Patient-reported factors associated with early arrival for stroke treatment.

OBJECTIVE: Timely evaluation and initiation of treatment is the key for improving stroke outcomes, although minimizing the time from symptom onset to the first contact with healthcare professionals remains a challenge. We aimed to identify patient-related factors associated with early hospital arrival. MATERIALS AND METHODS: In this cross-sectional survey, we included patients with stroke or transient ischemic attack admitted directly to one of two noncomprehensive stroke units or transferred to the units from comprehensive stroke centers in the Capital Region of Denmark. Patient-reported factors associated with early hospital arrival were analyzed using multivariable logistic regression analysis adjusted for age, sex, education, living arrangement, brain location of the stroke, stroke severity, patient-perceived symptom severity, history of prior stroke, stroke risk factors, and knowledge of stroke symptoms. RESULTS: In total, 479 patients with acute stroke were included (median age 74 (25th-75th percentile, 64-80), 40% women), of whom 46.4% arrived within 180 min of symptom onset. Factors associated with early hospital arrival were patients or bystanders choosing emergency medical service (EMS) for the first contact with a medical professional (adjusted odds ratio (OR), 3.41; 95% confidence interval, CI [1.57, 7.35]) or the patient's perceived symptom severity above the median score of 25 on a 100-point verbal scale (adjusted OR, 2.44; 95% CI [1.57, 3.82]). Living alone reduced the likelihood of early arrival (adjusted OR, 0.53; 95% CI [0.33, 0.86]). CONCLUSIONS: Only when patients perceived symptoms as severe or when EMS was selected as the first contact, early arrival for stroke treatment was ensured.

Prevention after stroke: A quality assurance study.

OBJECTIVES: In 1997, the Copenhagen Stroke Study revealed that stroke was recurrent in 23% of patients admitted with a stroke. Predictors of recurrence were history of transient ischaemic attack, atrial fibrillation, male gender and hypertension. In 2011, the Danish recurrence rate was 25%. With the aim of preventing recurrent stroke, a preventive clinic was established in 2014 at the Department of Neurology, Herlev Hospital. Data from the preventive clinic are analysed in the present study. MATERIALS AND METHODS: Data from visits to the clinic from October 2014 to October 2016 were collected from electronic medical records. Data on subsequent admissions with stroke were collected from October 2014 to the end of 2017. Data were collected and analyzed as a means of quality assurance. RESULTS: Data from 1083 patients showed that half of the patients were hypertensive at discharge regardless of admission with first ever or recurrent stroke. Nurses at the clinic initiated or intensified antihypertensive medication in 40% of patients. Blood pressure was at target in 64% of patients at last visit to the clinic. Stepwise Cox proportional hazard regression analysis of 1024 patients admitted with ischaemic stroke or transient ischaemic attack showed that tobacco smoking (HR 1.80), admission with a recurrent stroke (HR 1.76) and cholesterol-lowering treatment (HR 1.67) were independent predictors of stroke recurrence. CONCLUSIONS: The recurrence rate in Denmark has remained unchanged for two decades. Risk factors for recurrence seem to change over time. Identification and treatment of actual risk factors may be a way to reduce recurrence.

A Qualitative Inquiry Into Patient Reported Factors That Influence Time From Stroke Symptom Onset to Hospitalization.

ABSTRACT: BACKGROUND: Approximately 50% of Danish stroke patients did not arrive within the 4.5-hour revascularization window in 2018, and only 20% received acute revascularization therapy. Delay in seeking help was a major factor for missing the time window. This study explored patient-reported factors influencing the timing of a decision to seek help. METHODS: We performed a qualitative interview study to explore prehospital help-seeking behavior. Inclusion was guided by a purposive sampling of stroke and transient ischemic attack patients and, if necessary, bystanders. Semistructured explorative interviews with 8 patients and 2 bystanders were audio-recorded, transcribed verbatim, and analyzed via thematic analysis. RESULTS: Analysis yielded 3 main themes: (1) symptom interpretation, (2) barriers and enablers to response, and (3) participant suggested optimization of acute stroke response and awareness. DISCUSSION: Factors associated with prompt action to seek help were either a perception that the symptom indicated a serious illness or a strong emotional response. Patients with recurrent stroke failed to associate symptoms with a new stroke. Having a stroke in unfamiliar surroundings prompted delay in seeking help. Suggestions for optimization included targeted stroke campaigns. CONCLUSION: Response to stroke onset may be driven by perceptions of symptom severity and emotional response rather than the ability to correctly identify symptoms. Stroke education should include the information that new stroke symptoms may be different from the old ones because different parts of the brain may be affected.

Specific antismoking advice after stroke.

INTRODUCTION: Many stroke survivors would benefit from modification of their lifestyle in order to reduce their risk of recurrent stroke. We investigated if tailored smoking cessation advice would yield a higher smoking cessation rate and a higher rate with sustained abstinence in ex-smokers in the intervention group than among controls. MATERIAL AND METHODS: Patients admitted with an acute stroke or a transient ischaemic attack were included in a randomised controlled trial focusing on control of lifestyle risk factors and hypertension. Here, we report the intervention focused on smoking cessation. We used multiple logistic regression analysis to identify patient characteristics associated with smoking cessation. Analyses were by intention to treat excluding those who died or suffered severe disease. RESULTS: We included 254 patients with a history of smoking. Two years after inclusion, 15 of 57 (26%) baseline smokers in the intervention group had stopped smoking versus eight of 56 (14%) among controls (p = 0.112). Living with a partner (p = 0.012), having at least ten years of education (p = 0.012), and not being exposed to smoking at home (p = 0.036) were independent predictors of smoking cessation. CONCLUSION: We did not achieve our aim of higher smoking cessation rates in the intervention group. Future smoking cessation interventions should be more intensive, focus on patients' social circumstances and, if possible, involve patients' relatives. FUNDING: This study was supported by the Ludvig and Sara Elsass Foundation, the Lundbeck Foundation and The Danish Heart Foundation (Grant 07-4-B703-A1378-22384F). TRIAL REGISTRATION: This protocol is registered with Clinical Trials.gov (NCT 00253097).

Occurrence and severity of agitated behavior after severe traumatic brain injury.

PURPOSE: To investigate the occurrence and severity of agitation in patients after severe traumatic brain injury (TBI), to identify predictors of agitation and to study interrater reliability for a translated version of the Agitated Behavior Scale (ABS). DESIGN: Prospective observational study. From November 1, 2006, through October 2007, 46 consecutive patients with TBI were included in the early rehabilitation phase following neurosurgical intervention. Agitated behavior was assessed by the ABS, which was implemented in clinical practice. Logistic regression analysis identified predictors of agitated behavior and Intra Class Correlation was used to analyze reliability. FINDINGS: Agitated behavior occurred in 41% of patients, of whom one third exhibited severely agitated behavior. The interrater reliability between three nurses was good to excellent. CONCLUSIONS: Using ABS as a tool in care of patients with agitated behavior may be effective through working as a common language. CLINICAL RELEVANCE: We recommend the use of ABS as a routine assessment in early rehabilitation of patients with TBI.

Alcohol withdrawal syndrome: symptom-triggered versus fixed-schedule treatment in an outpatient setting.

AIMS: To investigate whether, in the treatment with chlordiazepoxide for outpatient alcohol withdrawal, there are advantages of symptom-triggered self-medication over a fixed-schedule regimen. METHODS: A randomized controlled trial in outpatient clinics for people suffering from alcohol dependence (AD) and alcohol-related problems; 165 adult patients in an outpatient setting in a specialized alcohol treatment unit were randomized 1:1 to either a symptom-triggered self-medication or tapered dose, using chlordiazepoxide. Alcohol withdrawal symptoms, amount of medication, duration of symptoms, time to relapse and patient satisfaction were measured. Patients assessed their symptoms using the Short Alcohol Withdrawal Scale (SAWS). Patient satisfaction was monitored by the Diabetes Treatment Satisfaction Questionnaire. We used the Well-Being Index and the European addiction severity index for the 1-year follow-up. RESULTS: We found no differences in the quantity of medication consumed, time to relapse, well being or treatment satisfaction. CONCLUSION: Symptom-triggered self-medication was as safe as fixed-schedule medication in treating outpatients with AD and mild to moderate symptoms of AWS. The SAWS is a powerful monitoring tool, because it is brief and permits the subject to log the withdrawal symptoms.

Blood pressure 1 year after stroke: the need to optimize secondary prevention.

Lowering blood pressure (BP) in stroke survivors reduces the risk of recurrent stroke. We tested the hypothesis that a nurse-led nonpharmacologic intervention would lower the BP of participants in an intervention group compared with a control group. A total of 349 patients who had sustained acute stroke or transient ischemic attack were randomly assigned to either usual care or to 4 home visits by a nurse. During the visits, the nurse measured and recorded BP and provided individually tailored counseling on a healthy lifestyle. A total of 303 patients completed the 1-year follow up. No change in systolic BP was noted in either the intervention group or the control group. Because of an increase in diastolic BP in the control group (P = .03), a difference in mean diastolic BP between the 2 groups was found at follow-up (P = .007). Mean BP at follow-up was 139/82 mm Hg in the intervention group and 142/86 mm Hg in the control group. Linear regression analysis demonstrated that BP at the point of discharge was the strongest predictor of BP 1 year later (P < .0001). The proportion of patients on antihypertensive medication increased in the intervention group (P = .002). Patients were compliant with antihypertensive therapy, and 92% of the hypertensive patients in the intervention group followed the advice to see a general practitioner (GP) for BP checkups. At follow-up, 187 patients (62%) were hypertensive, with no difference in the rate of hypertension seen between the groups. Our data indicate that home visits by nurses did not result in a lowering of BP. Patients complied with antihypertensive therapy and GP visits in the case of hypertension. Nonetheless, the majority of patients were hypertensive at the 1-year follow up.

Little change of modifiable risk factors 1 year after stroke: a pilot study.

BACKGROUND: Recurrent stroke accounts for about 25% of admissions for acute stroke. For the prevention of recurrent cerebro and cardiovascular disease, stroke patients are advised to change modifiable stroke risk factors before discharge from stroke units. AIMS: To investigate the change in modifiable risk factors 1 year after stroke and to explore the feasibility of a preventive programme aimed at stroke patients discharged from hospital. METHODS: From April 2004 to February 2005, 173 patients admitted to hospital with a diagnosis of stroke were consecutively included and interviewed about their medical history and modifiable risk factors before stroke. One-year follow-up with measurement of blood pressure was performed in 92% of surviving and able participants. RESULTS: One year after discharge, 121 participants were reinterviewed and 118 had their blood pressure measured. We found uncontrolled hypertension in 43 of 65 patients (66% of those receiving antihypertensive medication) and unknown hypertension in 30 of 53 patients (57% of those without antihypertensive medication). There was a reduction in the prevalence of excessive consumption of alcohol from 24 of 121 patients (20%) to 16 of 121 patients (13%) (P<0.05). The frequency of cigarette intake remained unchanged: 57 of 121 patients (47%) 1 year after stroke. The proportion of patients who were physically inactive increased from 36% (43 of 121 patients) before stroke to 59% (71 of 121) 1 year later (P<0.0001). CONCLUSIONS: The change in modifiable risk factors was inadequate 1 year after stroke. The pilot study indicated that a preventive programme should focus on hypertension, smoking and physical inactivity.

A psychometric validation of the Short Alcohol Withdrawal Scale (SAWS).

AIMS: The study aimed to evaluate psychometrically a Danish translation of the Short Alcohol Withdrawal Scale (SAWS) in an outpatient setting in patients with Alcohol Dependence (AD) and Alcohol Withdrawal Symptoms/Syndrome (AWS). METHODS: One hundred and twenty-two patients with AD and AWS filled in a 10-item rating scale to describe their symptoms with four graduations on five physical and five psychological items. The question of dimensionality of the construct was addressed in three different ways. First, a scree plot was constructed based on the polychoric correlations between items. Second, promax factor loadings were calculated for a two-factor model. These two steps were based on exploratory factor analysis. Third, specific violations such as local dependence and differential item functioning were investigated under the one-factor model in a confirmatory factor analysis. RESULTS: The scree plot supported one or two dimensions while the promax rotations gave little support for a two-factor model. The confirmatory analysis also supported a one-factor model. CONCLUSION: The decomposition of the polychoric correlation matrix into eigenvalues and vectors suggested that there was most likely one factor underlying the 10 items in the SAWS. This was confirmed by a confirmative factor analysis with only one component when specific model violations such as local dependence and differential item findings were investigated. The SAWS is easy to use.