Fintan O'Rourke

Comprehensive stroke units: a review of comparative evidence and experience

Background Stroke unit care offers significant benefits in survival and dependency when compared to general medical ward. Most stroke units are either acute or rehabilitation, but comprehensive (combined acute and rehabilitation) model (comprehensive stroke unit) is less common. Aim To examine different levels of evidence of comprehensive stroke unit compared to other organized inpatient stroke care and share local experience of comprehensive stroke units. Methods Cochrane Library and Medline (1980 to December 2010) review of English language articles comparing stroke units to alternative forms of stroke care delivery, different types of stroke unit models, and differences in processes of care within different stroke unit models. Different levels of comparative evidence of comprehensive stroke units to other models of stroke units are collected. Results There are no randomized controlled trials directly comparing comprehensive stroke units to other stroke unit models (either acute or rehabilitation). Comprehensive stroke units are associated with reduced length of stay and greatest reduction in combined death and dependency in a meta-analysis study when compared to other stroke unit models. Comprehensive stroke units also have better length of stay and functional outcome when compared to acute or rehabilitation stroke unit models in a cross-sectional study, and better length of stay in a ‘before-and-after’ comparative study. Components of stroke unit care that improve outcome are multifactorial and most probably include early mobilization. A comprehensive stroke unit model has been successfully implemented in metropolitan and rural hospital settings. Conclusions Comprehensive stroke units are associated with reductions in length of stay and combined death and dependency and improved functional outcomes compared to other stroke unit models. A comprehensive stroke unit model is worth considering as the preferred model of stroke unit care in the planning and delivery of metropolitan and rural stroke services.

Current and future concepts in stroke prevention

STROKE IS A MAJOR CAUSE OF MORBIDITY and mortality in an aging population. The current understanding of the pathophysiology of atherosclerotic diseases, the most common cause of stroke, and the evidence for existing therapeutic interventions for the prevention of stroke are presented. Specifically, we review the evidence for antiplatelet agents, anticoagulants, antihypertensive medications, lipid-lowering agents and carotid endarterectomy for stroke prevention.

Meta-analysis of the cardiovascular benefits of intensive lipid lowering with statins

Chan DKY, O’Rourke F, Shen Q, Mak JCS, Hung WT. Meta‐analysis of the cardiovascular benefits of intensive lipid lowering with statins.u2028Acta Neurol Scand: 2011: 124: 188–195.u2028© 2010 John Wiley & Sons A/S.

Health service management study for stroke: a randomized controlled trial to evaluate two models of stroke care.

Background The most effective and efficient model for providing organized stroke care remains uncertain. This study aimed to compare the effect of two models in a randomized controlled trial. Methods Patients with acute stroke were randomized on day one of admission to combined, co-located acute/rehabilitation stroke care or traditionally separated acute/rehabilitation stroke care. Outcomes measured at baseline and 90 days post-discharge included functional independence measure, length of hospital stay, and functional independence measure efficiency (change in functional independence measure score ÷ total length of hospital stay). Results Among 41 patients randomized, 20 were allocated co-located acute/rehabilitation stroke care and 21 traditionally separated acute/rehabilitation stroke care. Baseline measurements showed no significant difference. There was no significant difference in functional independence measure scores between the two groups at discharge and again at 90 days postdischarge (co-located acute/rehabilitation stroke care: 103·6 ± 22·2 vs. traditionally separated acute/rehabilitation stroke care: 99·5 ± 27·7; P = 0·77 at discharge; co-located acute/rehabilitation stroke care: 109·5 ± 21·7 vs. traditionally separated acute/rehabilitation stroke care: 104·4 ± 27·9; P= 0·8875 at 90 days post-discharge). Total length of hospital stay was 5·28 days less in co-located acute/rehabilitation stroke care compared with traditionally separated acute/rehabilitation stroke care (24·15 ± 3·18 vs. 29·42 ± 4·5, P = 0·35). There was significant improvement in functional independence measure efficiency score among participants assigned to co-located acute/rehabilitation stroke care compared with traditionally separated acute/rehabilitation stroke care (co-located acute/rehabilitation stroke care: median 1·60, interquartile range: 0·87–2·81; traditionally separated acute/rehabilitation stroke care: median 0·82, interquartile range: 0·27–1·57, P = 0·0393). Linear regression analysis revealed a high inverse correlation (R2 = 0·89) between functional independence measure efficiency and time spent in the acute stroke unit. Conclusion This proof-of-concept study has shown that co-located acute/rehabilitation stroke care was just as effective as traditionally separated acute/rehabilitation stroke care as reflected in functional independence measure scores, but significantly more efficient as shown in greater functional independence measure efficiency. Co-located acute/rehabilitation stroke care has potential for significantly improved hospital bed utilization with no patient disadvantage.

RELATIONSHIP BETWEEN HIP FRACTURE SUBTYPES, SURGICAL PROCEDURE, AND ANALGESIA USE

tation), hypothyroidism, and osteoporosis. His medications include carvedilol, valsartan, dusteride, hydralazine, risedronate, calcium, and vitamin D. Physical examination showed a Caucasian man who used a walker for ambulation and in no acute cardiopulmonary distress. Vital signs were within normal limits, and his body mass index was 21.3 kg/m. No craniofacial abnormalities were detected, and examination of the heart and lungs was normal. On neurological examination, the patient was slow in responding to questions but oriented to time, place, and person. Examination of the cranial nerves was within normal limits, and no lateralizing signs were observed in the examination of the motor system. To confirm the diagnosis of sleep apnea, the patient underwent an overnight sleep study and was found to have severe OSAH (respiratory disturbance index 430 events/h of sleep), with significant oxygen desaturations and a hypoxic burden of 7%. CPAP titration resulted in a significant reduction in respiratory events at a CPAP pressure of 12 cm. During follow-up, the patient stated that he used his CPAP every night and that his nighttime sleep and daytime activities had improved significantly. He was waking up from sleep at night two or three times only and felt rested in the morning when he got out of bed. He was able to read his papers, watch television, carry on a conversation with friends, and engage in activities at the assisted living facility without dozing off, and he stated that these changes had significantly improved his quality of life. Patient is now 92 years old and has been using his CPAP for more than 1 year. This report illustrates successful treatment of OSAH with CPAP in a nonagenarian. Despite the patient’s numerous contacts with the healthcare system in previous years and his long-standing symptoms of snoring and daytime sleepiness, he was referred for evaluation of his sleeprelated problem only a year ago. This indicates missed opportunities for screening and earlier diagnosis of sleep apnea and may be representative of the current state of affairs regarding sleep apnea, especially in older adults. Another important point that this report demonstrates is that age should not be a factor when considering CPAP for treatment of sleep apnea. Average nightly CPAP use of 4.8 hours by older adults with OSAH has been reported previously, and the current case report reinforces this previous finding. Although the primary objective of treatment of sleep apnea in individuals in the oldest-old age group should be to improve functional status and improve quality of life, future studies should focus on the effect of CPAP treatment in older adults with OSAH on healthcare utilization and expenditure. In conclusion, improvement in nighttime sleep, daytime activities, and overall quality of life was achieved after treatment of sleep-disordered breathing with CPAP in a nonagenarian, and this case illustrates that successful CPAP treatment of OSAH in individuals in the oldest-old age group is possible.

Subcutaneous unfractionated heparin-induced hyperkalaemia in an elderly patient.

Admission biochemistry were: sodium 132 mmol/L (135–145), potassium (K) 5.0 mmol/L (3.5–5.0), urea 11.2 mmol/L (3.0–8.0), creatinine 119 mmol/L (70–110). The raised urea/creatinine ratio, high normal-range plasma K and mild hyponatraemia were initially thought to be due to a combination of dehydration from poor oral intake, the use of frusemide and ramipril. Frusemide and ramipril were withheld shortly after admission. Potassium initially fell over the next 3 days to 4.7 mmol/L. Despite stable renal and cardiac function, potassium then rose again peaking at 6.9 mmol/L 3 days later. The hyperkalaemia was managed with an intravenous bolus of insulin/dextrose and oral resonium. As expected, potassium fell over the next 48 hours but remained high at 5.8 mmol/L. Other possible causes of hyperkalaemia were considered, including diabetic nephropathy; inadequate insulin dosing; adrenal insufficiency in the context of concomitant mild hyponatraemia; and subcutaneous heparin injection. The rapidity of the potassium rise in the setting of improving renal function made diabetic renal failure a less likely cause. Significant insulin deficiency was also unlikely with blood glucose levels ranging from 6 to 9 mmol/L. Adrenal insufficiency was excluded by an adequate response to short Synacthen test. Heparin was then discontinued. Potassium gradually returned to 4.5 mmol/L over the next 5 days. A rechallenge of heparin 5000 units twice daily subcutaneously a day later resulted in recurrence of hyperkalaemia (K 5.5 mmol/L).

Venous thromboembolism in psychogeriatric in-patients – A study of risk assessment, incidence, and current prophylaxis prescribing

BACKGROUNDnWhile venous thromboembolism (VTE) risk assessment and prophylaxis is well established for medical and surgical in-patients, there is a paucity of evidence, and therefore guidelines, in this area for psychogeriatric in-patients. We wished to determine VTE incidence, risk, and use of prophylaxis, in a psychogeriatric in-patient population.nnnMETHODSnRetrospective audit of consecutive psychogeriatric patients aged 65 years and over admitted to Bankstown Hospital over a 3-year period, 2007-2009. Using an adapted VTE risk scoring system, patients were assigned as low, medium, or high VTE risk.nnnRESULTSnA total of 192 patients were included in the study. Mean age was 79.1 ± 7.0 years. Out of the total, 55.2% of patients had diagnosis of dementia, and 33.3% had depression. Overall, 81.8% (157/192) were assessed as low risk, and 18.2% (35/192) as medium risk. Also, 16.7% (32/192) received VTE prophylaxis. Four new VTE events occurred in medium-risk group, and one in low-risk group (p = 0.004). Overall VTE incidence was 10.5/10,000 patient-days, but 44.2 per 10,000 in medium-risk group. VTE risk score was predictive of VTE events - IRR 6.02 (95% Confidence Intervals (CI) = 1.76-20.7, p = 0.004) for every one-point increment in risk. Depression was associated with significantly higher VTE occurrence (6.3% in those with diagnosis vs. 0.8% without, p = 0.043).nnnCONCLUSIONnUsing a VTE risk scoring system adapted for psychogeriatric in-patients, those assessed to be at medium risk had a significantly increased rate of VTE. On this basis, we would recommend VTE prophylaxis be prescribed for psychogeriatric in-patients assessed to be at medium and high level of risk.

Preferences, barriers and facilitators for establishing comprehensive stroke units: a multidisciplinary survey

OBJECTIVESnTo determine the preferences of multidisciplinary stroke clinicians for models of inpatient stroke unit care and perceived barriers to establishing a comprehensive stroke unit (CSU) model (acute and rehabilitation care in the same ward).nnnMETHODSnWritten questionnaires distributed and completed at multidisciplinary stroke unit case conferences in NSW, Australia.nnnRESULTSnTwenty hospitals with 22 stroke units were surveyed, 13 acute stroke units, 7 rehabilitation stroke units, 2 CSUs. Two hundred and twenty-eight respondents: 99 (43.4%) allied health, 72 (31.6%) nurses and 57 (25.0%) doctors. One hundred and fifty-one respondents (67.0%) thought CSU to be the best model. Seventy-three % of doctors and 79% of allied health preferred CSU v. 57% of nurses (P=0.041). Of doctors, rehabilitation specialists were most likely to favour comprehensive model (84.2%) and neurologists least (57.0%). The main perceived advantages of CSU were reduced cost and improved functional outcomes; perceived disadvantages were increased workload and unwell patients unable to participate in rehabilitation. Main perceived barriers to establishing CSU were lack of space, money, staffing and time.nnnCONCLUSIONnAlthough most current stroke unit care in NSW is based on the traditional model of acute and rehabilitation components in separate wards or hospitals, the majority of multidisciplinary stroke team clinicians believe CSU is the optimum model. What is known about the topic? Stroke unit care is known to improve survival and dependency but the optimum model of care is unproven, despite some small studies suggesting that the CSU model may result in better outcomes. What does this paper add? This paper is the first to survey stroke clinicians from various disciplines and types of unit, to determine their preferences for stroke unit model. What are the implications for practitioners? A majority of clinicians expressed a preference for the CSU model, suggesting that most would be comfortable caring for patients in both acute and rehabilitation phases of stroke care if further such units are established.

Improving the osteoporosis care gap in elderly patients following hip fractures: For the ICHIBAN initiative.

Hip fractures are the most frequently seen serious injuries in hospital patients.1 Current costs of osteoporotic hip fractures in Australia exceed

Prescription drug misuse/abuse in the elderly

500 million annually.2 By 2040, an estimated 512,000 hip fractures will occur in the United States each year at a cost of