Systematic Review and Meta-Analysis of Psychosocial Risk Factors for Stroke

Background Several studies have assessed the link between psychosocial risk factors and stroke; however, the results are inconsistent. We have conducted a systemic review and meta-analysis of cohort or case-control studies to ascertain the association between psychosocial risk factors (psychological, vocational, behavioral, interpersonal and neuropsychological) and the risk of stroke. Methods Systematic searches were undertaken in MEDLINE, EMBASE, CINAHL, PsycInfo and the Cochrane Database of Systematic Reviews between 2000 and January 2017. Two reviewers independently screened titles, abstracts and full texts. One reviewer assessed quality and extracted data, which was checked by a second reviewer. For studies that reported risk estimates, a meta-analysis was performed. Results We identified 41 cohort studies and five case-control studies. No neuropsychological papers were found. Overall pooled adjusted estimates showed that all other psychosocial risk factors were independent risk factors for stroke. Psychological factors increased the risk of stroke by 39% (HR 1.39 95% CI:1.27;1.51), vocational by 35% (HR 1.35 95% CI: 1.20;1.51), and interpersonal by 16% (HR 1.16 95% CI:1.03;1.31). and the effects of behavioral factors were equivocal (HR 0.94 95% CI: 0.20;4.31). The meta-analyses were affected by heterogeneity. Conclusions Psychosocial risk factors are associated with an increased risk of strok

Factors affecting thrombolysis in acute stroke: longer door-to-needle (DTN) time in younger people? [Abstract No. 53]

Introduction: Shortening the time to delivery of IV thrombolysis improves patient outcomes and reduces adverse events. This research aimed to explore patient and service delivery factors that increase or decrease DTN time for thrombolysis. Method: We conducted a Service Evaluation from July 2011 to March 2013, using stroke data from SINAP and DASH databases. Data was provided by 6 acute trusts in Lancashire and Cumbria which used telemedicine, and 11 stroke services within the North East of England which instead used face-to-face. Our investigation concentrates on admissions to hospital occurring out of routine working hours, when resources are particularly constrained. Descriptive and inferential analyses, focusing on multivariate Cox regressions models selected using a forward stepwise approach, were then carried out to determine which factors impacted on DTN time, our main outcome variable. Results: After testing alternative specifications, our final model included these potential risk factors: mode of thrombolysis decision-making (either face-to-face or telemedicine); hospital; age; sex. Our results show that DTN time was strongly influenced by patient’s age (p<0.01), with older people receiving thrombolysis more quickly. Among the statistically significant variables, type of hospital (p<0.001) appeared to affect DTN times, together with patient’s sex (p¼0.01), suggesting that males had shorter DTN times. Conclusion: Older age was associated with shorter DTN times, with this effect being independent of other factors. Therefore, our research suggests that age played a predominant role in the delivery of thrombolysis, rather than solely through the choice of assessing acute strokethrough face-to-face or telemedicine

Can an ethics code help to achieve equity in international research collaborations? Implementing the Global Code of Conduct for Research in Resource-Poor Settings in India and Pakistan.

The Global Code of Conduct for Research in Resource-Poor Settings (GCC) aims to stop the export of unethical research practices from higher to lower income settings. Launched in 2018, the GCC was immediately adopted by European Commission funding streams for application in research that is situated in lower and lower-middle income countries. Other institutions soon followed suit. This article reports on the application of the GCC in two of the first UK-funded projects to implement this new code, one situated in India and one in Pakistan. Through systematic ethics evaluation of both projects, the practical application of the GCC in real-world environments was tested. The findings of this ethics evaluation suggest that while there are challenges for implementation, application of the GCC can promote equity in international research collaborations

Delivering motivational interviewing early post stroke: standardisation of the intervention

Background We applied Motivational Interviewing (MI) techniques, early after stroke, to facilitate psychological adjustment to life post-stroke. In our trial, MI-plus-usual-care increased the likelihood of normal mood at 3-months post-stroke, compared to usual-care alone. Whilst appropriate training, manuals, and supervision may increase adherence to core principles of this complex intervention, unintended variability in implementation inevitably remains. We aimed to explore the impact of variability on participant outcome. Methods Using our trial data (411 participants), we explored variation in MI delivery, examining: therapist characteristics (stroke care expertise/knowledge, psychology training); MI content (fidelity to MI techniques assessed with Motivational Interviewing Treatment Integrity code, describing therapist behaviours as MI-consistent, MI-neutral or MI-inconsistent); and MI dose (number/duration of sessions). Results The four MI therapists (two nurses/two psychologists) had varying expertise and MI delivery. Across therapists, mean average session duration ranged 29.5–47.8 min. The percentage of participants completing the per-protocol four sessions ranged 47%–74%. These variations were not related to participant outcome. There were uniformly high frequencies (>99%) of MI-consistent and MI-neutral interactions, and low frequencies (<1%) of MI-inconsistent interactions. Conclusions Variation in therapist characteristics and MI dose did not affect participant outcome. These may have been tolerated due to high fidelity to MI principles

Does the Addition of Non-Approved Inclusion and Exclusion Criteria for rtPA Impact Treatment Rates? Findings in Australia, the UK, and the USA

Background: Strict criteria for recombinant tissue plasminogen activator (rtPA) eligibility are stipulated on licences for use in ischaemic stroke, however, practitioners may also add non-standard rtPA criteria. We examined eligibility criteria variation in 3 English-speaking countries including use of non-standard criteria, in relation to rtPA treatment rates. Methods: Surveys were mailed to 566 eligible hospitals in Australia (AUS), United Kingdom (UK) and the United States (USA). Criteria were pre-classified as standard (approved indication and contraindications ) or non-standard (approved warning or researcher ‘decoy’). Percentage for criterion selection was calculated/compared; linear regression was used to assess the association between use of non-standard criteria and rtPA treatment rates, and to identify factors associated with addition of non-standard criteria. Results: Response rates were 74% AUS, 65% UK, and 68% USA; mean rtPA treatment rates were 8.7% AUS, 12.7% UK and 8.7% USA. Median percentage of non-standard inclusions was 33% (all 3 countries) and included National Institutes of Health Stroke Scale (NIHSS) scores >4, computed tomography (CT) angiography documented occlusion, and favourable CT perfusion. Median percentage of non-standard exclusions was 25% AUS, 28% UK, and 60% USA, and included depressed consciousness, NIHSS>25, and use of antihypertensive infusions. No AUS or UK sites selected 100% of standard exclusions. Conclusions: Non-standard criteria for rtPA eligibility was evident in all three countries and could, in part, explain comparably low use of rtPA. Differences in the use of standard criteria may signify practitioner intolerance for those derived from original efficacy studies that are no longer relevant

Fidelity to a motivational interviewing intervention for those with post-stroke aphasia: A small scale feasibility study

Objective: Depression after stroke is common, and talk-based psychological therapies can be a useful intervention. Whilst a third of stroke survivors will experience communication difficulties impeding participation in talk-based therapies, little guidance exists to guide delivery for those with aphasia. We need to understand how to adapt talk-based therapies in the presence of aphasia. This study aimed to explore the feasibility of motivational interviewing (MI) in people with post-stroke aphasia. Methods: In a small-scale feasibility study, consecutive patients admitted to an acute stroke ward were screened for eligibility. People with moderate to severe aphasia were eligible. Those consenting received an intervention consisting of up to eight MI sessions delivered twice per week over four weeks. Sessions were modified using aids and adaptations for aphasia. Session quality was measured using the Motivational Interviewing Skills Code (MISC) to assess MI fidelity. Results: Three consenting patients identified early post-stroke took part; one male and two females ages ranging between 40s to 80s. Participants attended between five to eight MI sessions over four weeks. Aids and adaptations included visual cues, rating scales and modified reflections incorporating verbal and non-verbal behaviours. Sessions were tailored to individual participant need. Threshold MISC ratings could be achieved for all participants however, ratings were reduced when aids and adaptations were not used. Discussion: This small-scale feasibility study suggests that it is feasible to adapt MI for people with moderate to severe post-stroke aphasia. These findings merit further exploration of adapted MI as an intervention for this patient group. Key words: Stroke; Stroke survivors; Aphasia; Motivational interviewing; Feasibility studies

Oral Care Practices in Stroke: Findings from the UK and Australia

Aims: To examine current practice, perceptions of healthcare professionals and factors affecting provision for oral care post-stroke in the UK and Australia. Background: Poor oral care has negative health consequences for people post-stroke. Little is known about oral care practice in hospital for people post-stroke and factors affecting provision in different countries. Design: A cross-sectional survey. Methods: Questionnaires were mailed to stroke specialist nurses in UK and Australian hospitals providing inpatient acute or rehabilitation care post-stroke. The survey was conducted between April and November 2019. Non-respondents were contacted up to five times. Results: Completed questionnaires were received from 150/174 (86%) hospitals in the UK, and 120/162 (74%) in Australia. A total of 52% of UK hospitals and 30% of Australian hospitals reported having a general oral care protocol, with 53% of UK and only 13% of Australian hospitals reporting using oral care assessment tools. Of those using oral care assessment tools, 50% of UK and 38% of Australian hospitals used local hospital-specific tools. Oral care assessments were undertaken on admission in 73% of UK and 57% of Australian hospitals. Staff had received oral care training in the last year in 55% of UK and 30% of Australian hospitals. Inadequate training and education on oral care for pre-registration nurses were reported by 63% of UK and 53% of Australian respondents. Conclusion: Unacceptable variability exists in oral care practices in hospital stroke care settings. Oral care could be improved by increasing training, performing individual assessments on admission, and using standardised assessment tools and protocols to guide high quality care. The study highlights the need for incorporating staff training and the use of oral care standardised assessments and protocols in stroke care in order to improve patient outcomes

Regional Differences in Post-discharge Stroke Care in India: A Qualitative Study

Background: Stroke is the fourth leading cause of death and fifth leading cause of disability in India. Stroke rehabilitation can reduce mortality and improve outcomes, but India has limited resources to provide comprehensive stroke care after hospitalisation. Consequently, stroke survivors and family carers experience a range of challenges with long-term care and support. Secondary prevention and stroke rehabilitation services are important in post-discharge stroke care; however, there is insufficient information on post-discharge stroke services in India. Aim: This study aims to explore the clinical staff perspectives of post-discharge stroke services across different regions of India. Methods: Semi-structured interviews were undertaken with a purposive sample of health professionals from multidisciplinary stroke teams at the All India Institute of Medical Sciences, New Delhi (North), Baptist Christian Hospital (North-East), Sree Chitra Tirunal Institute for Medical Sciences and Technology (South) between July and August 2021. The interviews were conducted, translated, and transcribed by the research team. Data were analysed thematically using NVivo software. Results: Twenty-six health professionals participated: 9 Nurses, 7 Doctors, 5 Physiotherapists, 2 Speech and Language Therapists, and 1 Social Worker, Dietician, and Palliative Care team member. Four themes were identified: Integrated Inpatient Discharge Care Planning; Patient and Caregiver Engagement; Post-Discharge Care and Support; Resources and Workforce. Conclusion: Patient and caregiver engagement is an integral part of post-discharge processes; however, regional variation exists in the discharge planning, staff, resources, and services available for post-discharge support. Moreover, patient and caregiver challenges vary across geographical locations, educational backgrounds, financial status, family, and support networks

The accuracy of pulse oximetry in measuring oxygen saturation by levels of skin pigmentation: a systematic review and meta-analysis

Background During the COVID-19 pandemic, there have been concerns regarding potential bias in pulse oximetry measurements for people with high levels of skin pigmentation. We systematically reviewed the effects of skin pigmentation on the accuracy of oxygen saturation measurement by pulse oximetry (SpO2) compared with the gold standard SaO2 measured by CO-oximetry. Methods We searched Ovid MEDLINE, Ovid Embase, EBSCO CINAHL, ClinicalTrials.gov, and WHO International Clinical Trials Registry Platform (up to December 2021) for studies with SpO2–SaO2 comparisons and measuring the impact of skin pigmentation or ethnicity on pulse oximetry accuracy. We performed meta-analyses for mean bias (the primary outcome in this review) and its standard deviations (SDs) across studies included for each subgroup of skin pigmentation and ethnicity and used these pooled mean biases and SDs to calculate accuracy root-mean-square (Arms) and 95% limits of agreement. The review was registered with the Open Science Framework (https://osf.io/gm7ty). Results We included 32 studies (6505 participants): 15 measured skin pigmentation and 22 referred to ethnicity. Compared with standard SaO2 measurement, pulse oximetry probably overestimates oxygen saturation in people with the high level of skin pigmentation (pooled mean bias 1.11%; 95% confidence interval 0.29 to 1.93%) and people described as Black/African American (1.52%; 0.95 to 2.09%) (moderate- and low-certainty evidence). The bias of pulse oximetry measurements for people with other levels of skin pigmentation or those from other ethnic groups is either more uncertain or suggests no overestimation. Whilst the extent of mean bias is small or negligible for all subgroups evaluated, the associated imprecision is unacceptably large (pooled SDs > 1%). When the extent of measurement bias and precision is considered jointly, pulse oximetry measurements for all the subgroups appear acceptably accurate (with Arms < 4%). Conclusions Pulse oximetry may overestimate oxygen saturation in people with high levels of skin pigmentation and people whose ethnicity is reported as Black/African American, compared with SaO2. The extent of overestimation may be small in hospital settings but unknown in community settings