist services. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO 2015:CRD42015026602.

The integrated care pathway for post stroke patients (iCaPPS): a shared care approach between stakeholders in areas with limited access to specialist stroke care services.

BACKGROUND: Lack of intersectoral collaboration within public health sectors compound efforts to promote effective multidisciplinary post stroke care after discharge following acute phase. A coordinated, primary care-led care pathway to manage post stroke patients residing at home in the community was designed by an expert panel of specialist stroke care providers to help overcome fragmented post stroke care in areas where access is limited or lacking. METHODS: Expert panel discussions comprising Family Medicine Specialists, Neurologists, Rehabilitation Physicians and Therapists, and Nurse Managers from Ministry of Health and acadaemia were conducted. In Phase One, experts chartered current care processes in public healthcare facilities, from acute stroke till discharge and also patients who presented late with stroke symptoms to public primary care health centres. In Phase Two, modified Delphi technique was employed to obtain consensus on recommendations, based on current evidence and best care practices. Care algorithms were designed around existing work schedules at public health centres. RESULTS: Indication for patients eligible for monitoring by primary care at public health centres were identified. Gaps in transfer of care occurred either at post discharge from acute care or primary care patients diagnosed at or beyond subacute phase at health centres. Essential information required during transfer of care from tertiary care to primary care providers was identified. Care algorithms including appropriate tools were summarised to guide primary care teams to identify patients requiring further multidisciplinary interventions. Shared care approaches with Specialist Stroke care team were outlined. Components of the iCaPPS were developed simultaneously: (i) iCaPPS-Rehab© for rehabilitation of stroke patients at community level (ii) iCaPPS-Swallow© guided the primary care team to screen and manage stroke related swallowing problems. CONCLUSION: Coordinated post stroke care monitoring service for patients at community level is achievable using the iCaPPS and its components as a guide. The iCaPPS may be used for post stroke care monitoring of patients in similar fragmented healthcare delivery systems or areas with limited access to specialist stroke care services. TRIAL REGISTRATION: No.: ACTRN12616001322426 (Registration Date: 21st September 2016).

Factors Influencing the Prevalence of Mental Health Problems among Malay Elderly Residing in a Rural Community: A Cross-Sectional Study.

BACKGROUND AND PURPOSE: Mental health problems are common in old age, but frequently remain undetected and untreated. Mental health problems in the elderly are the result of a complex interaction of social, psychological and biological factors. The aim of this study is to determine the prevalence of mental health problems (depression, anxiety, and emotional stress) and their associated factors among the Malay elderly in a rural community of Perak, Malaysia. METHODS: It was a cross-sectional study. The Malay elderly aged 60 years and above were selected through convenient sampling to give a total of 230 respondents. The Depression, Anxiety, and Stress Scale (DASS-21) was used to assess the symptoms of depression, anxiety, and stress. Bivariate analyses were performed using chi-square tests and multiple logistic regression analyses were conducted to determine the association between the factors and each of the mental health statuses assessed. RESULTS: The results showed that the prevalence of depression, anxiety, and stress among the elderly respondents was 27.8%, 22.6%, and 8.7%, respectively. The significant factors for depression were single elderly (Adjusted OR = 3.27, 95%CI 1.66, 6.44), living with family (Adjusted OR = 4.98, 95%CI 2.05, 12.10), and poor general health status (Adjusted OR = 2.28, 95%CI 1.20, 4.36). Living with family was the only significant factor for anxiety (Adjusted OR = 2.68, 95%CI 1.09, 6.57). There was no significant factor for stress. CONCLUSIONS: Depression and anxiety among the Malay elderly in the rural community were very worrying. More equity in health should be created or strengthened in order to intensify the opportunity to identify, diagnose, and treat those with mental health problems. Living arrangement in the rural community was an important factor that had influenced depression and anxiety. Therefore, further research is recommended for more comprehensive information, as a result of which appropriate intervention can be made.

Care for post-stroke patients at Malaysian public health centres: self-reported practices of family medicine specialists.

BACKGROUND: Provision of post stroke care in developing countries is hampered by discoordination of services and limited access to specialised care. Albeit shortcomings, primary care continues to provide post-stroke services in less than favourable circumstances. This paper aimed to review provision of post-stroke care and related problems among Family Medicine Specialists managing public primary health care services. METHODS: A semi-structured questionnaire was distributed to 121 Family Physicians servicing public funded health centres in a pilot survey focused on improving post stroke care provision at community level. The questionnaire assessed respondents background and practice details i.e. estimated stroke care burden, current service provision and opinion on service improvement. Means and frequencies described quantitative data. For qualitative data, constant comparison method was used until saturation of themes was reached. RESULTS: Response rate of 48.8% was obtained. For every 100 patients seen at public healthcentres each month, 2 patients have stroke. Median number of stroke patients seen per month is 5 (IQR 2-10). 57.6% of respondents estimated total stroke patients treated per year at each centre was less than 40 patients. 72.4% lacked a standard care plan although 96.6% agreed one was needed. Patients seen were: discharged from tertiary care (88.1%), shared care plan with specialists (67.8%) and patients who developed stroke during follow up at primary care (64.4%). Follow-ups were done at 8-12 weekly intervals (60.3%) with 3.4% on 'as needed' basis. Referrals ranked in order of frequency were to physiotherapy services, dietitian and speech and language pathologists in public facilities. The FMS' perceived 4 important 'needs' in managing stroke patients at primary care level; access to rehabilitation services, coordinated care between tertiary centres and primary care using multidisciplinary care approach, a standardized guideline and family and caregiver support. CONCLUSIONS: Post discharge stroke care guidelines and access to rehabilitation services at primary care is needed for post stroke patients residing at home in the community.

Effects of substituting a portion of standard physiotherapy time with virtual reality games among community-dwelling stroke survivors.

BACKGROUND: Evidence indicates that the continuation of therapy among community-dwelling stroke survivors improves physical function. Community rehabilitation programmes often face limitations in terms of resources. It is imperative to include new motivational interventions to encourage some level of non-clinician management. The aim of this study was to determine whether there were any changes in physical function and activities of daily living when substituting a portion of the standard physiotherapy time with virtual reality games among community-dwelling stroke survivors. METHODS: In this controlled trial, the experimental group received 30 minutes of virtual reality balance games in addition to 90 minutes of standard physiotherapy. The control group continued with their two hours of routine standard physiotherapy. Both groups received 12 therapy sessions: two-hour sessions twice per week for six continuous weeks. Changes in physical function, activities of daily living and balance ability were assessed using the Timed Up and Go test, 30-second Sit to Stand test, Timed Ten-Metre Walk test, Six-Minute Walk test and the Barthel Index, and static balance was assessed using a probalance board. RESULTS: Twenty-eight participants completed post-intervention assessments. The results showed a significant within-subject effect on the Timed Up and Go test: F (1, 26) = 5.83, p = 0.02; and the 30-second Sit to Stand test; F (1, 26) = 13.50, p = 0.001. The between-subject effect was not significant (p > 0.05) for any of the outcome measurements. CONCLUSION: Substituting a portion of the standard physiotherapy time with virtual reality games was equally effective in maintaining physical function outcomes and activities of daily living among community-dwelling stroke survivors. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register, ACTRN12613000478718.