Quality of early stroke care and long-term mortality in patients with acute stroke: A nationwide follow-up study.

INTRODUCTION: High quality of early stroke care is essential for optimizing the chance of a good patient outcome. The quality of care may be monitored by process performance measures (PPMs) and previous studies have found an association between fulfilment of PPMs and short-term mortality. However, the association with long-term mortality remains to be determined. We aimed to evaluate the association between fulfilment of PPMs and long-term mortality for patients with acute stroke in Denmark. PATIENTS AND METHODS: We used data from Danish health care registers between 2008 and 2020 to identify all patients admitted with incident stroke (haemorrhagic (ICH) or ischaemic stroke). The quality of early stroke care was assessed using 10 PPMs. Mortality was compared using Cox proportional hazard ratios, risk ratios computed using Poisson regression, and standardized relative survival. RESULTS: We included 102,742 patients; 9804 cases of ICH, 88,591 cases of ischaemic stroke, and 4347 cases of unspecified strokes. The cumulative 10-year mortality risk was 56.8%. Fulfilment of the individual PPMs was associated with adjusted hazard rate ratios of death between 0.76 and 0.96. Patients with 100% fulfilment of all PPMs had a lower 10-year post-stroke mortality (adjusted risk ratio 0.90) compared to the patients with 0%-49% fulfilment and a standardized relative survival of 81.3%, compared to the general population. CONCLUSION: High quality of early stroke care was associated with lower long-term mortality following both ICH and ischaemic stroke, which emphasizes the importance of continued attention on the ability of stroke care providers to deliver high quality of early care.

Visual symptoms in acute stroke - A systematic review of observational studies.

OBJECTIVE: Atypical symptoms of stroke, such as non-specific visual symptoms, are a challenging aspect of acute stroke diagnostics. Among patients evaluated for stroke in the Emergency Department, 2-28% present with stroke chameleons, and 30-43% with stroke mimics. We aimed to identify the type of visual symptoms present in typical strokes, stroke mimics, and stroke chameleons. PATIENTS AND METHODS: By use of Preferred Reporting Items for Systematic Reviews and Meta-Analysis we searched PubMed and Embase for studies with reports of acute visual symptoms in typical strokes vs mimics or chameleons (PROSPERO protocol, ID CRD42022364749). Risk of bias was assessed by The Critical Appraisal Skills Program. RESULTS: Thirteen papers were included, comprising data from 9248 patients evaluated for stroke. Compared to mimics, visual symptoms in stroke presented more frequently as hemianopia (28.2% vs 4.8%, 7,4% vs 2.3%, 22% vs 0%), visual loss (11.6% vs 1.8%), visual field defect (11.6% vs 4%, 24% vs 2%, 19% vs 1.7%), eye movement disorder (19.4% vs 6.4%), eye deviation (9.6% vs 0.9%), gaze palsy (32.1% vs 8.6%), oculomotor disturbance (37% vs 0%), and visual inattention (17.5% vs 4%). Compared to strokes, mimics more often presented "non-systematized visual trouble" (10% vs 3%) and blurred vision (22% vs 5%), whereas "visual disturbance" was reported more often in stroke chameleons than in typical strokes (10% vs 3%). CONCLUSION: Detailed reports of visual symptoms were lacking in most studies, however blurred vision and "non-systematized visual trouble" were more frequent in mimics, "visual disturbance" in stroke chameleons, and negative visual symptoms such as visual field defects in typical strokes. A more systematic and detailed approach to visual symptoms may facilitate acute stroke recognition in patients with visual symptoms.

Glucocorticoid-induced myopathy in the intensive care unit.

Glucocorticoids (GC) are used for intensive care unit (ICU) patients on several indications. We present a patient who was admitted to the ICU due to severe respiratory failure caused by bronchospasm requiring mechanical ventilation and treated with methylprednisolone 240 mg/day in addition to antibiotics and bronchiolytics. When the sedation was lifted on day 10, the patient was awake but quadriplegic. Blood samples revealed elevated muscle enzymes, electromyography showed myopathy, and a muscle biopsy was performed. Glucocorticoid-induced myopathy was suspected, GC treatment was tapered, and muscle strength gradually returned. The patient made full recovery from the quadriplegia a few months later.

Treatment of critical illness polyneuropathy and/or myopathy - a systematic review.

INTRODUCTION: The objective was to search the literature with a view to providing a general description of critical illness myopathy/polyneuropathy (CIM/CIP), including its genesis and prevention. Furthermore, it was our aim to determine whether new treatments have occurred in the past five years. MATERIAL AND METHODS: PubMed, Cinahl and Swedmed+ were searched using the terms CIM, CIP and intensive care. The search was narrowed by adding the limits: humans, English, Danish, Norwegian, Swedish and, furthermore, articles had to have been published in the past five years as we aimed to focus on new knowledge. RESULTS: A total of 74 articles were found. We excluded articles focusing on children and intensive care, tight insulin therapy in patients without CIM/CIP and articles focusing on Guillain-Barré syndrome, triage, bleeding, alcohol or meningitis. Of the remaining 36 articles, only five focused on CIM/CIP treatment. Their relevant original references were found and used too. CONCLUSION: CIM/CIP is the most commonly occurring intensive care unit (ICU)-acquired neuromuscular dysfunction, and it is associated with a significant increase in length of stay, delayed weaning from mechanical ventilation, prolonged rehabilitation and, consequently, more expenses. To treat/prevent this condition, it seems reasonable to ensure maximal functional status for survivors of an ICU-stay by applying a multimodal therapeutic approach that includes intensive insulin therapy, minimal sedation and, as suggested by new evidence, early physiotherapy and electrical muscle stimulation.