Piotr Sobolewski

Self-reported quality of life in multiple sclerosis patients: preliminary results based on the Polish MS Registry

Background The aim of the study was to analyze selected clinical and sociodemographic factors and their effects on the quality of life (QoL) of multiple sclerosis (MS) patients registered in the Polish MS Registry. Methods This was a cross-sectional observational study performed in Poland. Data on personal and disease-specific factors were collected between January 1, 2011, and December 31, 2015, via the web portal of the Polish MS Registry. All patients were assessed by a physician and asked to complete the Polish language versions of the following self-evaluation questionnaires: EuroQol 5-Dimensions, EuroQoL Visual Analog Scale, and Multiple Sclerosis Impact Scale. Univariate analysis and logistic regression were performed to determine the factors associated with QoL. Results The study included 2,385 patients (female/male ratio 2.3:1) with clinically confirmed MS (mean age 37.8±9.2 years). Average EuroQol 5-Dimensions index was 0.72±0.24, and the mean EuroQoL Visual Analog Scale score was 64.2±22.8. The average Multiple Sclerosis Impact Scale score was 84.6±11.2 (62.2±18.4 for physical condition and 23.8±7.2 for mental condition). Lower QoL scores were significantly associated with higher level of disability (odds ratio [OR], 0.932; 95% confidence interval [CI], 0.876–0.984; P=0.001), age >40 years (OR, 1.042; 95% CI, 0.924–1.158; P=0.012), longer disease duration (OR, 0.482; 95% CI, 0.224–0.998; P=0.042), and lack of disease modifying therapies (OR, 0.024; 95% CI, 0.160–0.835; P=0.024). No significant associations were found between QoL, sex, type of MS course, patient’s education, and marital status. Conclusion The Polish MS Registry is the first national registry for long-term observation that allows for self-evaluation of the QoL. QoL of Polish patients with MS is significantly lower compared with the rest of the population. The parameter is mainly affected by the level of disability, duration of the disease, and limited access to immunomodulatory therapy.

Intravenous thrombolysis with rt-PA for acute ischemic stroke within 24 h of a transient ischemic attack

BACKGROUND Intravenous thrombolysis (iv-thrombolysis) with the use of rt-PA in patients after recent transient ischemic attack (TIA) is an important clinical problem. The aim of the study was to assess the impact of TIA within 24h preceding acute ischemic stroke (AIS) on the safety and efficacy of iv-thrombolysis. METHODS We retrospectively evaluated the clinical and demographic data of 400 patients with AIS who were consecutively treated with iv-thrombolysis from September 2006 to May 2011 in three stroke centers. RESULTS At three-month follow-up, 58.0% of patients were independent (modified Rankin scale; mRS 0-2), 17.8% had died, 17.0% suffered hemorrhagic transformation (HT) and 4.3% experienced symptomatic intracerebral hemorrhage (SICH). There were 29 patients (7.3%) who had a previous ipsilateral TIA within 24h before established stroke. In the TIA subgroup, there was no significant higher percentage of favorable outcome (p=0.07) and higher SICH rate (p=0.15). Multivariate analysis showed the impact of prior TIA within 24h before stroke onset in the presence of SICH (p=0.01), no impact of TIA on unfavorable outcomes after three months (p=0.25) and on the mortality rate within three months (p=0.41). CONCLUSION TIA within 24h prior to ischemic stroke can portend severe intracerebral bleeding in patients qualified to iv-thrombolysis with the use of rt-PA.

Intravenous thrombolysis in patients aged more than 80 years in the three rural hospitals in southeast Poland: An observational study

Approximately 30% of acute ischemic stroke (AIS) occurs in people aged over 80 years. Older patients are increasingly receiving intravenous thrombolysis (IV‐thrombolysis) for AIS; however, the majority of treatments are carried out in urban hospitals. The aim of the present study was to assess the safety and effectiveness of IV‐thrombolysis in patients aged older than 80 years.

Renal Dysfunction in Post-Stroke Patients

Background The presence of chronic kidney disease (CKD) is an indicator of a worse long-term prognosis in patients with ischemic stroke (IS). Unfortunately, not much is known about renal function in the population of post-IS subjects. The aim of our study was to assess the prevalence of renal damage and impaired renal function (IRF) in the population of post-IS subjects. Methods This prospective analysis concerned 352 consecutive post-IS survivors hospitalized in Pomeranian stroke centers (Poland) in 2009. In this group estimated glomerular filtration rate (eGFR) according to MDRD (modification of diet in renal diseases) and CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) formulas and urine albumin/creatinine ratio (ACR) were determined. Results Among survivors decreased eGFR (<60 mL/min./1.73m2 according to MDRD or CKD-EPI) or ACR≥30mg/g were detected in 40.38% (23.07% Men, 55.32% Women; P<0.01). The highest prevalence of IRF was noted in post-IS subjects with atheromatic and lacunar IS. In multivariate analysis the ACR≥30mg/g was predicted by older age, diabetes mellitus (DM) and physical disability (modified Rankin scale 3–5 pts.). The association with reduced eGFR was proved for sex (female), DM and physical disability. Conclusions CKD is a frequently occurring problem in the group of post-IS subjects, especially after lacunar and atheromatic IS. Post-IS patients, mainly the elderly women, with physical disability and diabetes mellitus, should be regularly screened for CKD. This could reduce the risk of further cardiovascular events and delay the progression of IRF.

Increasing prevalence and incidence of multiple sclerosis in Poland.

Epidemiologic data on multiple sclerosis (MS) in Poland are limited. Our objectives were to assess a mean annual incidence rate, and MS prevalence on December 31, 2015 in the Swietokrzyskie province (central Poland). We analyzed data of 1525 patients, collected in the Polish Multiple Sclerosis Registry. On December 31, 2015, overall crude prevalence of MS was not less than 121.3/100,000 (95% CI, 114.6-128.4). Significantly higher prevalence was recorded in females (167.1; 95% CI, 155.6-179.1) than in males (73.2; 95% CI, 64.2-82.6; P<0.001). The age-adjusted prevalence standardized to the European standard population was 114.2/100,000 (95% CI, 106.2-121.5). The female-male ratio was 2.4:1. The mean annual incidence was 4.5/100,000 (95% CI, 3.8-5.2). Increased MS prevalence and incidence compared to 2010 and previous studies from Poland confirmed that central Poland is a high risk area for MS.

Length of stay in emergency department and cerebral intravenous thrombolysis in community hospitals.

Objectives Current guidelines for the early management of patients with acute ischemic stroke recommend completion of an evaluation within 60 min of the patient’s arrival at the emergency department (ED) because prolongation of ED length of stay (LOS) may reduce the efficacy of acute stroke treatment. Aim To evaluate the LOS in EDs at the community-based Polish stroke centers, to determine logistic, social, epidemiological, and clinical factors responsible for its prolongation, and to assess the association between increased LOS and the implementation of cerebral intravenous (IV) thrombolysis. Materials and methods This study carried out an evaluation of the medical records of 8398 patients with stroke and transient ischemic attack who consecutively reported to the Pomeranian Stroke Registry from 2010 to 2012. Results The median ED LOS in the studied cohort was 97 (44–196) min and was prolonged (>60 min) in 63.1% of patients. Prolongation of ED LOS contributed to a low (4.9%) IV thrombolysis rate. Functional status at discharge was worse in patients with prolonged versus nonprolonged LOS [modified Rankin scale: 2 (0–3) vs. 1 (0–3) points; P<0.001]. Multivariate analysis showed that onset-to-door time more than 270 min or unknown time of symptoms onset, referral to ED in urban areas, living alone, presence of diabetes, motor, sensory, visual, and gait deficits at stroke onset, and NIHSS score on admission contributed toward prolongation of ED LOS. Conclusion A prolonged ED LOS, because of ineffective prehospital logistics, ED urban location, patients’ risk factors, and cohabitation profile and stroke symptoms and severity, commonly exists among patients with stroke and transient ischemic attack and contributes toward a low rate of IV thrombolysis in Polish community hospitals.

The role of additional computed tomography in the decision-making process on the secondary prevention in patients after systemic cerebral thrombolysis

Introduction Patients with ischemic stroke undergoing intravenous (iv)-thrombolysis are routinely controlled with computed tomography on the second day to assess stroke evolution and hemorrhagic transformation (HT). However, the benefits of an additional computed tomography (aCT) performed over the next days after iv-thrombolysis have not been determined. Methods We retrospectively screened 287 Caucasian patients with ischemic stroke who were consecutively treated with iv-thrombolysis from 2008 to 2012. The results of computed tomography performed on the second (control computed tomography) and seventh (aCT) day after iv-thrombolysis were compared in 274 patients (95.5%); 13 subjects (4.5%), who died before the seventh day from admission were excluded from the analysis. Results aCTs revealed a higher incidence of HT than control computed tomographies (14.2% vs 6.6%; P=0.003). Patients with HT in aCT showed higher median of National Institutes of Health Stroke Scale score on admission than those without HT (13.0 vs 10.0; P=0.01) and higher presence of ischemic changes >1/3 middle cerebral artery territory (66.7% vs 35.2%; P<0.01). Correlations between presence of HT in aCT and National Institutes of Health Stroke Scale score on admission (rpbi 0.15; P<0.01), and the ischemic changes >1/3 middle cerebral artery (phi=0.03) existed, and the presence of HT in aCT was associated with 3-month mortality (phi=0.03). Conclusion aCT after iv-thrombolysis enables higher detection of HT, which is related to higher 3-month mortality. Thus, patients with severe middle cerebral artery infarction may benefit from aCT in the decision-making process on the secondary prophylaxis.

Intravenous Thrombolysis with Recombinant Tissue-type Plasminogen Activator for Acute Ischemic Stroke in Patients with Metabolic Syndrome

BACKGROUND The metabolic syndrome (MetS) is common in patients with acute ischemic stroke (IS); however, its impact on outcome after intravenous thrombolysis (iv-thrombolysis) remains unclear. Thus, we aimed at evaluating the relationship between MetS and functional long-term outcome, mortality, and the presence of hemorrhagic complications in patients with IS treated with iv-thrombolysis. METHODS We retrospectively evaluated the demographic and clinical data of 535 Caucasian patients with acute IS who were consecutively treated with iv-thrombolysis from September 2006 to June 2013 in 2 experienced stroke centers in Poland. A favorable functional long-term outcome was defined as a modified Rankin scale score less than or equal to 2 points on day 90, and hemorrhagic complications were assessed with European Cooperative Acute Stroke Study criteria. RESULTS MetS was recognized in 192 (35.9%) patients (44.8% men; mean age, 70.8 ± 11.1 years), diabetes in 29.7%, dyslipidemia in 79.2%, and arterial hypertension in 75.5%. At 3 months, favorable outcome was found in 55.3% of patients, symptomatic intracerebral hemorrhage (SICH) in 18.3%, and 4.4 % of patients died. There was no difference regarding the presence of favorable outcome between patients with and without MetS (52.6% versus 56.9%, P = .34). The presence of SICH and 3-month mortality were more frequent in patients with MetS than without MetS (6.8% versus 2.9%, P = .03 and 23.4% versus 15.5%, P = .02, respectively); however, a multivariate analysis showed no impact of MetS on mortality or SICH. CONCLUSIONS Results of our study provide no data to suggest that the effect of intravenous tissue-type plasminogen activator differs based on the presence or absence of MetS.

Is there a bad time for intravenous thrombolysis? The experience of Polish stroke centers

BACKGROUND AND PURPOSE The outcome in acute stroke strongly depends on patient-related issues, as well as on the availability of human and diagnostic resources. Our aim was to evaluate safety and effectiveness of intravenous alteplase for stroke according to the time of admission to the hospital. MATERIALS AND METHODS We analyzed the data of all acute stroke patients treated with alteplase between October 2003 and December 2010, contributed to the Safe Implementation of Thrombolysis for Stroke registry from 27 Polish stroke centers. According to the time of admission we distinguished between: (1) non-working days (Friday 14:30-Monday 08:00 plus national holidays); (2) out-of-office hours (non-working days plus 14:30-08:00 during working days); and (3) night hours (time from 23:00 to 06:00). Patients admitted during regular working hours (Monday 08:00-Friday 14:30, excluding national holidays) were used as the reference. RESULTS Of 1330 patients, 448 (32.5%) were admitted on non-working days, 868 (65.3%) at out-of-office hours, and 105 (7.9%) during night hours. In multivariate logistic regression, none of the evaluated periods showed association with symptomatic intracranial hemorrhage, 7-day mortality, and neurological improvement ≥4 points in the National Institutes of Health Stroke Scale score at day 7. Patients admitted during night hours had lower odds (OR 0.53, 95% CI: 0.29-0.95, p=0.032) for achieving favorable outcome (modified Rankin Scale score 0-2). CONCLUSIONS There is no bad time for thrombolysis. Stroke centers should feel confident about the treatment outside regular working hours, irrespective of equipment and staff availability. However, it may be reasonable to pay additional attention during nighttime.

The impact of demographic and logistic factors on effectiveness and safety of IV thrombolysis in patients with acute ischemic stroke in a rural hospital in southeastern Poland.

Intravenous thrombolysis (IV thrombolysis) with recombinant tissue plasminogen activator (rt-PA) is an effective therapy for acute ischemic stroke (AIS) (1). Only a few studies have reported on the safety and efficacy of thrombolytic therapy in patients from rural regions (2,3). In the region of our stroke unit (SU), air transport and telemedicine systems are not used in routine practice. Despite this, many patients reach the hospital in the critical ‘time window’, allowing the use of rt-PA. Sandomierz is a small town located in southeast Poland. Our SU cares for a population of 238 000 living in three districts: Sandomierz, Opatów, and Tarnobrzeg township. Approximately 63·4% of residents live in rural areas (RAs). We cooperate with five neighboring hospitals (NH). Between 2006 and 2012 in our SU, 1728 patients with AIS were treated, including 280 patients (16·2%) treated with IV thrombolysis (aged 41–92, mean 70·12 ± 11·12). We treated 41·8% of patients from regions of NH, 65·8% of whom were transported through emergency departments (EDs) of NH. We studied the results of treatment of rural and urban populations and impact of the delayed transport on safety and effectiveness of IV thrombolysis. In the sub-group of patients from urban areas, there was a higher rate of good long-term functional outcome (P = 0·154). The presence of hemorrhagic transformation and symptomatic intracerebral hemorrhage was similar in both groups (P = 0·74 and P = 0·47, respectively); however, mortality was higher in patients from RAs (P = 0·06). In the group of patients who was transported through ED of NH, we found a lower incidence of good outcome at three-months (P = 0·044) and higher mortality (P = 0·029). In multivariate regression, we confirmed these correlations (Table 1). Transportation of patients with AIS to a local hospital results in delay of treatment initiation (4,5). Delivery of patients directly to hospitals with an SU gives them a better chance for good long-term outcome and lower mortality rate.