Sandy Middleton

Fibrinogen-coated albumin microcapsules reduce bleeding in severely thrombocytopenic rabbits.

Severe thrombocytopenia frequently occurs in patients receiving chemotherapy and in patients with autoimmune disorders. Thrombocytopenia is associated with bleeding, which may be serious and life threatening. Current treatment strategies for thrombocytopenia may require transfusion of allogeneic platelets, which is associated with serious drawbacks. These include the occurrence of anti-platelet antibodies, which may result in refractoriness to further platelet transfusions, and the potential risk of transfer of blood-borne diseases. Therefore, we have recently developed a platelet substitute product (Synthocytes), which is composed of human albumin microcapsules with fibrinogen immobilized on their surface. Here we show that the intravenous administration of these microcapsules not only corrects the prolonged bleeding time in rabbits rendered thrombocytopenic either by anti-platelet antibodies or by chemotherapy, but also reduces bleeding from surgical wounds inflicted in the abdominal skin and musculature. No potential systemic prothrombotic effect of the microcapsules was observed in a model of rabbit venous thrombosis. As for the mechanism of action, experiments with normal and thrombocytopenic human blood in an endothelial cell matrix-coated perfusion chamber demonstrated an interaction between the fibrinogen-coated albumin microcapsules and native platelets. It was shown that the fibrinogen-coated albumin microcapsules could facilitate platelet adhesion to endothelial cell matrix and correct the impaired formation of platelet aggregates in relatively platelet-poor blood. This study indicates that fibrinogen-coated albumin microcapsules can act to improve primary hemostasis under thrombocytopenic conditions and may eventually be a promising agent for prophylaxis and treatment of bleeding in patients with severe thrombocytopenia.

Barriers to the Use of Anticoagulation for Nonvalvular Atrial Fibrillation A Representative Survey of Australian Family Physicians

Background and Purpose— Anticoagulation reduces the risk of stroke in nonvalvular atrial fibrillation yet remains underused. We explored barriers to the use of anticoagulants among Australian family physicians. Methods— The authors conducted a representative, national survey. Results— Of the 596 (64.4%) eligible family physicians who participated, 15.8% reported having a patient with nonvalvular atrial fibrillation experience an intracranial hemorrhage with anticoagulation and 45.8% had a patient with known nonvalvular atrial fibrillation experience a stroke without anticoagulation. When presented with a patient at “very high risk” of stroke, only 45.6% of family physicians selected warfarin in the presence of a minor falls risk and 17.1% would anticoagulate if the patient had a treated peptic ulcer. Family physicians with less decisional conflict and longer-standing practices were more likely to endorse anticoagulation. Conclusion— Strategies to optimize the management of nonvalvular atrial fibrillation should address psychological barriers to using anticoagulation.

Protocol and pilot data for establishing the Australian Stroke Clinical Registry

Background Disease registries assist with clinical practice improvement. The Australian Stroke Clinical Registry aims to provide national, prospective, systematic data on processes and outcomes for stroke. We describe the methods of establishment and initial experience of operation. Methods Australian Stroke Clinical Registry conforms to new national operating principles and technical standards for clinical quality registers. Features include: online data capture from acute public and private hospital sites; opt-out consent; expert consensus agreed core minimum dataset with standard definitions; outcomes assessed at 3 months post-stroke; formal governance oversight; and formative evaluations for improvements. Results Qualitative feedback from sites indicates that the web-tool is simple to use and the user manuals, data dictionary, and training are appropriate. However, sites desire automated data-entry methods for routine demography variables and the opt-out consent protocol has sometimes been problematic. Data from 204 patients (median age 71 years, 54% males, 60% Australian) were collected from four pilot hospitals from June to October 2009 (mean, 50 cases per month) including ischaemic stroke (in 72%), intracerebral haemorrhage (16%), transient ischaemic attack (9%), and undetermined (3%), with only one case opting out. Conclusion Australian Stroke Clinical Registry has been well established, but further refinements and broad roll-out are required before realising its potential of improving patient care through clinician feedback and allowance of local, national, and international comparative data.

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.

Stroke management: updated recommendations for treatment along the care continuum

The Australian Clinical Guidelines for Stroke Management 2010 represents an update of the Clinical Guidelines for Stroke Rehabilitation and Recovery (2005) and the Clinical Guidelines for Acute Stroke Management (2007). For the first time, they cover the whole spectrum of stroke, from public awareness and prehospital response to stroke unit and stroke management strategies, acute treatment, secondary prevention, rehabilitation and community care. The guidelines also include recommendations on transient ischaemic attack. The most significant changes to previous guideline recommendations include the extension of the stroke thrombolysis window from 3 to 4.5 h and the change from positive to negative recommendations for the use of thigh‐length antithrombotic stockings for deep venous thrombosis prevention and the routine use of prolonged positioning for contracture management.

What people say about travelling outdoors after their stroke: A qualitative study

BACKGROUND/AIM Reduced walking ability and loss of confidence are common after stroke. Many people cannot drive or use public transport, which can restrict participation. This qualitative study aimed to explore the experiences and attitudes of people following stroke to travelling outdoors early after hospital discharge. METHODS Two semi-structured interviews were conducted with 19 people post-stroke, all of whom were receiving rehabilitation to increase outdoor travel. Mean age was 68.6 years (SD 11.7years). Eight significant others also participated. Interviews were conducted at home (median 21 days post-discharge), with a second interview three months later. Questions focussed on common destinations, modes of travel including driving when relevant and factors that influenced outdoor travel. Qualitative data were analysed using constant comparative (grounded theory) methods, resulting in themes and categories. RESULTS People with stroke were categorised as either a hesitant or confident explorer, in relation to walking, catching public transport and driving. Factors influencing outdoor travel included their emotional disposition, having meaningful destinations, expectations of recovery and the sphere of influence, including family and therapists. These factors could have an enabling or restricting effect. A pre-stroke walking habit also positively contributed to outdoor travel. Gate-keeping by therapists, general practitioners and family members seemed to adversely affect travel. CONCLUSIONS   This emerging theory offers insights into the experiences and attitudes to outdoor travel of people who were ambulant and participating in community rehabilitation following a stroke. Future research could explore the experiences of people with more severe mobility, cognitive and communication problems.

Care of patients with a diagnosis of chronic obstructive pulmonary disease: a cluster randomised controlled trial.

Objective: To evaluate a partnership model of care for patients with a diagnosis of chronic obstructive pulmonary disease (COPD).

Determinants of successful clinical networks: the conceptual framework and study protocol.

BackgroundClinical networks are increasingly being viewed as an important strategy for increasing evidence-based practice and improving models of care, but success is variable and characteristics of networks with high impact are uncertain. This study takes advantage of the variability in the functioning and outcomes of networks supported by the Australian New South Wales (NSW) Agency for Clinical Innovations non-mandatory model of clinical networks to investigate the factors that contribute to the success of clinical networks.Methods/DesignThe objective of this retrospective study is to examine the association between external support, organisational and program factors, and indicators of success among 19 clinical networks over a three-year period (2006-2008). The outcomes (health impact, system impact, programs implemented, engagement, user perception, and financial leverage) and explanatory factors will be collected using a web-based survey, interviews, and record review. An independent expert panel will provide judgements about the impact or extent of each networks initiatives on health and system impacts. The ratings of the expert panel will be the outcome used in multivariable analyses. Following the rating of network success, a qualitative study will be conducted to provide a more in-depth examination of the most successful networks.DiscussionThis is the first study to combine quantitative and qualitative methods to examine the factors that contribute to the success of clinical networks and, more generally, is the largest study of clinical networks undertaken. The adaptation of expert panel methods to rate the impacts of networks is the methodological innovation of this study. The proposed project will identify the conditions that should be established or encouraged by agencies developing clinical networks and will be of immediate use in forming strategies and programs to maximise the effectiveness of such networks.

Quality in Acute Stroke Care (QASC): process evaluation of an intervention to improve the management of fever, hyperglycemia, and swallowing dysfunction following acute stroke

Background Our randomized controlled trial of a multifaceted evidence-based intervention for improving the inpatient management of fever, hyperglycemia, and swallowing dysfunction in the first three-days following stroke improved outcomes at 90 days by 15%. We designed a quantitative process evaluation to further explain and illuminate this finding. Methods Blinded retrospective medical record audits were undertaken for patients from 19 stroke units prior to and following the implementation of three multidisciplinary evidence-based protocols (supported by team-building workshops, and site-based education and support) for the management of fever (temperature ≥37·5°C), hyperglycemia (glucose >11 mmol/l), and swallowing dysfunction in intervention stroke units. Results Data from 1804 patients (718 preintervention; 1086 postintervention) showed that significantly more patients admitted to hospitals allocated to the intervention group received care according to the fever (n = 186 of 603, 31% vs. n = 74 of 483, 15%, P < 0·001), hyperglycemia (n = 22 of 603, 3·7% vs. n = 3 of 483,0·6%, P = 0·01), and swallowing dysfunction protocols (n = 241 of 603, 40% vs. n = 19 of 483, 4·0%, P ≤ 0·001). Significantly more patients in these intervention stroke units received four-hourly temperature monitoring (n = 222 of 603, 37% vs. n = 90 of 483, 19%, P < 0·001) and six-hourly glucose monitoring (194 of 603, 32% vs. 46 of 483, 9·5%, P < 0·001) within 72 hours of admission to a stroke unit, and a swallowing screen (242 of 522, 46% vs. 24 of 350, 6·8%, P ≤ 0·0001) within the first 24 hours of admission to hospital. There was no difference between the groups in the treatment of patients with fever with paracetamol (22 of 105, 21% vs. 38 of 131, 29%, P = 0·78) or their hyperglycemia with insulin (40 of 100, 40% vs. 17 of 57, 30%, P = 0·49). Interpretation Our intervention resulted in better protocol adherence in intervention stroke units, which explains our main trial findings of improved patient 90-day outcomes. Although monitoring practices significantly improved, there was no difference between the groups in the treatment of fever and hyperglycemia following acute stroke. A significant link between improved treatment practices and improved outcomes would have explained further the success of our intervention, and we are still unable to explain definitively the large improvements in death and dependency found in the main trial results. One potential explanation is that improved monitoring may have led to better overall surveillance of deteriorating patients and faster initiation of treatments not measured as part of the main trial.

Fever, hyperglycaemia and swallowing dysfunction management in acute stroke: A cluster randomised controlled trial of knowledge transfer

BackgroundHyperglycaemia, fever, and swallowing dysfunction are poorly managed in the admission phase of acute stroke, and patient outcomes are compromised. Use of evidence-based guidelines could improve care but have not been effectively implemented. Our study aims to develop and trial an intervention based on multidisciplinary team-building to improve management of fever, hyperglycaemia, and swallowing dysfunction in patients following acute stroke.Methods and designMetropolitan acute stroke units (ASUs) located in New South Wales, Australia will be stratified by service category (A or B) and, within strata, by baseline patient recruitment numbers (high or low) in this prospective, multicentre, single-blind, cluster randomised controlled trial (CRCT). ASUs then will be randomised independently to either intervention or control groups. ASUs allocated to the intervention group will receive: unit-based workshops to identify local barriers and enablers; a standardised core education program; evidence-based clinical treatment protocols; and ongoing engagement of local staff. Control group ASUs will receive only an abridged version of the National Clinical Guidelines for Acute Stroke Management. The following outcome measures will be collected at 90 days post-hospital admission: patient death, disability (modified Rankin Score); dependency (Barthel Index) and Health Status (SF-36). Additional measures include: performance of swallowing screening within 24 hours of admission; glycaemic control and temperature control.DiscussionThis is a unique study of research transfer in acute stroke. Providing optimal inpatient care during the admission phase is essential if we are to combat the rising incidence of debilitating stroke. Our CRCT will also allow us to test interventions focussed on multidisciplinary ASU teams rather than individual disciplines, an imperative of modern hospital services.Trial RegistrationAustralia New Zealand Clinical Trial Registry (ANZCTR) No: ACTRN12608000563369