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References - старонка 457

30

(1), 40-48.

Abstract: Background and Purpose-Early admission to hospital followed by correct diagnosis with minimum delay is a prerequisite for successful intervention in acute stroke. This study aimed at clarifying in detail the factors related to these delays. Methods-This was a prospective, multicenter, consecutive study that explored factors influencing the time from stroke or transient ischemic attack (TIA) onset until patient arrival at the emergency department, stroke unit, and CT laboratory. Within 3 days of hospital admission, the patients and/or their relatives were interviewed by use of a standardized structured protocol, and the patients' neurological deficits were assessed. No information about this study was given to the public or to the staff. Results-Patients (n = 329) were studied at 15 Swedish academic or community-based hospitals: 252 subjects with brain infarct, Is with intracerebral hemorrhage, and 59 with TIA. Among stroke and TIA patients, the median times from onset to hospital admission, stroke unit, and CT scan laboratory were 4.8 and 4.0 hours, 8.8 and 7.5 hours, and 22.0 and 17.5 hours, respectively. From multivariate ANOVA with logarithmically transformed time for increasing delay to hospital admission as the dependent variable, a profile of significant risk factors was obtained. This included patients with a brain infarct, gradual onset, mild neurological symptoms, patients who were alone and did not contact anybody when symptoms occurred, patients who lived in a large catchment area, those who did not use ambulance transportation, and those who visited a primary care site. These factors explained 45.3% of the variance in delayed hospital admission. The median time from arrival at the emergency department to arrival at the stroke unit or CT scan laboratory (whichever occurred first) was 2.6 and 2.7 hours in the stroke and TLA groups, respectively. A large catchment area, moderate to mild neurological deficit, and waiting for the physician at the emergency department were all significantly related to in- hospital delay. Conclusions-Increased public awareness of the need to seek medical or other attention promptly after stroke onset, to use an ambulance with direct transportation to the acute-care hospital, and to have more effective in-hospital organization will be required for effective acute treatment options to be available to stroke patients

Keywords: acute/acute stroke/acute treatment/ambulance/ARRIVAL TIME/attention/awareness/brain/brain infarct/cerebrovascular disorders/CT/CT scan/deficit/delay/delayed/DESIGN/diagnosis/emergency/emergency department/emergency service/hemorrhage/hospital/hospitalization/hospitals/infarct/information/intervention/intracerebral/intracerebral hemorrhage/ISCHEMIA/ischemic/medical/multicenter study/neurological/neurological deficit/neurological deficits/onset/PA/patients/PHILADELPHIA/primary/primary care/prospective/protocol/relatives/risk/risk factors/staff/stroke/stroke management/stroke onset/stroke patients/stroke unit/Sweden/symptoms/THERAPY/TIA/transient/transient ischemic attack/treatment/use/variance

Williams, G.R., Jiang, J.G., Matchar, D.B. and Samsa, G.P. (1999), Incidence and occurrence of total (first-ever and recurrent) stroke. Stroke,

30

(12), 2523-2528.

Abstract: Background and Purpose-It has recently been hypothesized that the figure of approximately half a million strokes substantially underestimates the actual annual stroke burden for the United States. The majority of previously reported study was designed to estimate the occurrence, incidence, and characteristics of total (first-ever and recurrent) stroke by using a large administrative claims database representative of all 1995 US inpatient discharges. Methods-We used the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, release 4, which contains approximate to 20% of all 1995 US inpatient discharges. Because the accuracy of International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding is suboptimal, we performed a literature review of ICD-9-CM 430 to 438 validation studies. The pooled results from the literature review were used to make appropriate adjustments in the analysis to correct for some of the inaccuracies of the diagnostic codes. Results- There were 682 000 occurrences of stroke with hospitalization (95% CI 660 000 to 704 000) and an estimated 68 000 occurrences of stroke without hospitalization. The overall incidence rate for occurrence of total stroke (first-ever and recurrent) was 259 per 100 000 population (age- and sex-adjusted to 1995 US population). Incidence rates increased exponentially with age and were consistently higher for males than for females. Conclusions-We conservatively estimate that there were 750 000 first-ever or recurrent strokes in the United States during 1995, This new figure emphasizes the importance of preventive measures for a disease that has identifiable and modifiable risk factors and for the development of new and improved treatment strategies and infrastructures that can reduce the consequences of stroke

Keywords: ACCURACY/acute/age/analysis/ANGIOGRAPHY/BLACKS/burden/CAROTID ENDARTERECTOMY/database/development/diagnosis/disease/epidemiology/females/hospitalization/ICD-9-CM/incidence/literature review/males/measures/MINNESOTA/PA/PHILADELPHIA/POPULATION/rate/RATES/review/risk/risk factors/strategies/stroke/strokes/studies/total/treatment/United States/US/validation

Williams, L.S., Weinberger, M., Harris, L.E., Clark, D.O. and Biller, J. (1999), Development of a stroke-specific quality of life scale. Stroke,

30

(7), 1362-1369.

Abstract: Background and Purpose-Clinical stroke trials are increasingly measuring patient-centered outcomes such as functional status and health-related quality of life (HRQOL). No stroke-specific HRQOL measure is currently available. This study presents the initial development of a valid, reliable, and responsive stroke-specific quality of life (SS-QOL) measure, for use in stroke trials. Methods-Domains and items for the SS-QOL were developed from patient interviews, The SS-QOL, Short Form 36, Beck Depression Inventory, National Institutes of Health Stroke Scale, and Barthel Index were administered to patients 1 and 3 months after ischemic stroke. Items were eliminated with the use of standard psychometric criteria. Construct validity was assessed by comparing domain scores with similar domains of established measures. Domain responsiveness was assessed with standardized effect sizes. Results-All 12 domains of the SS-QOL were unidimensional. In the final 49-item scale, all domains demonstrated excellent internal reliability (Cronbach's alpha values for each domain greater than or equal to 0.73). Most domains were moderately correlated with similar domains of established outcome measures (r(2) range, 0.3 to 0.5), Most domains were responsive to change (standardized effect sizes >0.4). One- and 3-month SS-QOL scores were associated with patients' self-report of HRQOL compared with before their stroke (P<0.001), Conclusions-The SS-QOL measures HRQOL, its primary underlying construct, in stroke patients. Preliminary results regarding the reliability, validity, and responsiveness of the SS-QOL are encouraging. Further studies in diverse stroke populations are needed

Keywords: Barthel Index/cerebral infarction/CLINICAL-TRIALS/criteria/development/effect/functional/functional status/HEALTH/health-related quality of life/internal/interviews/ischemic/ischemic stroke/measure/measures/OF-LIFE/outcome/outcome measures/outcomes/PA/patient interviews/patients/PHILADELPHIA/primary/quality/quality of life/reliability/responsiveness/scores/status/STROKE/stroke patients/stroke trials/studies/trials/use/validity

Wolf, P.A., Clagett, G.P., Easton, J.D., Goldstein, L.B., Gorelick, P.B., Kelly-Hayes, M., Sacco, R.L. and Whisnant, J.P. (1999), Preventing ischemic stroke in patients with prior stroke and transient ischemic attack - A statement for healthcare professionals from the Stroke Council of the American Heart Association. Stroke,

30

(9), 1991-1994

Keywords: AHA Scientific Statements/American Heart Association/ATRIAL-FIBRILLATION/CAROTID ENDARTERECTOMY/CEREBRAL INFARCTION/COMMUNITY/DEMENTIA/ischemia/ischemic/ischemic stroke/MINNESOTA/PA/patients/PATTERNS/PHILADELPHIA/prevention/RECURRENCE/RISK-FACTORS/ROCHESTER/SEP/stroke/transient/transient ischemic attack

Wolfe, C.D.A., Tilling, K., Beech, R. and Rudd, A.G. (1999), Variations in case fatality and dependency from stroke in western and central Europe. Stroke,

30

(2), 350-356.

Abstract: Background and Purpose - There are significant variations in mortality rates from stroke in Europe. a European Union BIOMED Concerted Action was established to assess and determine the reasons for the variations in case fatality and disability after stroke. Methods - Hospital-based stroke registers were established in 12 centers in 7 western and central European countries to collect demographic, clinical, and resource use details at the time of first-ever stroke during 1993-1994, At 3 months, details of survival, activity of daily living score, and use of health services were recorded. Multinomial logistic regression was used to estimate the relationship between centers and outcome (dead, functionally independent, functionally dependent), with adjustment for case mix and resource use variables, and to predict outcomes for the full cohort. This should minimize the bias due to loss to follow-up. Results - A total of 4534 stroke events were registered. The mean age was 71.9 years (SD, 12.53). There were significant differences between centers for all case mix and resource use variables (P < 0.001). Multinomial logistic regression modeling of outcome indicated that for those patients initially unconscious (588), center was not significantly related to outcome (P = 0.427). For those initially conscious, there were wide variations in death and dependency between centers after adjustment for case mix, type of bed, and use of CT scan. The predicted proportion dead at 3 months ranged from 42% (95% CI, 35% to 49%) in one UK center to 19% (95% CI, 14% to 24%) in France. Conclusions - Areas with high mortality rates within western and central Europe have been identified for stroke outcome, and there appears to be opportunity for considerable health gain in certain centers. adjustment for case mix and health service resource use does not explain these differences in outcome. Although there are true differences in outcome,the aspects of care that need to be altered to improve outcome remain unclear despite detailed data collection, Comparisons of outcome of the same design used in the present study do not allow rational policy decisions to be made

Keywords: activity/age/bias/CARE/case fatality/case mix/case-fatality/clinical/cohort/conscious/CT/CT scan/daily/data collection/death/dependency/design/diagnosis-related groups/disability/England/Europe/fatal outcome/fatality/follow up/follow-up/gain/health/health services/HOSPITAL SERVICES/logistic regression/loss/modeling/MORTALITY/mortality rates/outcome/outcomes/PA/patients/PHILADELPHIA/policy/QUALITY/RATES/regression/resource use/score/SEVERITY/SOUTHERN ENGLAND/stroke/stroke outcome/survival/total/UK/use

Wolman, R.L., Nussmeier, N.A., Aggarwal, A., Kanchuger, M.S., Roach, G.W., Newman, M.F., Mangano, C.M., Marschall, K.E., Ley, C., Boisvert, D.M., Ozanne, G.M., Herskowitz, A., Graham, S.H. and Mangano, D.T. (1999), Cerebral injury after cardiac surgery - Identification of a group at extraordinary risk. Stroke,

30

(3), 514-522.

Abstract: Background and Purpose-Cerebral injury after cardiac surgery is now recognized as a serious and costly healthcare problem mandating immediate attention. To effect solution, those subgroups of patients at greatest risk must be identified, thereby allowing efficient implementation of new clinical strategies. No such subgroup has been identified; however, patients undergoing intracardiac surgery are thought to be at high risk, but comprehensive data regarding specific risk, impact on cost, and discharge disposition are not available. Methods-We prospectively studied 273 patients enrolled from 24 diverse US medical centers, who were undergoing intracardiac and coronary artery surgery. Patient data were collected using standardized methods and included clinical, historical, specialized testing, neurological outcome and autopsy data, and measures of resource utilization. Adverse outcomes were defined a priori and determined after database closure by a blinded independent panel. Stepwise logistic regression models were developed to estimate the relative risks associated with clinical history and intraoperative and postoperative events. Results-Adverse cerebral outcomes occurred in 16% of patients (43/273), being nearly equally divided between type I outcomes (8.4%; 5 cerebral deaths, 16 nonfatal strokes, and 2 new TIAs) and type II outcomes (7.3%; 17 new intellectual deterioration persisting at hospital discharge and 3 newly diagnosed seizures). Associated resource utilization was significantly increased-prolonging median intensive care unit stay from 3 days (no adverse cerebral outcome) to 8 days (type I; P<0.001) and from 3 to 6 days (type II; P<0.001), and increasing hospitalization by 50% (type II, P=0.04) to 100% (type I, P<0.001). Furthermore, specialized care after hospital discharge was frequently necessary in those with type I outcomes, in that only 31% returned home compared with 85% of patients without cerebral complications (P<0.001). Significant risk factors for type I outcomes related primarily to embolic phenomena, including proximal aortic atherosclerosis, intracardiac thrombus, and intermittent clamping of the aorta during surgery. For type II outcomes, risk factors again included proximal aortic atherosclerosis, as well as a preoperative history of endocarditis, alcohol abuse, perioperative dysrhythmia or poorly controlled hypertension, and the development of a low-output state after cardiopulmonary bypass. Conclusions-These prospective multicenter findings demonstrate that patients undergoing intracardiac surgery combined with coronary revascularization are at formidable risk, in that 1 in 6 will develop cerebral complications that are frequently costly and devastating. Thus, new strategies for perioperative management-including technical and pharmacological interventions-are now mandated for this subgroup of cardiac surgery patients

Keywords: abuse/alcohol/aorta/aortic/aortic atherosclerosis/AORTIC-STENOSIS/artery/ASCENDING AORTA/atherosclerosis/attention/autopsy/bypass/CA/cardiac/cardiac surgery/cardiopulmonary/CARDIOPULMONARY BYPASS/cardiopulmonary bypass/cerebral/cerebral complications/cerebral embolism and thrombosis/clinical/combined/complications/coronary/coronary artery/coronary artery surgery/coronary heart disease/coronary revascularization/CORONARY-ARTERY BYPASS/cost/database/deaths/development/discharge disposition/effect/endocarditis/high risk/history/home/hospital/hospital discharge/hospitalization/hypertension/II/implementation/injury/intensive care/intensive care unit/intraoperative/logistic regression/measures/medical/methods/models/NERVOUS-SYSTEM COMPLICATIONS/neurological/neurological outcome/NEUROPSYCHIATRIC COMPLICATIONS/OPERATIONS/outcome/outcomes/PA/patients/perioperative/PHILADELPHIA/postoperative/postoperative complications/prospective/PROTECTION/regression/resource utilization/revascularization/risk/risk factors/risks/seizures/specific/strategies/STROKE/strokes/subgroups/surgery/testing/thrombus/TRANSESOPHAGEAL ECHOCARDIOGRAPHY/US/utilization

Wong, J.H., Lubkey, T.B., Suarez-Almazor, M.E. and Findlay, J.M. (1999), Improving the appropriateness of carotid endarterectomy - Results of a prospective city-wide study. Stroke,

30

(1), 12-15.

Abstract: Background and Purpose-In light of previously reported concerns regarding carotid endarterectomy (CEA) use in our city, our goal was to determine the influence of a prospective audit and educational campaign on the performance of CEA with respect to surgical appropriateness and complication frequency. Methods- Results of our previous audit of 291 CEAs, along with CEA practice guidelines and notification of prospective surveillance, were supplied to surgeons performing CEA in our city. After this, 184 consecutive patients undergoing CEA from September 1996 to August 1997 were followed prospectively. On the basis of blinded standardized remeasurements of angiographic carotid stenoses, CEA was classified as appropriate for patients with symptomatic carotid stenoses greater than or equal to 70%, uncertain for those with symptomatic stenoses <70% or asymptomatic stenoses greater than or equal to 60%, and inappropriate for patients with asymptomatic carotid stenoses <60% or preoperative neurological or medical instability. Results-Forty percent of patients were asymptomatic. Compared with our prior audit, the fate of appropriate CEAs improved from 33% previously to 49% of cases in the present study (P = 0.0005), uncertain indications did not change significantly (49% versus 47%; P = 0.61), and inappropriate indications dropped from 18% to 4% (P = 0.00002). Perioperative stroke or death occurred in 6.4% of symptomatic patients but developed in only 2.7% of asymptomatic patients, which was improved from the 5.1% rate previously found. Conclusions-In our city, the use of a surgical audit identified areas of concern regarding CEA, and subsequent education and ongoing surveillance significantly improved the use and performance of this procedure

Keywords: ANGIOGRAMS/appropriateness/asymptomatic/asymptomatic patients/audit/Canada/carotid/carotid endarterectomy/carotid stenosis/complication/COMPLICATIONS/death/education/endarterectomy/EPIDEMIOLOGY/frequency/guidelines/health services misuse/instability/medical/neurological/PA/patients/PERFORMANCE/PHILADELPHIA/practice/practice guidelines/prospective/rate/RISK/STENOSIS/STROKE/surveillance/use

Wong, K.S. (1999), Risk factors for early death in acute ischemic stroke and intracerebral hemorrhage - A prospective hospital-based study in Asia. Stroke, 2014-07-19 18:44
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