Christine Matthis

A vasculitis centre based management strategy leads to improved outcome in eosinophilic granulomatosis and polyangiitis (Churg–Strauss, EGPA): monocentric experiences in 150 patients

Objective To evaluate a vasculitis centre based management strategy for eosinophilic granulomatosis and polyangiitis (Churg-Strauss, EGPA). Methods A retrospective cohort study at a vasculitis referral centre was performed. All EGPA patients admitted from 1990 to 2009 were included. A structured interdisciplinary work-up for proof of diagnosis, Disease Extent Index and Birmingham Vasculitis Activity Score was performed. Immunosuppressive therapy was initiated and regularly adapted. Treatment targets were induction and maintenance of remission according to definitions given by the European League Against Rheumatism and the European Vasculitis Study Group. Outcomes were mortality, rate of remission, relapses, adverse events and prednisolone-dose. Results Out of 269 patients with suspected EGPA 150 fulfilled the inclusion criteria. Of those, 104 had more than one follow-up visit resulting in a mean follow up of 53±4.9 months. By using additional data sources the follow-up concerning survival was extended to 92±5 month. Severe organ manifestations occurred at heart (46%), kidney (18%) and lungs (10%). Cyclophosphamide was used in 107 patients (71%). The prednisolone-doses of all patients were within the targeted range (i.e. ≤7.5mg) in 69% of the total follow-up time; the median dose at end of follow-up was 5mg/d. The 10-year survival rate was 89% resulting in mortality comparable to the general population (SMR 1.29). Only patients with cardiac failure associated with EGPA had an increased mortality (SMR 3.06). Conclusions Regular re-evaluation and target-orientated adaption of therapy may lead to normalization of life expectancy and attenuation of disease progression. Continued centre based interdisciplinary treatment should be standard of care.

Does location of vertebral deformity within the spine influence back pain and disability

OBJECTIVE Vertebral deformity is associated with back pain and disability. The aim of this analysis was to determine whether location within the spine influences the strength of association between vertebral deformity, back pain and disability. METHODS Men and women aged 50 years and over were recruited from population registers in 30 European centres. Subjects were invited for an interviewer administered questionnaire, and for lateral spinal radiographs. The questionnaire included questions about back pain, general health and functional ability. The spinal radiographs were evaluated morphometrically and vertebral deformity defined according to the McCloskey-Kanis method. RESULTS 756 (11.7%) men and 885 (11.8%) women had evidence of one or more vertebral deformities. Among women with a single deformity, after adjusting for age and centre, those with a lumbar deformity were more likely than those with a thoracic deformity to report back pain, both currently (OR=1.4; 95% CI 1.0, 2.0) and in the past year (OR=1.5; 95% CI 1.0, 2.3). No association was observed in men. Among women with two deformities, those with adjacent deformities were more likely than those with non-adjacent deformities to report poor general health (OR=2.2; 95%CI 0.9, 5.6), impaired functional ability (OR=1.9; 95%CI 0.8, 4.7) and current back pain (OR=2.1; 95%CI 0.9, 4.9), though none of these associations were statistically significant. By contrast, among men, non-adjacent deformities were associated with impaired functional ability compared with those with adjacent deformities. CONCLUSION Location within the spine influences the strength of association between self reported health factors and vertebral deformity.

The quality of acute stroke care- an analysis of evidence-based indicators in 260 000 patients.

BACKGROUND Stroke patients should be cared for in accordance with evidence-based guidelines. The extent of implementation of guidelines for the acute care of stroke patients in Germany has been unclear to date. METHODS The regional quality assurance projects that cooperate in the framework of the German Stroke Registers Study Group (Arbeitsgemeinschaft Deutscher Schlaganfall-Register, ADSR) collected data on the care of stroke patients in 627 hospitals in 2012. The quality of the acute hospital care of patients with stroke or transient ischemic attack (TIA) was assessed on the basis of 15 standardized, evidence-based quality indicators and compared across the nine participating regional quality assurance projects. RESULTS Data were obtained on more than 260 000 patients nationwide. Intravenous thrombolysis was performed in 59.7% of eligible ischemic stroke patients patients (range among participating projects, 49.7-63.6%). Dysphagia screening was documented in 86.2% (range, 74.8-93.1%). For the following indicators, the defined targets were not reached for all of Germany: anti-aggregation within 48 hours, 93.4% (range, 86.6-96.4%); anticoagulation for atrial fibrillation, 77.6% (range, 72.4-80.1%); standardized dysphagia screening, 86.2% (range, 74.8-93.1%); oral and written information of the patients or their relatives, 86.1% (range, 75.4-91.5%). The rate of patients examined or treated by a speech therapist was in the target range. CONCLUSION The defined targets were reached for most of the quality indicators. Some indicators, however, varied widely across regional quality assurance projects. This implies that the standardization of care for stroke patients in Germany has not yet been fully achieved.

Statin treatment in patients with acute ischemic stroke.

Background and purpose We aimed to investigate the association of statin treatment with outcomes in patients with acute ischemic stroke. Methods Over a 4.5-year period (starting November 2007), 12 781 patients (mean age, 72·8 ± 12·6 years; 48·6% women) with acute ischemic stroke from 15 hospitals in Schleswig-Holstein, Germany, were enrolled in a population-based study and prospectively evaluated. The primary outcomes were the mortality during hospitalization and the disability (modified Rankin Scale score ≥2) at discharge from hospital. The secondary outcomes were the mortality and disability at three-months after discharge. Results A total of 7535 patients (59%) with acute ischemic stroke were treated with statins. During hospitalization (mean, nine-days), the in-hospital mortality rate (4·7%; 95% confidence interval, 4·3–5·1%) was lower in patients treated with statins than in those without statins (2·3% vs. 7·9%, respectively; P < 0·001). At three-months after discharge, the mortality rate (6·9%; 95% confidence interval, 6·4–7·5%) was lower in patients treated with statins than in those without statins (5·0% vs. 10·6%, respectively; P < 0·001). Adjusted logistic regression analysis showed that statin treatment was associated with reduced rates of in-hospital mortality (odds ratio, 0·39; 95% confidence interval, 0·31–0·48; P < 0·001) and three-month mortality (odds ratio, 0.47; 95% confidence interval, 0·34–0·63; P < 0·001). A comparison of the patient groups revealed that patients on statins were likely to have lower disability rates at discharge (59% vs. 67%, respectively; P < 0·001) and after three-months (33% vs. 42%, respectively; P < 0·001) in patients who had survived the stroke. Conclusion Statin treatment may improve the outcomes in patients with acute ischemic stroke. Further studies are necessary to confirm this finding.

Dysphagia in Patients with Acute Ischemic Stroke: Early Dysphagia Screening May Reduce Stroke-Related Pneumonia and Improve Stroke Outcomes.

Background: Dysphagia is associated with poor outcome in stroke patients. Studies investigating the association of dysphagia and early dysphagia screening (EDS) with outcomes in patients with acute ischemic stroke (AIS) are rare. The aims of our study are to investigate the association of dysphagia and EDS within 24 h with stroke-related pneumonia and outcomes. Methods: Over a 4.5-year period (starting November 2007), all consecutive AIS patients from 15 hospitals in Schleswig-Holstein, Germany, were prospectively evaluated. The primary outcomes were stroke-related pneumonia during hospitalization, mortality, and disability measured on the modified Rankin Scale ≥2-5, in which 2 indicates an independence/slight disability to 5 severe disability. Results: Of 12,276 patients (mean age 73 ± 13; 49% women), 9,164 patients (74%) underwent dysphagia screening; of these patients, 55, 39, 4.7, and 1.5% of patients had been screened for dysphagia within 3, 3 to <24, 24 to ≤72, and >72 h following admission. Patients who underwent dysphagia screening were likely to be older, more affected on the National Institutes of Health Stroke Scale score, and to have higher rates of neurological symptoms and risk factors than patients who were not screened. A total of 3,083 patients (25.1%; 95% CI 24.4-25.8) had dysphagia. The frequency of dysphagia was higher in patients who had undergone dysphagia screening than in those who had not (30 vs. 11.1%; p < 0.001). During hospitalization (mean 9 days), 1,271 patients (10.2%; 95% CI 9.7-10.8) suffered from stroke-related pneumonia. Patients with dysphagia had a higher rate of pneumonia than those without dysphagia (29.7 vs. 3.7%; p < 0.001). Logistic regression revealed that dysphagia was associated with increased risk of stroke-related pneumonia (OR 3.4; 95% CI 2.8-4.2; p < 0.001), case fatality during hospitalization (OR 2.8; 95% CI 2.1-3.7; p < 0.001) and disability at discharge (OR 2.0; 95% CI 1.6-2.3; p < 0.001). EDS within 24 h of admission appeared to be associated with decreased risk of stroke-related pneumonia (OR 0.68; 95% CI 0.52-0.89; p = 0.006) and disability at discharge (OR 0.60; 95% CI 0.46-0.77; p < 0.001). Furthermore, dysphagia was independently correlated with an increase in mortality (OR 3.2; 95% CI 2.4-4.2; p < 0.001) and disability (OR 2.3; 95% CI 1.8-3.0; p < 0.001) at 3 months after stroke. The rate of 3-month disability was lower in patients who had received EDS (52 vs. 40.7%; p = 0.003), albeit an association in the logistic regression was not found (OR 0.78; 95% CI 0.51-1.2; p = 0.2). Conclusions: Dysphagia exposes stroke patients to a higher risk of pneumonia, disability, and death, whereas an EDS seems to be associated with reduced risk of stroke-related pneumonia and disability.

Short-term risk and predictors of stroke after transient ischemic attack

BACKGROUND Transient ischemic attack (TIA) is a marker of stroke, especially in the early phase following this event. The aims of this study are to determine the short-term risk of stroke and to evaluate the independent predictors of stroke in patients with TIA who are hospitalized within 48 hours after symptom onset. METHODS During a 36-month period (beginning in November 2007), 3554 patients (mean age: 70.5 ± 13 years; 49.9% female; mean NIHSS score: 1.4 ± 2.5) from 15 hospitals suffering from TIA were prospectively evaluated. RESULTS Of the 3554 patients, 43 (1.2%) suffered from stroke during hospitalization (6.5 ± 4.3 days). We identified the following independent predictors for stroke after TIA: male sex (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.3-5; P=0.008), age ≥65 years (OR, 4.7; 95% CI, 1.4-15; P=0.01), hyperlipidemia (OR, 2.4; 95% CI, 1.2-4.8; P=0.015), and dysarthria (OR, 2; 95% CI, 1.1-5.0; P=0.038). CONCLUSION Patient characteristics (male sex, age, and hyperlipidemia) and TIA symptom (dysarthria) may be useful in defining stroke after TIA in patients who were hospitalized with TIA.

The prognostic impact of the stroke unit concept after transient ischemic attack

BACKGROUND AND PURPOSE Transient ischemic attack (TIA) is associated with high short-term risk of stroke, especially in the early phase following the event. Data about the impact of the early hospitalization in a stroke unit on patients with TIA are sparse. This study compares the prognostic impact of the stroke unit concept with conventional care on patients with TIA. METHODS During a 30-month period (beginning April 2005), 878 patients (mean age, 70±12years; 44.3% female) with TIA admitted within 24h of symptom onset were prospectively evaluated. The adjusted logistic regression analyses were used to estimate the odds ratio for the stroke risk during hospitalization and the 90-day mortality. RESULTS Of 878 patients, 591 (67.3%) were treated in the stroke unit, and 287 (32.7%) underwent conventional care. Patients receiving stroke-unit care had significantly higher rates of cranial computed tomography (96.3% vs. 88.1%; P<.001) and brain-supplying artery ultrasound (97.1% vs. 91.3%; P<.001) investigations. The stroke risk during hospitalization was 1.7% in patients treated in stroke unit and 2.4% in patients received a conventional care. A relevant difference between the groups was not found (1.7% vs. 2.4%; P=.45). The 90-day mortality rate was 1.7% in the stroke unit group compared to 2.2% in the conventional care group (1.7% vs. 2.2%; P=.66). The adjusted logistic regression analyses revealed no difference in stroke rates (odds ratio, 0.68; 95% confidence interval, 0.24-1.9) and in the 90-day mortality (odds ratio, 0.63; 95% confidence interval, 0.2-1.96) between the stroke unit concept and conventional care. CONCLUSION The prognostic impact of the stroke unit care for patients with transient ischemic attack appears to be similar to that of the conventional care. Further randomized studies are needed to investigate the impact of stroke-unit care on patients with transient ischemic attack.

Use of cranial CT to identify a new infarct in patients with a transient ischemic attack

Research on infarct detection by noncontrast cranial computed tomography (CCT) in patients with transient ischemic attack (TIA) is sparse. However, the aims of this study are to determine the frequency of new infarcts in patients with TIA, to evaluate the independent predictors of infarct detection, and to investigate the association between a new infarct and early short‐term risk of stroke during hospitalization. We prospectively evaluated 1533 consecutive patients (mean age, 75.3 ± 11 years; 54% female; mean National Institutes of Health Stroke Scale [NIHSS] score, 1.7 ± 2.9) with TIA who were admitted to hospital within 48 h of symptom onset. A new infarct was detected by CCT in 47 (3.1%) of the 1533 patients. During hospitalization, 17 patients suffered a stroke. Multivariate logistic regression analysis revealed the following independent predictors for infarct detection: NIHSS score ≥10 (odds ratio [OR], 4.8), time to CCT assessment >6 h (OR 2.2), and diabetes (OR 2.3). The evidence of a new infarct was not associated with the risk of stroke after TIA. The frequency of a new infarct in patients with TIA using CCT is low. The use of the CCT tool to predict the stroke risk during hospitalization in patients with TIA is found to be inappropriate. The estimated clinical predictors are easy to use and may help clinicians in the TIA work up.

TIA-Treatment: Stroke Units versus General Wards Mono-Center Study

Background and Purpose: Transient ischemic attack (TIA) is associated with a high short-term risk of stroke. The aim of this study is to compare the diagnostic evaluation, therapeutic procedures, and secondary prevention strategies in TIA patients who were directly admitted to a stroke unit (SU) and received semi-intensive care in comparison to those who were treated in general wards (GW) in a mono-center study. Methods: During a 6-year period (2008-2013), 1114 TIA patients who were admitted to the Department of Neurology at the University of Schleswig-Holstein, campus Lubeck, were evaluated in a mono-center study. Results: A total of 604 (57%) TIA patients were admitted to the SU, whereas 453(37%) patients were admitted to the GW. Patients with a TIA who were undergoing treatment in an SU were significantly younger (69.1 vs. 71.0 years; P=0.023) and had higher rates of paresis (30.1 vs. 21.8%; p<0.003), hypertension (79.7 vs. 74.3%; P=0.042) and hypercholesterolemia (57.2 vs. 46.7%; P=0.001) than those who were undergoing treatment in the GW. Patients in SUs received significantly higher rates of carotid revascularization for symptomatic carotid stenosis (5.8% vs. 0.4%; P<0.001), dysphagia screening (47.6 vs. 27.3%; P<0.001), speech therapy (33.0 vs. 14.8%; P<0.001), and physiotherapy (51.0 vs. 37.2%; P<0.001) in comparison to those admitted to GWs. The TIA etiology; cardioembolism was significantly more common (18.0 vs. 12.7%; P=0.037) in patients treated in stroke unit, whereas the undetermined etiology of TIA was significantly less diagnosed in patients who were admitted to SI-SU than those treated in CC (50. vs. 58%; P=0.037). Carotid revascularization for symptomatic stenosis was more performed in patients who underwent stroke unit care than those who were treated in general wards (5.8 vs. 0.4%, P<0.001). Conclusion: TIA-Treatment in the SU appears to be correlated with more diagnostic and therapeutic procedures in comparison to care in general wards.

Stroke recurrence in patients with recently symptomatic carotid stenosis and scheduled for carotid revascularization

Patients with symptomatic carotid stenosis (sCS) have a higher risk of stroke recurrence following the first ischaemic event. Guidelines recommend that patients undergo carotid revascularization (CR), preferably within 2 weeks of the event. We aimed to determine the rate of stroke recurrence during hospitalization in patients who were admitted to the hospital with an acute ischaemic event and who underwent CR for recently sCS.