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Objectives: To assess the prevalence of and reasons for barriers to discharge from inpatient rehabilitation, to measure the resulting additional days in hospital, and to determine if these were predicted by key demographic or clinical variables. Design, setting and participants: Prospective open cohort study of 360 patients admitted into two inpatient rehabilitation units in Melbourne over an 8-month and a 10-month period in 2008. Main Outcome Measure(s): Occurrence of discharge barriers, their causes and the duration of unnecessary hospitalisation. Result(s): There were 360 patients in the study sample, 186 were female (51.7%), and mean age was 58.4 years. Fifty-nine (16.4%) patients had a discharge barrier. The most frequent causes of discharge barriers were patients being nonweight bearing after lower limb fracture, family deliberations about discharge planning, waiting for home modifications and waiting for accommodation. Patients with acquired brain damage and lower limb fracture were the impairment groups most likely to experience a discharge barrier. Over the study period, 21.0% (3152/14976) of all bed-days were occupied by patients deemed to have a discharge barrier. Regression analysis showed that age, sex, impairment group and dependency level on admission all influenced the occurrence of a discharge barrier. Although regression analysis showed that dependency on admission and age group were significant predictors of additional days in hospital resulting from discharge barriers (P = 0.006), these variables explained only 11% of the additional bed-days. Conclusion(s): Barriers to discharge from inpatient rehabilitation are common and substantial, and they represent an important opportunity for improvement.

Background and Purpose-Controversy surrounds the need for routine hospital admission for transient ischemic attack. The Monash Transient Ischemic Attack Triaging Treatment (M3T) model adopts rapid management in the emergency department followed by outpatient management prioritized by stroke mechanism. We compared safety and processes of care between M3T and the previous model of routine admission. Methods-Study cohorts consisted of patients managed with M3T (2004-2007) and the previous model (2003-2004). We determined 90-day stroke outcome using clinical and medical record review and data linkage to the population level state-wide hospital discharge morbidity database. We compared models of care using risk difference analysis, followed by logistic regression to adjust for previous indicators of risk. Secondary outcomes were proportions admitted, proportions undergoing carotid ultrasound, times to ultrasound and revascularization, and medication prescription. Results-In M3T (mean age, 64.7+/-14.7) 85/488 (17.4%) patients were admitted compared with 117/169 (62.9%) in the previous model (mean age, 72.5+/-13.9). With near-complete follow-up, 90-day stroke outcome was 1.50% (95% confidence interval, 0.73%-3.05%) in M3T and 4.67% (95% confidence interval, 2.28%-9.32%) in the previous model (P=0.03). Compared with the previous model, the adjusted odds ratio of stroke for M3T was 0.46 (95% confidence interval, 0.12-1.68; P=0.24). M3T was associated with greater proportions undergoing carotid ultrasound (P<0.001) and receiving antiplatelet therapy (P=0.005). Conclusions-The M3T system was associated with low 90-day stroke outcome in transient ischemic attack patients, providing proof of concept that these patients may be managed safely without routine hospital admission using a closely supervised protocol in the emergency department. © 2012 American Heart Association, Inc.

Objective: Accurate prediction of neurologic outcome after hypoxic coma is important. Previous systematic reviews have not used summary statistics to summarize and formally compare the accuracy of different prognostic tests. We therefore used summary receiver operating characteristic curve (SROC) and cluster regression Methods to compare motor and pupillary responses with sensory evoked potential (SEP) and EEG in predicting outcome after hypoxic coma. Method(s): We searched PubMed, MEDLINE, and Embase (1966-2007) for reports in English, German, and French and identified 25 suitable studies. An SROC was constructed for each marker (SEP, EEG, M1 and M<=3), and the area under the curve (AUC), a measure of diagnostic accuracy, was determined. For comparison, we calculated the differences between the AUC for each test and M1 reference standard. Result(s): The AUC for absent SEP was larger than those for M1, M<=3, absent pupillary response, and EEG when the examinations were performed within the first 24 hours. The difference between the AUC for SEP (AUC 0.891) and that for M1 (AUC 0.786) was small (0.105, 95% confidence interval 0.023-0.187), only reaching significance on day 1 after coma onset. The use of M<=3 improved the diagnostic accuracy of motor signs. Conclusion(s): This study demonstrated that sensory evoked potential (SEP) is marginally better than M1 at predicting outcome after hypoxic coma. However, the superiority of SEP diminishes after day 1 and when M<=3 is used. The findings therefore caution against the tendency to generalize that SEP is a better marker than clinical signs. © 2010 by AAN Enterprises, Inc.

Objective: To study the accuracy of the ABCD2 score in predicting early stroke risk following TIA and to model post-test probability of stroke for varying cutoff scores and baseline stroke risk. Method(s): Medline, PubMed, Embase, conference proceedings, and manuscript references up to October 2010 were searched for studies reporting ABCD2 score and stroke outcome after TIA. Additional data were requested from authors. Meta-analysis, meta-regression, and post-test probability modeling were undertaken to assess prediction of stroke at 2, 7, and 90 days. Result(s): Of 44 eligible studies, data were available for 33(16,070 patients):26/33 reported stroke at 2 days (533 strokes), 32/33 at 7 days (781 strokes), and 28/33 at 90 days (1,028 strokes) after TIA. Using scores 0-3 ("low risk") and 4-7 ("high risk") for stroke at 7 days, pooled measures were sensitivity 0.89 (0.87-0.91), specificity 0.34 (0.33-0.35), positive predictive value 0.08 (0.07-0.09), negative predictive value 0.98 (0.98-0.98), positive likelihood ratio (PLR) 1.43 (1.33-1.54), negative likelihood ratio (NLR) 0.40 (0.33-0.50), and area under the curve (AUC) 0.70 (0.62-0.78). Results were similar at days 2 and 90. There was moderate heterogeneity while pooling PLR (p < 0.01, I2 >50%), with stroke specialist TIA diagnosis associated with slightly higher PLR. At 5% baseline stroke risk, ABCD2 >3 indicated an absolute increase in 7-day stroke risk of only 2.0% while a score <=3 indicated a 2.9% decrease in risk. Changes in risk were very small when baseline stroke risk was lower. Conclusion(s): The ABCD2 score leads to only small revisions of baseline stroke risk particularly in settings of very low baseline risk and when used by nonspecialists. Copyright © 2012 by AAN Enterprises, Inc.

Background: Patients on dialysis for end-stage renal failure (ESRF) are undergoing cardiac surgery with increasing frequency. Furthermore, ESRF is known to be an important risk factor for complications of cardiac operations performed with cardiopulmonary bypass. Aim(s): To evaluate the outcome of dialysis-dependent patients undergoing cardiac surgery at one institution. Method(s): A retrospective analysis was performed on consecutive patients with ESRF dependent upon maintenance haemodialysis or peritoneal dialysis who underwent cardiac surgery from January 1998 to August 2002. Result(s): Thirty-eight patients on dialysis underwent cardiac surgery during this time period (1.5% of total cases). The most common cause for ESRF was diabetic nephropathy (n = 12). Operations performed included isolated coronary artery bypass grafting (CABG, n = 22), CABG and valve surgery (n = 8), and valve surgery alone (n = 6). When allowing for age, sex, surgeon and operative category, the odds ratio for mortality risk of dialysis patients, compared with all others, was 4.9 (95% confidence interval (CI): 1.7-13.9, p = 0.003), and for morbidity risk, was 2.8 (95% CI: 1.4-5.4, p = 0.003). Conclusion(s): Patients on dialysis have an increased morbidity and mortality following cardiac surgery, however we believe ESRF should not be regarded as an absolute contraindication to cardiac surgery or cardiopulmonary bypass. © 2005 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.