Search

Background and Purpose-Mobile stroke units (MSUs) are increasingly used worldwide to provide prehospital triage and treatment. The benefits of MSUs in giving earlier thrombolysis have been well established, but the impacts of MSUs on endovascular thrombectomy (EVT) and effect on disability avoidance are largely unknown. We aimed to determine the clinical impact and disability reduction for reperfusion therapies in the first operational year of the Melbourne MSU. Methods-Treatment time metrics for MSU patients receiving reperfusion therapy were compared with control patients presenting to metropolitan Melbourne stroke units via standard ambulance within MSU operating hours. The primary outcome was median time difference in first ambulance dispatch to treatment modeled using quantile regression analysis. Time savings were subsequently converted to disability-adjusted life years avoided using published estimates. Results-In the first 365-day operation of the Melbourne MSU, prehospital thrombolysis was administered to 100 patients (mean age, 73.8 years; 62% men). The median time savings per MSU patient, compared with the control cohort, was 26 minutes (P<0.001) for dispatch to hospital arrival and 15 minutes (P<0.001) for hospital arrival to thrombolysis. The calculated overall time saving from dispatch to thrombolysis was 42.5 minutes (95% CI, 36.0-49.0). In the same period, 41 MSU patients received EVT (mean age, 76 years; 61% men) with median dispatch-to-treatment time saving of 51 minutes ([95% CI, 30.1-71.9], P<0.001). This included a median time saving of 17 minutes ([95% CI, 7.6-26.4], P=0.001) for EVT hospital arrival to arterial puncture for MSU patients. Estimated median disability-adjusted life years saved through earlier provision of reperfusion therapies were 20.9 for thrombolysis and 24.6 for EVT. Conclusions-The Melbourne MSU substantially reduced time to reperfusion therapies, with the greatest estimated disability avoidance driven by the more powerful i

Background: Diagnostic coding is frequently used in stroke research. However, few data exist regarding the accuracy of Transient Ischemic Attack (TIA) codes in Australia. Aim(s): To determine the accuracy of ICD-10 Australian Modification (AM) diagnostic codes assigned to patients with neurologist diagnosed TIA. Method(s): ICD-10AM codes were identified for patients with suspected TIA treated at Monash Medical Centre, Australia (2004-2007). Coding accuracy was assessed against final neurologist diagnosis using the 24-hour criterion (clinical TIA). Assignment of a TIA code of G45.3, G45.8 or G45.9 to a patient with neurologist confirmed TIA was considered true positive and TIA mimics were considered false positives. Result(s): ICD-10AM codes were available for 336/488 (68.9%; 95% Confidence Interval 64.6%-72.8%) patients. Clinical TIA was confirmed in 209/336 (62.2%; 56.9%-67.2%). Evaluation of ICD-10AM codes for clinical TIA revealed: sensitivity 0.76 (0.69-0.81), specificity 0.43 (0.34-0.51), Positive Predictive Value 0.68 (0.62-0.74), Negative Predictive Value 0.51 (0.42-0.61). Mean age was slightly higher in those assigned a TIA code (66.4+/-13.7) compared with a non-TIA code (62.3+/-15.6; p < 0.02). Patients with symptoms lasting less than one hour were more likely to be assigned a TIA code than those with symptoms lasting more than one hour (p < 0.001). Discussion(s): ICD10AM codes are sensitive for clinical TIA, but insufficiently specific. These data may help to estimate measurement error when using administrative datasets for TIA research.

We previously demonstrated the safety and effectiveness of a nonadmission-based model for TIA care (Monash TIA Triaging Treatment [M3T]). In this microcosting study, we used a pre-post cohort design with multivariable uncertainty analyses to compare actual resource utilization costs between M3T (years 2004-2007) and the previous admission-based model (2003). Average total episode costs per patient were significantly less for M3T (Australian dollars [AUD] 1,927.00, 95% confidence interval [CI] AUD 1,829.00-1,037.00) compared with the admission-based model (AUD 4,841.00, 95% CI AUD 4,178.00-5,590.00). Nonadmission care in M3T was substantially costsaving with a median 3 (95% uncertainty interval 0.7-6.0) additional strokes averted per 100 patients treated, based on an observed 90-day stroke rate of 1.50% (95% CI 0.73%-3.05%) and 4.67% (95% CI 2.28%-9.32%) in the admission-based model.Copyright © 2015 American Academy of Neurology.

Introduction: Adherence to secondary prevention recommendations vary. Audit and feedback may be used as an effective means of changing clinician behaviour in general practice. Aim(s): To investigate the usefulness of audit and feedback to improve secondary stroke prevention in primary care. Method(s): General practitioners (GPs) involved in the intervention arm of the Shared Team Approach between Nurses and Doctors for Improved Risk Factor Management (STAND FIRM) randomised controlled trial were invited to participate in an education activity on stroke. GPs attended a seminar on secondary stroke prevention and then were instructed to identify 20 patients with a history of stroke/ TIA in their general practice. The GPs documented stroke risk factors, and the pharmacological and non-pharmacological treatments prescribed to the patients they identified. As an educational reinforcing activity, the participating GPs were instructed to comment on how the management of the audited patients could be improved. Result(s): Six of 14 GPs attending the seminar participated in the clinical audit, providing data for 101 patients. Prescription rates in these patients were 83% for antihypertensives, 79% for antithrombotics, and 75% for cholesterol-lowering medications. Two GPs provided comments on how the management of their 40 audited patients might be improved. These GPs indicated that in 9/40 patients, they would consider prescribing a new prevention medication. Other changes suggested by GPs included: checking medication adherence and providing advice on lifestyle changes. Conclusion(s): Comprehensive education activities permit reflection on clinical practice. GPs identified many areas of their secondary prevention management that could be improved.

Het doel van deze studie was om middels een experimenteel onderzoek meer te weten te komen over het exploratiegedrag van tienjarigen wanneer zij techniektaken uitvoerden. Daarbij is onderzocht wat het verband is tussen exploratietijd en inzichtverwerving, wat het verband is tussen exploratie-intensiteit en inzicht verwerving en hoe sekse deze verbanden beïnvloedt. De gegevens over het exploratiegedrag zijn verkregen middels video-observatie, waarna de gegevens zijn gecodeerd om de exploratie-intensiteit en de mate van inzichtverwerving vast te stellen. Er hebben 38 kinderen van tien jaar oud deelgenomen aan dit onderzoek. De onderzoeksgroep bestond voor 68% uit meisjes en 32% uit jongens. Op basis van de literatuur werd verwacht dat naarmate een kind langer met de techniektaken bezig is, het inzichtniveau toeneemt en de exploratie-intensiteit afneemt; en dat jongens een lagere mate van exploratie-intensiteit en een hoger niveau van inzicht laten zien dan meisjes. Uit de resultaten bleek dat exploratietijd een positief effect heeft op het inzichtniveau. De hypotheses met betrekking tot exploratie-intensiteit konden niet nader worden onderzocht omdat de consistentie van deze gegevens onvoldoende was. Ten slotte bleek dat jongens een hoger inzichtniveau lieten zien dan meisjes. Verder onderzoek is nodig om de gevonden uitkomsten te bevestigen en om de generaliseerbaarheid te vergroten.

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.

Background: it is uncertain as to which measures of gait best predict those who are likely to fall. Our aim was to investigate the associations of gait and gait variability measures with incident falls risk. Method(s): individuals aged 60-86 years (n = 412) were randomly selected from the Tasmanian electoral roll. Average gait and gait variability measures were collected on a computerised walkway. Falls were recorded prospectively over 12 months. Log multinomial regression was used to estimate the relative risk of single and multiple falls associated with gait measures. Covariates included age, sex, sensorimotor and cognitive measures, mood and medications. Result(s): in this population-based study greater intra-individual variability in step length and double-support phase were linearly associated with increased risk of multiple falls (P = 0.04). Non-linear associations with multiple falls were found for gait speed P = 0.002, cadence P = 0.004 and step time variability P = 0.03. None of the gait measures predicted risk of single falls. Conclusion(s): there is an increased risk of multiple falls, but not single falls, in older people with poorer gait. Specific measures of gait and gait variability seem to confer this risk and may be amenable to interventions designed to reduce the risk of multiple falls in older people. © The Author 2011. Published by Oxford University Press on behalf of the British Geriatrics Society.

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.

Objective: To determine the predictive value of the ABCD2 score for early risk of stroke in Australian patients who have had transient ischaemic attack (TIA). Design, participants and setting: Cohort study of 512 consecutive patients with suspected TIA referred by the emergency department to the acute stroke unit (in accordance with the TIA pathway) of an urban tertiary hospital in Melbourne, Victoria, between 1 June 2004 and 30 November 2007. Main Outcome Measure(s): Overall accuracy, estimated by the area under the curve (AUC) of receiver operating characteristic plots (of true positive rate v false positive rate), and sensitivity, specificity, predictive values and likelihood ratios at prespecified cut-off ABCD2 scores for stroke within 2, 7 and 90 days. Result(s): 24 patients were excluded because their symptoms lasted more than 24 hours. All included patients were reviewed by a stroke physician; TIA was confirmed in 301/488 (61.7%). Most (289/301; 96.0%) had complete follow-up. Stroke occurred in 4/292 patients (1.37%; 95% CI, 0.37%-3.47%) within 2 days and 7/289 (2.42%; 95% CI, 0.98%-4.93%) within 90 days; no patient had a stroke between 2 and 7 days. The AUCs for stroke in patients with confirmed TIA were 0.80 (95% CI, 0.68-0.91) and 0.62 (95% CI, 0.40-0.83) for stroke within 2 days and 90 days, respectively. At a cut-off of >=5, the ABCD2 score had modest specificity for stroke within 2 days (0.58) and 90 days (0.58), but positive predictive values (2 days, 0.03; 90 days, 0.04) and positive likelihood ratios (2 days, 2.40; 90 days, 1.71) were both poor. The score performed similarly poorly at other prespecified cut-off scores. Conclusion(s): Given its poor predictive value, the use of the ABCD2 score alone may not be dependable for guiding clinical treatment decisions or service organisation in an Australian tertiary setting. Validation in other Australian settings is recommended before it can be applied with confidence.

Background: The ABCD2 score is recommended by several stroke guidelines to stratify stroke risk after TIA and aid in management decisions. There are however, conflicting reports regarding its accuracy in clinical practice. Aim(s): To assess ABCD2 score predictive ability when dichotomised at commonly used cut-offs. Method(s): Medline, PubMed, Embase, conference programmes and manuscript references were searched for articles published January 2005 to May 2010. Authors were invited to contribute additional data. Using random effects meta-analysis, pooled positive (PLR) and negative (NLR) likelihood ratios were determined as estimates of predictive capacity for stroke at 2, 7, 30 and 90 days after TIA. Heterogeneity was evaluated using meta-regression. Result(s): Data were available for 27 studies (13,443 patients). Dichotomising the score at 3 (0-3 low risk, 4-7 high risk), pooled PLRs at day 2, 7, 30 and 90 were 1.40 (95%CI 1.28-1.53), 1.43 (1.32-1.55), 1.30 (1.19-1.42) and 1.38 (1.29-1.48) respectively. Corresponding pooled NLRs were 0.39 (95%CI 0.30-0.50), 0.39 (0.30-0.50), 0.51 (0.23-1.15) and 0.41 (0.34-0.48). There was significant PLR heterogeneity across all cut-offs (P < 0.01, I2 > 50%). Random error explained the majority of NLR heterogeneity. Conclusion(s): In this pooled analysis of likelihood ratios, the ABCD2 score had limited capacity to confidently assign risk of early stroke.