To conduct a systematic review to elucidate the frequency, recovery, and associated outcomes for poststroke aphasia over the long-term.
Using the Cochrane Stroke Strategy, we searched 10 databases, ...13 journals, 3 conferences, and the gray literature.
Our a priori protocol criteria included unselected samples of adult stroke patients from randomized controlled trials or consecutive cohorts. Two independent reviewers rated abstracts and articles for exclusion or inclusion, resolving discrepancies by consensus.
We documented aphasia frequencies by stroke type and setting, and computed odds ratios (ORs) with their 95% confidence intervals (CIs) for outcomes.
We retrieved 2168 citations, reviewed 248 articles, and accepted 50. Median frequencies for mixed stroke (ischemic and hemorrhagic) were 30% and 34% for acute and rehabilitation settings, respectively. Frequencies by stroke type were lowest for acute subarachnoid hemorrhage (9%) and highest for acute ischemic stroke (62%) when arrival to the hospital was ≤3 hours from stroke onset. Articles monitoring aphasia for 1 year demonstrated aphasia frequencies 2% to 12% lower than baseline. Negative outcomes associated with aphasia included greater odds of in-hospital death (OR=2.7; 95% CI, 2.4-3.1) and longer mean length of stay in days (mean=1.6; 95% CI, 1.0-2.3) in acute settings. Patients with aphasia had greater disability from 28 days (OR=1.5; 95% CI, 1.3-1.7) to 2 years (OR=1.7; 95% CI, 1.6-2.0) than those without aphasia. By 2 years, they used more rehabilitation services (OR=1.5; 95% CI, 1.3-1.6) and returned home less frequently (OR=1.4; 95% CI, 1.2-1.7).
Reported frequencies of poststroke aphasia range widely, depending on stroke type and setting. Because aphasia is associated with mortality, disability, and use of health services, we recommend long-term interdisciplinary vigilance in the management of aphasia.
BACKGROUND AND PURPOSE—Guidelines advocate screening all acute stroke patients for dysphagia. However, limited data are available regarding how many and which patients are screened and how failing a ...swallowing screen affects patient outcomes. We sought to evaluate predictors of receiving dysphagia screening after acute ischemic stroke and outcomes after failing a screening test.
METHODS—We used the Ontario Stroke Registry from April 1, 2010, to March 31, 2013, to identify patients hospitalized with acute ischemic stroke and determine predictors of documented dysphagia screening and outcomes after failing the screening test, including pneumonia, disability, and death.
RESULTS—Among 7171 patients, 6677 patients were eligible to receive dysphagia screening within 72 hours, yet 1280 (19.2%) patients did not undergo documented screening. Patients with mild strokes were significantly less likely than those with more severe strokes to have documented screening (adjusted odds ratio, 0.51; 95% confidence interval CI, 0.41–0.64). Failing dysphagia screening was associated with poor outcomes, including pneumonia (adjusted odds ratio, 4.71; 95% CI, 3.43–6.47), severe disability (adjusted odds ratio, 5.19; 95% CI, 4.48–6.02), discharge to long-term care (adjusted odds ratio, 2.79; 95% CI, 2.11–3.79), and 1-year mortality (adjusted hazard ratio, 2.42; 95% CI, 2.09–2.80). Associations were maintained in patients with mild strokes.
CONCLUSIONS—One in 5 patients with acute ischemic stroke did not have documented dysphagia screening, and patients with mild strokes were substantially less likely to have documented screening. Failing dysphagia screening was associated with poor outcomes, including in patients with mild strokes, highlighting the importance of dysphagia screening for all patients with acute ischemic stroke.
Abstract Dickey L, Kagan A, Lindsay MP, Fang J, Rowland A, Black S. Incidence and profile of inpatient stroke-induced aphasia in Ontario, Canada. Objectives To determine the incidence rate of ...inpatient stroke-induced aphasia in Ontario, Canada, and to examine the demographic and clinical characteristics for stroke patients with and without aphasia. Design Age- and sex-specific incidence rates for aphasia in Ontario were calculated using the Ontario Stroke Audit. In addition, data collected from the Registry of the Canadian Stroke Network (RCSN) were used to determine the demographic and clinical characteristics for stroke patients with and without aphasia. Setting All hospitals and regional stroke centers in Ontario, Canada. Participants The Ontario Stroke Audit is a representative weighted sample of more than 3000 stroke inpatients admitted to emergency departments in all hospitals in Ontario within the 2004/2005 fiscal year. RCSN data included a cohort of more than 15,000 consecutive patients presenting with stroke at 12 regional stroke centers in Ontario from 2003 to 2007. Interventions Not applicable. Main Outcome Measures Presence of aphasic symptoms on admission to hospital and at discharge, age and sex, stroke type and severity, severity of disability, services received in hospital, length of stay, and discharge destination. Results Thirty-five percent (1131/3207) of adult patients admitted with a diagnosis of stroke in the province of Ontario during the 2004 to 2005 Ontario Stroke Audit had symptoms of aphasia at the time of discharge. This amounts to an incidence rate of 60 per 100,000 persons per year. Risk of aphasia increased significantly with age. In comparison with nonaphasic stroke patients, patients with aphasia were older, presented with more severe strokes on admission, had more severe disability, and were more frequently discharged to long-term care and/or rehabilitation (unadjusted results). Adjusting for stroke severity, age, sex, comorbidity, and stroke subtype, the presence of aphasia was found to be an independent predictor of longer hospital stays, increased use of rehabilitation services, and higher rates of thrombolytic therapy. Conclusions A significant number of people with stroke experience aphasia, with advancing age associated with a higher risk. The profile and patterns for stroke patients with aphasia differed significantly from those who did not experience aphasia as a residual disability after stroke, particularly in relation to service usage. Given the personal and system cost associated with aphasia, best practices in the area of stroke should include recommendations on how to best serve this population throughout the clinical pathway.
We evaluated the influence of age on the association between sex and the incidence of stroke or transient ischemic attack (TIA) using a population-based cohort from Ontario, Canada.
We followed a ...cohort of adults (≥18 years) without prior stroke from January 1, 2003 (cohort start date) to March 31, 2018, to identify incident events. We calculated hazard ratios (HRs), in women compared to men, of incident stroke or TIA, adjusted for demographics and comorbidities, overall and stratified by stroke type. We calculated piecewise adjusted HRs for each decade of age to evaluate the effect of age on sex differences in stroke incidence.
We followed 9.2 million adults for a median of 15 years and observed 280,197 incident stroke or TIA events. Compared with men, women had an overall lower adjusted hazard of stroke or TIA (HR, 0.82 95% CI, 0.82-0.83), with similar findings across all stroke types except for subarachnoid hemorrhage (HR, 1.29 95% CI, 1.24-1.33). We found a U-shaped association between age and sex differences in the incidence of stroke or TIA: compared with men, the hazard of stroke was higher in women among those aged ≤30 years (HR, 1.26 95% CI, 1.10-1.45), lower among those between ages 40 and 80 years (eg, age 50-59, HR, 0.69 95% CI, 0.68-0.70), and similar among those aged ≥80 years (HR, 0.99 95% CI, 0.98-1.01).
Overall, women have a lower hazard of stroke than men, but this association varies by age and across stroke types. Recognition of age-sex variations in stroke incidence can help guide prevention efforts to reduce stroke incidence in both men and women.
The use of a validated tool for risk assessment to inform hospital discharge, combined with rapid follow-up, led to a lower risk of death or hospitalization for cardiovascular causes within 30 days ...among patients with acute heart failure.
Warfarin is the most effective stroke prevention medication for high-risk individuals with atrial fibrillation, yet it is often underused. This study examined the magnitude of this problem in a large ...contemporary, prospective stroke registry.
We analyzed data from the Registry of the Canadian Stroke Network, a prospective database of consecutive patients with stroke admitted to 12 designated stroke centers in Ontario (2003 to 2007). We included patients admitted with an acute ischemic stroke who (1) had a known history of atrial fibrillation; (2) were classified as high risk for systemic emboli according to published guidelines; and (3) had no known contraindications to anticoagulation. Primary end points were the use of prestroke antithrombotic medications and admission international normalized ratio.
Among patients admitted with a first ischemic stroke who had known atrial fibrillation (n=597), strokes were disabling in 60% and fatal in 20%. Preadmission medications were warfarin (40%), antiplatelet therapy (30%), and no antithrombotics (29%). Of those taking warfarin, three fourths had a subtherapeutic international normalized ratio (<2.0) at the time of stroke admission. Overall, only 10% of patients with acute stroke with known atrial fibrillation were therapeutically anticoagulated (international normalized ratio >/=2.0) at admission. In stroke patients with a history of atrial fibrillation and a previous transient ischemic attack or ischemic stroke (n=323), only 18% were taking warfarin with therapeutic international normalized ratio at the time of admission for stroke, 39% were taking warfarin with subtherapeutic international normalized ratio, and 15% were on no antithrombotic therapy.
In high-risk patients with atrial fibrillation admitted with a stroke, and who were candidates for anticoagulation, most were either not taking warfarin or were subtherapeutic at the time of ischemic stroke. Many were on no antithrombotic therapy. These findings should encourage greater efforts to prescribe and monitor appropriate antithrombotic therapy to prevent stroke in individuals with atrial fibrillation.
It is currently unclear how the shift towards virtual care during the 2019 novel coronavirus (COVID-19) pandemic may have impacted chronic disease management at a population level. The goals of our ...study were to provide a description of the levels of use of virtual care services relative to in-person care in patients with chronic disease across Ontario, Canada and to describe levels of healthcare utilization in low versus high virtual care users.
We used linked health administrative data to conduct a population-based, repeated cross-sectional study of all ambulatory patient visits in Ontario, Canada (January 1, 2018 to January 16, 2021). Further stratifications were also completed to examine patients with COPD, heart failure, asthma, hypertension, diabetes, mental illness, and angina. Patients were classified as low (max 1 virtual care visit) vs. high virtual care users. A time-series analysis was done using interventional autoregressive integrated moving average (ARIMA) modelling on weekly hospitalizations, outpatient visits, and diagnostic tests.
The use of virtual care increased across all chronic disease patient populations. Virtual care constituted at least half of the total care in all conditions. Both low and high virtual care user groups experienced a statistically significant reduction in hospitalizations and laboratory testing at the start of the pandemic. Hospitalization volumes increased again only among the high users, while testing increased in both groups. Outpatient visits among high users remained unaffected by the pandemic but dropped in low users.
The decrease of in-person care during the pandemic was accompanied by an increase in virtual care, which ultimately allowed patients with chronic disease to return to the same visit rate as they had before the onset of the pandemic. Virtual care was adopted across various chronic conditions, but the relative adoption of virtual care varied by condition with highest rates seen in mental health.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Among 2802 patients hospitalized with heart failure, 31 percent had a preserved ejection fraction. These patients, as compared with those with reduced ejection fraction, were more likely to be older ...and female and to have a history of hypertension and atrial fibrillation. However, the presenting features, complications, readmission rates, and mortality rates were similar in the two groups.
Among patients with heart failure, 31 percent had a preserved ejection fraction. These patients were more likely to be older and female and to have a history of hypertension and atrial fibrillation.
Heart failure has classically been considered to be a clinical syndrome associated with cardiac dilatation and impaired cardiac contractility.
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However, studies have found that increasing numbers of patients presenting with clinical heart failure have an ejection fraction of more than 50 percent.
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This entity, which has been termed “heart failure with preserved ejection fraction,” is attributed to abnormalities of diastolic function, although the exact mechanism is debated.
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Prior data suggest that patients who have heart failure with preserved ejection fraction tend to be older, to be female, and to have a history of hypertension.
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OBJECTIVE:We determined whether patient characteristics (age, sex, comorbidities), stroke severity, and quality of care explained a proportion of the association between atrial fibrillation (AF) and ...increased disability and mortality in patients with acute ischemic stroke.
METHODS:The study included a prospective cohort of consecutive patients admitted with acute ischemic stroke included in the Registry of the Canadian Stroke Network (July 1, 2003 to March 31, 2008). Multivariable logistic regression analyses were used to determine the magnitude of association between AF and modified Rankin score 4–5 at discharge, 30-day mortality, and 1-year mortality.
RESULTS:There were 10,528 patients admitted with acute ischemic stroke. AF was associated with an increased risk of severe disability and mortality, but the magnitude of association was substantially attenuated in the full multivariable modelsmodified Rankin score 4–5 at discharge (univariate odds ratio OR 1.74, 95% confidence interval CI 1.57–1.93; multivariable OR 1.19, 95% CI 1.03–1.36), 30-day mortality (univariate OR 2.52, 95% CI 2.25–2.84; multivariable OR 1.36, 95% CI 1.17–1.58), and 1-year mortality (univariate OR 2.41, 95% CI 2.19–2.66; multivariable OR 1.25, 95% CI 1.10–1.42). Older age and increased stroke severity explained most of the association between AF and poor stroke outcomes. We found no association between AF and poor stroke outcomes in patients receiving therapeutic preadmission oral anticoagulant therapy.
CONCLUSIONS:Older age and increased stroke severity explain most of the association between AF and poorer outcomes after acute ischemic stroke. Nonuse of oral anticoagulant therapy represents the most important modifiable care gap to mitigate the association between AF and poor outcomes after ischemic stroke.
Previous studies have found higher stroke case fatality in patients admitted to the hospital on weekends compared to weekdays, but the reasons for this association are not known.
This was a cohort ...study using data from the Registry of the Canadian Stroke Network. We included consecutive patients with acute stroke or TIA seen in the emergency department or admitted to the hospital at 11 stroke centers in Ontario, Canada, between July 1, 2003, and March 30, 2008 (n = 20,657). We compared in-hospital stroke care and 7-day all-cause stroke case fatality rates between patients seen on weekends and weekdays, with adjustment for stroke severity and other baseline factors.
Overall rates of hospital presentation were lower on weekends compared to weekdays, with lower rates of weekend presentation among individuals with minor stroke and TIA compared to those with more severe strokes. Stroke care, including admission to a stroke unit, neuroimaging, and dysphagia screening, was similar in those treated on weekends and weekdays. All-cause 7-day fatality rates were higher in patients seen on weekends compared to weekdays (8.1% vs 7.0%), even after adjustment for age, sex, stroke severity, and comorbid conditions (adjusted hazard ratio 1.12, 95% confidence interval 1.00 to 1.25).
Stroke fatality is higher with weekend compared to weekday admission, even after adjustment for case mix.
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