Sexuality is not the issue

To compare outcomes between stroke patients managed on the stroke unit, on general wards with stroke team support or at home by specialist domiciliary team and to derive prognostic variables that will identify patients most suitable for management by each strategy. To describe organisational aspects of individual strategies of stroke care and to evaluate cost-effectiveness of each strategy and its acceptability to patients, carers and professionals. Prospective single-blind randomised controlled trial undertaken in patients recruited from a community-based stroke register. Suburban district in south-east England. Patients with disabling stroke who could be supported at home. The stroke unit gave 24-hour care provided by specialist multidisciplinary team based on clear guidelines for acute care, prevention of complications, rehabilitation and secondary prevention. The stroke team provided management on general wards with specialist team support. The team undertook stroke assessments and advised ward-based nursing and therapy staff on acute care, secondary prevention and rehabilitation aspects. Domiciliary care involved management at home under the supervision of a GP and stroke specialist with support from specialist team and community services. Support was provided for a maximum of 3 months. The primary measure was death or institutionalisation at 1 year. Secondary measures were dependence, functional abilities, mood, quality of life, resource use, length of hospital stay, and patient, carer and professional satisfaction. Of the 457 patients randomised, 152 patients were allocated to the stroke unit; 152 patients to stroke team and 153 patients to domiciliary stroke care (average age 76 years, 48% women). The groups were well matched for baseline characteristics, stroke type and severity, level of impairment and initial disability. Fifty-one (34%) patients in the domiciliary group were admitted to hospital after randomisation. Mortality and institutionalisation at 1 year were lower on stroke unit compared with stroke team or domiciliary care. Significantly fewer patients on the stroke unit died compared with those managed by the stroke team. The proportion of patients alive without severe disability at 1 year was also significantly higher on the stroke unit compared with stroke team or domiciliary care. These differences were present at 3 and 6 months after stroke. Stroke survivors managed on the stroke unit showed greater improvement on basic activities of daily living compared with other strategies. Achievement of higher levels of function was not influenced by strategy of care. Quality of life at 3 months was significantly better in stroke unit and domiciliary care patients. There was greater dissatisfaction with care on general wards compared with stroke unit or domiciliary care. Poor outcome with domiciliary care and on general wards was associated with Barthel Index <5, incontinence and, on general wards, age over 75 years. The total costs of stroke per patient over the 12-month period were pound 11,450 for stroke unit, pound 9527 for stroke team and pound 6840 for home care. However, the mean costs per day alive for the stroke unit were significantly less than those for the specialist stroke team patients, but no different from domiciliary care patients. Costs for the domiciliary group were significantly less than for those managed by the specialist stroke team on general wards. Stroke units were found to be more effective than a specialist stroke team or specialist domiciliary care in reducing mortality, institutionalisation and dependence after stroke. A role for specialist domiciliary services for acute stroke is not supported by this study. Management of patients with strokes on general medical wards, even with specialist team input, is not supported by this study. The stroke unit intervention was less costly per patient day alive and more effective than the stroke team intervention. The stroke unit was more effective and of equivalent cost when compared to home care. Hence, the stroke unit is a more cost-effective intervention than either stroke team or home care. Further research is needed to understand processes contributing to the reduction in mortality on stroke units and to determine the generalisability of these results and the factors that will influence the implementation of the findings of this study in clinical practice.

Aim: Ischemic stroke is one of the leading causes of morbidity and mortality Worldwide. It is recommended to treat stroke patients in specialized care centers known as stroke units (SU). The aim of this study is to investigate the impact of the stroke unit on the treatment of stroke patients in the emergency department (ED). Material and Methods: This retrospective observational study was performed in the emergency department of Dokuz Eylül University Faculty of Medicine Hospital. Patients aged 18 years and over with a diagnosis of ischemic stroke were included in the study. A comparison was made between the demographic characteristics, treatments given, length of stay in the emergency department and hospital, and mortality rates before and after the SU was introduced. Results: A total of 1,546 patients were included in this study; 583 of the patients were admitted before the SU was established, and 963 were admitted after. The majority of stroke patients (56%) were male. The mean age of patients before the SU was 72±12.4 years and after SU it was 70±12.9 years. The highest number of admissions was observed in the 71-80 age group. The most common symptoms for hospital admission were weakness in arms and legs and dysarthria. Thrombolytic treatment was administered to 1.2% of ischemic stroke patients before the SU and 5.5% after the SU (p=0.00). The mean hospital length of stay was 10.7±8.3 days before the SU and 9.4±8.3 days after. Mortality was 8.6% before the SU and 6.7% after. Conclusion: The establishment of the Stroke Unit (SU) resulted in an increased rate of thrombolytic treatment. In thisstudy SU had no effect on mortality. Despite the increase in the number of patients, there was no change in the length of stay in the ED; however, hospital length of stay was shortened.

Recent confirmation of mechanical thrombectomy efficacy is putting pressure on stroke systems of care, most of which were created and developed in the thrombolysis era to ease the access of patients with stroke to stroke unit care and intravenous thrombolysis. The advent of the endovascular treatment (EVT) for acute ischemic strokes caused by large artery occlusions and the evidence that EVT benefit declines with increasing time after symptom onset force us to consider and favor systems of care that prioritizes rapid access to EVT in an equitable way. In a study performed in Catalonia, patients living in areas primarily covered by nonendovascular stroke centers are 3× less likely to receive EVT than patients living in metropolitan areas.1 This unbalance justifies significantly changing the way we triage patients with stroke at the prehospital level, and the development of simple clinical scales by Emergency Medical Services is, therefore, of crucial importance. During the past 2 years, many clinical scales have been explored for their capacity to identify patients with Emergent Large Vessel Occlusion (ELVO; Table), including different items and different categories. Some of them include an arbitrary selection of items, …

OLDER PRACTITIONERS (INCLUDING ONE OF THE AUthors of this Editorial) will recall the days when patients with stroke were either treated at home or admitted to the hospital for compassionate observation. Neurologists made efforts to localize lesions and confirm functional areas of the brain and brainstem and described many vascular syndromes. Because the individual patient gained little, if anything, from these exercises, there was a public and professional aura of therapeutic helplessness surrounding stroke. Fortunately, those days are over. Optimism about the benefits of treatment coupled with a sense of urgency to deal quickly with every patient with stroke has swept away that nihilism. Coronary care units were introduced in the 1950s and spread rapidly because they saved lives. These units provided the models for intensive care units concentrating on respiratory enhancement, later for the introduction of trauma units, and eventually for strokeunits. In the late1970s theearliestobservational stroke units produced useful data on stroke cause, prognostic indicators, and the effect of cerebral ischemic lesions on cardiac function. Even before specific interventions to diminish theextentofpermanentbraindysfunctionbecameavailable, good general medical care and measures to stabilize cardiac functionprovidedbyknowledgeable staff resulted inearlier discharge and fewer deaths. Bed sores and contractures were prevented, attention to the airway reduced the occurrence of pneumonia from aspiration, and cardiac monitoring detected serious arrhythmias, all of which contributed to reducing disability and death. Early rehabilitation was encouraged and, among other benefits, the incidence of deep vein thrombosis was diminished through the use of antithrombotics. The benefits of stroke units have been evaluated in an increasing number of studies. The Cochrane Collaboration meta-analysis of more than 3500 patients in 20 trials comparing stroke units with general care units indicates that stroke unit care results in significant reductions in death (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.710.97), death or dependency (OR, 0.75; 95% CI, 0.65-0.87), and death or institutionalization (OR, 0.76; 95% CI, 0.65-0.90). Compared with conventional care on a general medical ward, care in an organized stroke unit reduces death and dependency with an absolute risk reduction of 5.6%. The number needed to be treated (NNT) in the stroke unit compared with a general medical setting is only 18. The ideal stroke unit provides multidisciplinary care to ensure normalization of physiological variables including temperature, fluid and electrolyte balance, blood glucose levels, and blood pressure; to promote early mobilization, physiotherapy, appropriate nutrition; and possibly to prevent depression. The impact of dedicated stroke units on the stroke population depends on how well these units are staffed and on their availability, accessibility, and cost. Until recently, 2 obstacles limited the widespread adoption of dedicated stroke units. First, few neurologists and other professionals were interested in stroke. Second, no known therapy had a positive effect on reducing the amount of ultimate brain damage. Despite benefits proven for expert general management, an indifferent approach to acute stroke care remained commonplace. Indifference changed to excited anticipation with the publication of the National Institute of Neurological Disorders and Stroke trial demonstrating benefit of tissue-type plasminogen activator (tPA) for patients with acute ischemic stroke. Careful scrutiny of the results by North American and more recently European agencies led quickly to the approval of tPA for use within 3 hours of the onset of the first symptoms of ischemic stroke. Guidelines to ensure proper application of tPA were developed. As an immediate result of this trial an urgent need has arisen to improve public and professional education about stroke, institute systems of stroke care, and improve early access to an increased number of stroke units. The dramatic change in outlook for as many as 10% of patients in the early stages of ischemic stroke quite suddenly requires the service side of medicine to develop a stroke infrastructure. In this issue of THE JOURNAL, the Brain Attack Coalition, representing several key US medical organizations, discusses the challenge of improving stroke care. A series of

Background HSPA is a tool to monitor, evaluate, and improve health systems based on their achievements within different dimensions, e.g., access to care, quality, and population health. Next to the overall system, HSPA also allows to analyze its performance for specific groups across dimensions. In a pilot for a German HSPA, a conceptual framework was developed, and indicators for every dimension were selected and analyzed. This presentation illustrates the results of the German HSPA pilot using the example of access to and quality of care for ischemic stroke. Methods Selected indicators include stroke unit (SU) density, availability of a SU within 30 minutes by car, share of inpatient cases treated in a hospital with a SU, and inpatient mortality from 2014 to 2020, respectively. Indicators were analyzed based on nation-wide hospital discharge data. Travel time was computed and provided by the Federal Institute for Research on Building, Urban Affairs and Spatial Development. Results About 475 SU were identified in hospital data (2014: 463), compared to 350 certified SU in Germany. In 75% of Germany's 11,000 municipalities, 100% of the population could reach a SU within 30 minutes by car. Number of inpatient ischemic stroke cases was about 250,000 per year. Of the 215,000 cases without transfer from another hospital, 93% were treated in a hospital with a SU in 2020 (2014: 88%). Inpatient mortality was about 6,4% for all ischemic stroke cases and 6,1% for cases without transfer, varying only slightly over time. SU treatment showed large, and inpatient mortality minor regional variation. Conclusions Access to and quality of inpatient stroke care seems comparatively good in Germany, as SU density is high and mortality low in the European context. However, regional variation should be further tackled. The example shows how HSPA can be used to assess different strands of care by connecting health system dimensions, to produce actionable evidence for policy. Key messages • Health system performance assessment (HSPA) is a tool for the evaluation and improvement of the overall system but also of the care for specific groups or diseases across health system dimensions. • The results of the German HSPA pilot show a good access and quality for the case of inpatient stroke care. Regional variations might be further reduced via improvements in hospital planning.

Essential Workflow and Performance Measures for Optimizing Acute Ischemic Stroke Treatment in India.

There is no clear consensus among current guidelines on the preferred admission ward [i.e. intensive care unit (ICU) or stroke unit (SU)] for patients with intracerebral hemorrhage. Based on expert opinion, the American Heart Association and European Stroke Organization recommend treatment in neurological/neuroscience ICUs (NICUs) or SUs. The European Stroke Organization guideline states that there are no studies available directly comparing outcomes between ICUs and SUs. We performed an observational study comparing outcomes of 10811 consecutive non-comatose patients with intracerebral hemorrhage according to admission ward [ICUs, SUs and normal wards (NWs)]. Primary outcomes were the modified Rankin Scale score at discharge and intrahospital mortality. An additional analysis compared NICUs with SUs. Treatment outside an SU was associated with higher odds for an unfavorable outcome [ICU vs. SU: odds ratio (OR), 1.27; 95% confidence interval (CI), 1.09-1.46; NW vs. SU: OR, 1.28; 95% CI, 1.08-1.52] and higher odds for intrahospital mortality (ICU vs. SU: OR, 2.11; 95% CI, 1.75-2.55; NW vs. SU: OR, 1.52; 95% CI, 1.23-1.89). A subgroup analysis of severely affected patients treated in dedicated NICUs (vs. SUs) showed that they had a lower risk of a poor outcome (OR, 0.45; 95% CI, 0.26-0.79). Treatment in SUs was associated with better functional outcome and reduced mortality compared with ICUs and NWs. Our findings support the current guideline recommendations to treat patients with intracerebral hemorrhage in SUs or NICUs and suggest that some patients may further benefit from NICU treatment.

The consideration of stroke as a medical emergency and the development of new specific treatments to be applied in a narrow therapeutic window have shown the need to establish an adequate organization system for the management of stroke. It should be considered as an integral process both outside and inside the hospital. General care is essential and must already start outside the hospital, and comprises respiratory and cardiac care, fluid and metabolic management, especially blood glucose control, avoiding the administration of glucose solutions, blood pressure control, early treatment of hyperthermia and prevention and treatment of neurologic and systemic complications. In the early 70s, the first stroke units (SU) were established as intensive-care SU, but failed to show improvement in terms of reduction of mortality-morbidity. Nowadays, the concept has changed to a non-intensive-care SU. The benefit of these SU has been amply demonstrated in terms of reduction in mortality and in long institutionalization, as well as better functional outcome compared with general wards, and the efficacy of a neurology ward compared to a general medicine department has also been shown, but at the moment there are no studies analyzing the differences between a stroke team (ST) in a department of neurology and a SU. In this regard, we have performed a sequential analysis comparing both SU and ST and demonstrated a reduction in length of stay, complications and acute care costs with an improvement in functional state at hospital discharge, a reduction in the discharge to nursing homes with an increase in patients translated into rehabilitation wards. With these data, we can conclude that SU, not ST are the most effective organizational model for acute stroke management. Definitely, the SU make the difference.

Background: One of the challenges in stroke management is how to provide rehabilitation services to stroke patients in Iran. Objectives: This study aimed to evaluate and compare the cost-effectiveness of rehabilitation interventions for stroke patients in three settings: Hospitals, stroke units, and homes. Methods: This cross-sectional study was conducted from the perspective of the health system. A Markov model with a 20-year time horizon and 3-month cycles was used to analyze costs and outcomes. Cost data were collected from 210 patients undergoing rehabilitation in hospitals, homes, or stroke units. The cost-effectiveness analysis (CEA) was conducted by calculating the incremental cost-effectiveness ratio (ICER) using Tree Age software. Results: The average rehabilitation cost for the home strategy ($2306 ± 35.018) was less than that for the hospital ($2955 ± 48.18) and stroke unit ($3485 ± 51.63) strategies. Furthermore, the QALY of the home strategy (26.03) was 8 times higher than that of the hospital (17.99) and 19 times higher than that of the stroke unit (7.03). The average cost-effectiveness ratios for the hospital, stroke unit, and home groups were $11424, $33159, and $7233 per QALY, respectively. The ICERs for stroke unit and home rehabilitation relative to hospital rehabilitation were $2517 and $2145 per QALY, respectively. Conclusions: According to the results, the home-based rehabilitation strategy is more cost-effective than hospital and stroke unit rehabilitation strategies. Given the high rates of stroke and its associated costs in Iran, it is suggested that policymakers lay the groundwork for providing these services at home.

Background: Acute cerebral stroke is a common problem that is frequently associated with dysphagia resulting in an increased risk of aspiration pneumonia, complication, and mortality. Methods: A literature review was carried out using the search terms ‘stroke unit and endoscopy', ‘stroke unit and dysphagia', and ‘stroke unit and gastroenterology'. Results: Only few papers focus on the role of endoscopy in stroke units. One major role is the early detection of dysphagia by flexible endoscopic evaluation of swallowing (FEES). FEES appears to have a higher sensitivity and specificity compared to bedside tests and challenges videofluoroscopy. In contrast, other stroke-associated gastrointestinal complications requiring endoscopic diagnostic or therapeutic intervention, such as gastrointestinal bleeding, abdominal pain, or stasis, and the need to provide fluid and food via gastrostomy or jejunostomy are rarely seen in stroke units and become relevant during and after the rehabilitation phase. Conclusion: FEES should involve an interdisciplinary team comprising neurologists, speech and language pathologists and/or therapists, as well as gastroenterologic endoscopists.

Introduction Reduced upper extremity function after stroke has previously been reported in 70-80% of patients with stroke in the acute stage and is one of the most common impairments after acute stroke impaired motor function, both in upper and lower extremity, influence the stroke unit care and planning of the rehabilitation, partly due to the economic costs. There is limited information in upper extremity function within the first days after a stroke. Prior studies include either both first and recurrent stroke or only one type of stroke. Objectives To investigate the frequency impaired arm and hand function in an unselected group of patients with first occasion of stroke. Method All patients at a stroke unit at Sahlgrenska University Hospital were assessed during 18 months. From the hospital records, the patients were identified, the patient charts were read and first stroke diagnosis was confirmed (by either imaging or clinical assessment). Impaired upper extremity function was defined in the following manner: assessed with the Modified Motor Assessment Scale (M-MAS UAS -95) by physiotherapist working at the stroke unit within 72 hours after stroke onset or if this was found in the patients chart, other standardized assessments of upper extremity function performed by the physical therapist, the occupational therapist or the physicians on the ward. Results During the study period 984 patients with first ever stroke (438 women 44.5%) were admitted to the stroke unit. A total of 213 patients were not at the stroke unit within 72 hours after onset and therefore excluded; 90 patients had unclear stroke onset time, 49 patients were located at another ward, 36 patients were in the intensive care unit, 25 in other hospitals in Sweden and 12 patients were hospitalized in another country. There were 771 patients over 18 years old at the stroke unit within 72 hours after stroke onset. Of these 56 patients (7.3%), were not living in the catchment area and therefore excluded. Of the 715 patients living in the geographical catchment area, 58, (8.1%) hade other upper extremity injury prior the stroke onset. Of the remaining first ever stroke patients (n=657), 311 patients (47.3%) hade impaired arm and hand function within 72 hours after stroke onset. Conclusion The frequency of impaired upper extremity function in this unselected population of first occasion of stroke is lower than previously reported. The Copenhagen stroke study noted 69 % impaired at admission and 43 % at one week. This indicates that today’s stroke patients present less frequent with impaired motor function in the upper extremity. However, they may have difficulties in functional activities which may influence content of rehabilitation process.

Introduction: Since mid-2000, stroke guidelines were revised and 18 stroke units (SU) settled in Paris area (France). Our Emergency Medical Service (EMS) in a catchment of 500 000 inhabitants registered all acute strokes where dispatch of an Advanced Life Support (ALS) ambulance was decided since 1993. Methods: Data were collected from an EMS registry (1993-2019). The study included patients 16 years old and over, with an acute stroke requiring an ALS ambulance. Collected data were gender, age (by quartile), time periods (1993-99, 2000-04, 2005-09, 2010-14, 2015-19) and receiving care facility: SU, neurosurgery, intensive care unit (ICU), emergency department (ED), radiology department (MRI or scanner) or left on scene (LOS dead or alive). Comparisons were performed with Chi-2 test. Results: This study included 2955 stroke patients, mean age was 70.7 years old, sex ratio was 0.93. Table 1 and graphic 1 results show the emergence of SU during mid-2000, with a decrease of ED transfers, while neurosurgery and ICU remained steady (p&lt;10 -3 ). This decrease of ED was more important for older age groups (≥ 75 years old). Conclusion: Older age groups benefitted more from specialized pathways including ICU and SU, with less transports to ED, but never clearly from neurosurgery. Development of SU probably explains the decreased number of younger patients in neurosurgery. Literature shows that direct pathway to SU significantly improved prognosis of stroke patients. This registry of ALS transports shows its growing use in EMS dispatch, as for ST+ myocardial infarction, while transports to ED decrease. It would be interesting to compare these results with those of faster Basic Life Support transports.

BackgroundEstablishing a stroke unit (SU) in every hospital may be infeasible because of limited resources. In Australia, it is recommended that hospitals that admit ≥100 strokes per year should have a SU. We aimed to describe differences in processes of care and outcomes among hospitals with and without SUs admitting at least 100 patients/year.MethodsNational stroke audit data of 40 consecutive patients per hospital admitted between 1/7/2010-31/12/2010 and organizational survey for annual admissions were used. Descriptive analyses and multilevel regression were used to compare patient outcomes. Sensitivity analysis including only hospitals meeting all of the Australian SU criteria (e.g., co-location of beds; inter-professional team; weekly meetings; regular training) was performed.ResultsTwo thousand eight hundred ninety-eight patients from 72/108 eligible hospitals completing the audit (SU = 60; patients: 2,481 [mean age 76 years; 55% male] and non-SU patients: 417 [mean age 77; 53% male]). Hospitals with SUs had greater adherence to recommended care processes than non-SU hospitals. Patients treated in a SU hospital had fewer new strokes while in hospital (OR: 0.20; 95% CI 0.06, 0.61) and there was a borderline reduction in the odds of dying in hospital compared to patients in non-SU hospitals (OR 0.57 95%CI 0.33, 1.00). Among SU hospitals meeting all SU criteria (n = 59; 91%) the adjusted odds of having a poor outcome was further reduced compared with patients attending non-SU hospitals.ConclusionHospitals annually admitting ≥100 patients with acute stroke should be prioritized for establishment of a SU that meet all recommended criteria to ensure better outcomes.

Stroke unit care represents the major advancement in stroke management and it is applicable to all stroke patients. The Lombardia Health-Care Program for the period 2000-2004 planned to implement new semi-intensive stroke units in order to guarantee access to such units to all stroke patients. As has happened in other countries, there is a need to coordinate and streamline the process of care in order to optimise resources and outcome. The aim of the Stroke Unit Network (SUN) project is the improvement of the quality of stroke care in the acute and post-acute phase, developing an efficient network between hospitals involved in stroke care in order to quickly identify patients' needs and to improve cultural exchange on clinical and therapeutic information between people involved in the process of care. A web-based network has been created connecting the Lombardia Stroke Units and the departments in which stroke units will be implemented; a website to facilitate the exchange of scientific data, the discussion of clinical problems, the sharing of research projects and results, and a web-based quality register in order to verify quality, efficacy and efficiency of stroke units participating in the project providing important, consistently available data to monitor progress in reducing the incidence of stroke and associated disability and mortality. The Lombardia Stroke Unit Network Project, promoting and facilitating the exchange of know-how and collecting data on the quality of the processes of care provided, can significantly improve stroke care in Lombardia.

Background: Despite the compelling scientific evidence on the superiority of stroke unit care, far from all acute stroke patients have access to stroke unit care. In congruence with what has been observed when other new methods are introduced in health care, we hypothesized that there has been an inequality in the buildup phase of stroke units but that the gradients between patient groups have decreased as the total capacity of stroke unit care has increased. The purpose of this study was to explore if patients in a national sample who were socioeconomically disadvantaged (low education or low income) had reduced access to stroke unit care and if differences varied over time. Methods: All patients 18-74 years of age registered between 1995 and 2009 in Riks-Stroke, the Swedish stroke register, were included. The Stroke Unit Trialists' definition of a stroke unit has been adopted by Riks-Stroke and hospitals participating in the registry. Basic patient characteristics, stroke risk factors, process and outcome variables are recorded in Riks-Stroke. Socioeconomic data were accessed from Statistics Sweden. Multiple logistic regression analyses were used to calculate odds ratios (ORs) for stroke unit care between prespecified patient subgroups. Results: A total of 319,240 stroke patients were included in Riks-Stroke during the years 1995-2009, and 124,173 were aged between 18 and 74 years; they were included in the final analyses. After adjustment for confounders in a multiple regression model, women were treated in stroke units slightly less often [OR 0.97, 95% confidence interval (CI) 0.95-0.99]. There were no statistically significant associations between stroke unit care and age or between stroke unit care and cohabiting or living alone. The highest level of education predicted access to stroke unit care (secondary vs. primary school: OR 1.04, 95% CI 1.01-1.07; university vs. primary school: OR 1.06, 95% CI 1.02-1.10). Differences according to level of education diminished over time (p = 0.001). Income was not independently associated with stroke unit care, and over time the proportion of patients treated in stroke units increased at a similar rate in all income groups (p = 0.12). Conclusions: Even in a country with modest socioeconomic differences in the general population and public financing of all acute hospital care, socioeconomic inequalities in access to stroke unit care were evident during the early years, but they diminished as the total capacity for stroke unit care increased.