Escala PAINAD: adaptación y validación en pacientes no comunicativos hospitalizados e impacto de una intervención formativa a enfermeras para su administración

[spa] INTRODUCCIÓN: El dolor tiene un gran impacto en los pacientes hospitalizados y es un indicador de calidad de los cuidados de enfermería. La escala Pain Assessment in Advanced Dementia (PAINAD) valora el dolor en personas con trastornos de comunicación y con demencia avanzada, pero no ha sido validada en una población distinta a ésta. Los hospitales públicos de Cataluña (España) recomiendan utilizar su versión española (PAINAD-Sp), para evaluar el dolor en pacientes adultos que no se pueden comunicar. Aunque, desde su implementación en los planes de cuidados en el año 2010 no se ha realizado ningún programa de formación a los profesionales de enfermería, contribuyendo a su infrautilización. OBJETIVOS: I. Adaptar y validar la escala PAINAD-Sp en pacientes hospitalizados con trastornos neurológicos y pacientes oncológicos en situación de últimos días con dificultad para comunicar el dolor de forma verbal y motora. II. Evaluar el impacto de una intervención formativa a enfermeras en la utilización de la escala PAINAD-Sp en pacientes adultos hospitalizados con dificultad para comunicar el dolor. METODOLOGÍA: De acuerdo con los objetivos principales se diseñaron dos estudios: I. ESTUDIO PSICOMÉTRICO DESCRIPTIVO TRANSVERSAL. La validación de la escala se desarrolló en dos fases: (1) Análisis de contenido por un comité de expertos. En el período de septiembre-diciembre 2016 se llevó a cabo la fase 1. Se formó un comité de diez expertos en el ámbito neurológico, oncológico y del dolor. Cada experto evaluó los cinco ítems de la escala en términos de claridad y relevancia de acuerdo a una escala descriptiva de cuatro puntos (1=no apropiado, 2 =poco apropiado, 3=moderadamente apropiado, 4=completamente apropiado). Se calculó el índice de validez de contenido para cada ítem para verificar que el 80% de los expertos asignaba una puntuación de 3 o 4 puntos. La versión final se nombró escala PAINAD-Sp_Hosp. (2) validación de las propiedades psicométricas de la escala PAINAD-Sp_Hosp. Se llevó a cabo de enero- diciembre 2017 en las unidades de hospitalización del Hospital Universitari Germans Trias i Pujol, Institut Català d’Oncologia Badalona, Hospital Universitari Vall d’Hebron y Hospital Universitari de Bellvitge. El estudio transversal incluyó 325 pacientes que fueron evaluados simultáneamente por dos observadores tanto en reposo como en movimiento. Se analizaron las propiedades psicométricas en términos de validez de constructo, fiabilidad, y sensibilidad al cambio. II: ESTUDIO ANTES-DESPUÉS INTERVENCIÓN NO CONTROLADO. Se evaluó el uso de la escala PAINAS-Sp durante dos períodos de seis meses, antes y después de la intervención formativa online a enfermeras durante febrero de 2017 en dos hospitales públicos. Los datos se obtuvieron de los registros de pacientes de cada centro. La variable resultado fue el número de pacientes evaluados mediante la escala PAINAD-Sp durante el ingreso. Las variables secundarias fueron: el número de evaluaciones realizadas por paciente durante el ingreso, la puntuación total en la escala (0-10) y específica por ítem (0-2) y el tratamiento farmacológico administrado. RESULTADOS: I. Se obtuvo un alfa de Cronbach superior a 0,70 en ambas situaciones y una fiabilidad interobservador de 0,80. El análisis factorial confirmatorio mostró que el modelo se ajusta adecuadamente a una estructura unidimensional. En relación a la sensibilidad al cambio, la media de las diferencias fue superior durante la movilización que en situación de reposo (diferencia de medias fue de 1,15). II. Participaron un total de 401 enfermeras en la intervención formativa. En el período a estudio un total de 219 pacientes hospitalizados fueron evaluados mediante la escala PAINAD-Sp: 29 en el periodo pre-intervención y 190 post-intervención (p<.001). La administración de analgésicos y antipiréticos disminuyó (p<.001) después de la intervención formativa, mientras que el uso de hipnóticos y sedantes en pacientes se incrementó. CONCLUSIONES: La escala PAINAD-Sp_Hosp mostró buenas propiedades psicométricas en términos de validez y fiabilidad en pacientes neurológicos y oncológicos incapaces de comunicar el dolor por sí mismos. La realización de formación teórico-práctica puede ser una manera eficaz de mejorar las actitudes de las enfermeras frente a la identificación, evaluación y abordaje del dolor en pacientes con dificultad para comunicar el dolor.[eng] BACKGROUND: Pain has a significant impact on hospitalized patients and is a quality indicator for nursing care. The Pain Assessment in Advanced Dementia (PAINAD) scale measures pain in people with communication disorders and advanced dementia, but it has not been validated in any other population. Public hospitals in Catalonia (Spain) recommend using the Spanish version of the Pain Assessment in Advanced Dementia (PAINAD-Sp) scale for assessing pain in adult patients unable to self-report. However, since its inclusion in Catalonian nursing care plans in 2010, there have been no training programs for nurses, contributing to its current underuse. OBJECTIVES: I. Adapt and validate the PAINAD-Sp scale in hospitalized patients with neurological disorders and in end-of-life cancer patients with difficulty self-reporting. II. Assess the impact of a nurse training intervention to nurses on the use of the PAINAD-Sp scale in hospitalized patients with neurological disorders and in end-of-life cancer patients with difficulty self-reporting. METHODS: Two studies were designed according to the main objectives: I. CROSS-SECTIONAL STUDY. The validation study of the scale had two phases: (1) analysis of the content by a committee of experts. Phase 1 took place from September to December 2016. The committee involved ten experts from various areas of specialization: neurology, oncology and pain. Each expert evaluated the five items of the scale in terms of clarity and relevance according to a four-point descriptive scale (1 = not appropriate, 2 = somewhat appropriate, 3 = moderately appropriate, 4 = completely appropriate). It was employed a content validity index (CVI) to verify that at least 80% of the consulting experts assigned a score of 3 or 4. The final version was dubbed the PAINAD-Sp_Hosp scale. (2) Validation of the psychometric properties of the PAINAD-Sp_Hosp. We collected phase 2 data from January 2017 to December 2017 in four hospitals in Barcelona: Hospital Universitari Germans Trias i Pujol, Institut Català d’Oncologia Badalona, Hospital Universitari Vall d’Hebron, and Hospital Universitari de Bellvitge. The cross-sectional study included 325 patients who were simultaneously evaluated by two observers both at rest and in movement. We analyzed psychometric properties in terms of construct validity, reliability and sensitivity to change. II: UNCONTROLLED BEFORE-AFTER STUDY DESIGN. It was evaluated the use of the PAINAD- Sp scale over two six-month periods before and after an online training intervention for nurses in February 2017, in two public hospitals. Data were collected from patient records in each center. The primary outcome was the number of patients receiving PAINAD-Sp assessments during admission. Secondary outcomes were: the number of assessments undertaken per patient during admission, the total (0 to 10) and item- specific (0 to 2) PAINAD-Sp score, and pharmacological treatment administered. RESULTS: I. We obtained Cronbach alpha > 0.70 in both situations and an inter-rater reliability of 0.80. Confirmatory factor analysis indicated that the model adjusted adequately to a unidimensional structure. In terms of sensitivity to change, the mean difference was greater in movement than at rest (difference in means was 1.15). II. There were 401 nurses who took part in the training program. Over the study period, 219 patients received PAINAD-Sp assessments: 29 in the pre-intervention period and 190 in the post-intervention period (p <.001). Administration of analgesics and antipyretics decreased (p < .001) after the intervention, while use of hypnotic drugs and sedatives increased. CONCLUSIONS: The PAINAD-Sp_Hosp scale had good psychometric qualities in terms of validity and reliability in neurology and oncology patients unable to self-report pain. Theoretical and practical training may be an effective way to improve nurses’ approach to identifying, assessing, and managing pain in patients with difficulty self-reporting

Formación a enfermeras en la valoración del dolor en pacientes con afasia secundaria al ictus

Objetivo: determinar el impacto de una formación dirigida a enfermeras en el uso de la versión española de la escala Pain Assessment in Advanced Dementia en pacientes adultos con afasia secundaria a un ictus. Método: estudio antes y después no controlado. Se realizó una formación teórico-práctica en el uso de la escala a 341 enfermeras. La variable principal fue el número de pacientes con ictus evaluados mediante la escala de dolor durante el ingreso. Para el análisis de las variables se utilizó el test exacto de Fisher para las variables categóricas, y la prueba no paramétrica U de Mann-Whitney para las variables cuantitativas. Resultados: el 99% de las enfermeras contestaron correctamente el test de conocimientos con una nota media de 94.6/100. En el período a estudio un total de 80 pacientes hospitalizados se evaluaron mediante la escala de evaluación de dolor: 23 en el período pre-formación y 57 en el período post-formación. El uso de analgésicos y antipiréticos fue superior en el periodo pre-formación. Solamente se encontraron diferencias estadísticamente significativas en el consumo de hipnóticos y sedantes (p=0,015), siendo superior tras la formación. Conclusiones: La formación en instrumentos de evaluación del dolor es eficaz en el abordaje del dolor de los pacientes afásicos tras sufrir un ictus

Genome-wide association study of white blood cell counts in patients with ischemic stroke

[Background and Purpose] Immune cells play a key role in the first 24h poststroke (acute phase), being associated with stroke outcome. We aimed to find genetic risk factors associated with leukocyte counts during the acute phase of stroke.[Methods] Ischemic stroke patients with leukocyte counts data during the first 24h were included. Genome-wide association study and gene expression studies were performed.[Results] Our genome-wide association study, which included 2064 (Discovery) and 407 (Replication) patients, revealed a new locus (14q24.3) associated with leukocyte counts. After Joint analysis (n=2471) 5 more polymorphisms reached genome-wide significance (P<5×10−8). The 14q24.3 locus was associated with acute stroke outcome (rs112809786, P=0.036) and with ACOT1 and PTGR2 gene expression. Previous polymorphisms associated with leukocyte counts in general-population did not show any significance in our study.[Conclusions] We have found the first locus associated with leukocyte counts in ischemic stroke, also associated with acute outcome. Genetic analysis of acute endophenotypes could be useful to find the genetic factors associated with stroke outcome. Our findings suggested a different modulation of immune cells in stroke compared with healthy conditions.Peer reviewe

Early neurological change after ischemic stroke is associated with 90-day outcome

BACKGROUND AND PURPOSE: Large-scale observational studies of acute ischemic stroke (AIS) promise to reveal mechanisms underlying cerebral ischemia. However, meaningful quantitative phenotypes attainable in large patient populations are needed. We characterize a dynamic metric of AIS instability, defined by change in National Institutes of Health Stroke Scale score (NIHSS) from baseline to 24 hours baseline to 24 hours (NIHSSbaseline - NIHSS24hours = ΔNIHSS6-24h), to examine its relevance to AIS mechanisms and long-term outcomes.METHODS: Patients with NIHSS prospectively recorded within 6 hours after onset and then 24 hours later were enrolled in the GENISIS study (Genetics of Early Neurological Instability After Ischemic Stroke). Stepwise linear regression determined variables that independently influenced ΔNIHSS6-24h. In a subcohort of tPA (alteplase)-treated patients with large vessel occlusion, the influence of early sustained recanalization and hemorrhagic transformation on ΔNIHSS6-24h was examined. Finally, the association of ΔNIHSS6-24h with 90-day favorable outcomes (modified Rankin Scale score 0-2) was assessed. Independent analysis was performed using data from the 2 NINDS-tPA stroke trials (National Institute of Neurological Disorders and Stroke rt-PA).RESULTS: For 2555 patients with AIS, median baseline NIHSS was 9 (interquartile range, 4-16), and median ΔNIHSS6-24h was 2 (interquartile range, 0-5). In a multivariable model, baseline NIHSS, tPA-treatment, age, glucose, site, and systolic blood pressure independently predicted ΔNIHSS6-24h (R2=0.15). In the large vessel occlusion subcohort, early sustained recanalization and hemorrhagic transformation increased the explained variance (R2=0.27), but much of the variance remained unexplained. ΔNIHSS6-24h had a significant and independent association with 90-day favorable outcome. For the subjects in the 2 NINDS-tPA trials, ΔNIHSS3-24h was similarly associated with 90-day outcomes.CONCLUSIONS: The dynamic phenotype, ΔNIHSS6-24h, captures both explained and unexplained mechanisms involved in AIS and is significantly and independently associated with long-term outcomes. Thus, ΔNIHSS6-24h promises to be an easily obtainable and meaningful quantitative phenotype for large-scale genomic studies of AIS.</p

Early neurological change after ischemic stroke is associated with 90-day outcome

BACKGROUND AND PURPOSE: Large-scale observational studies of acute ischemic stroke (AIS) promise to reveal mechanisms underlying cerebral ischemia. However, meaningful quantitative phenotypes attainable in large patient populations are needed. We characterize a dynamic metric of AIS instability, defined by change in NIH stroke scale score (NIHSS) from baseline to 24 hours (baseline – 24h = ΔNIHSS(6–24h)), to examine its relevance to AIS mechanisms and long-term outcomes. METHODS: Patients with NIHSS prospectively recorded within 6h after onset and then 24h later were enrolled in the GENISIS (Genetics of Early Neurological InStability after Ischemic Stroke) study. Stepwise linear regression determined variables that independently influenced ΔNIHSS(6–24h). In a subcohort of tPA-treated patients with large vessel occlusion (LVO), the influence of early sustained recanalization and hemorrhagic transformation (HT) on ΔNIHSS(6–24h) was examined. Finally, the association of ΔNIHSS(6–24h) with 90-day favorable outcomes (modified Rankin scale score 0–2) was assessed. Independent analysis was performed using data from the two NINDS tPA stroke trials. RESULTS: For 2555 AIS patients, median baseline NIHSS was 9 (IQR 4–16) and median ΔNIHSS(6–24h) was 2 (IQR 0–5). In a multivariable model, baseline NIHSS, tPA treatment, age, glucose, site and systolic blood pressure independently predicted ΔNIHSS(6–24h) (R(2)=0.15). In the LVO subcohort, early sustained recanalization and HT increased the explained variance (R(2)=0.27), but much of the variance remained unexplained. ΔNIHSS(6–24h) had significant and independent association with 90-day favorable outcome. For the subjects in the two NINDS tPA trials, ΔNIHSS(3–24h) was similarly associated with 90-day outcomes. CONCLUSIONS: The dynamic phenotype, ΔNIHSS(6–24h), captures both explained and unexplained mechanisms involved in AIS, and is significantly and independently associated with long-term outcomes. Thus, ΔNIHSS(6–24h) promises to be an easily obtainable and meaningful quantitative phenotype for large-scale genomic studies of AIS

A multitrait genetic study of hemostatic factors and hemorrhagic transformation after stroke treatment

Thrombolytic recombinant tissue plasminogen activator (r-tPA) treatment is the only pharmacologic intervention available in the ischemic stroke acute phase. This treatment is associated with an increased risk of intracerebral hemorrhages, known as hemorrhagic transformations (HTs), which worsen the patient's prognosis. To investigate the association between genetically determined natural hemostatic factors' levels and increased risk of HT after r-tPA treatment. Using data from genome-wide association studies on the risk of HT after r-tPA treatment and data on 7 hemostatic factors (factor [F]VII, FVIII, von Willebrand factor [VWF], FXI, fibrinogen, plasminogen activator inhibitor-1, and tissue plasminogen activator), we performed local and global genetic correlation estimation multitrait analyses and colocalization and 2-sample Mendelian randomization analyses between hemostatic factors and HT. Local correlations identified a genomic region on chromosome 16 with shared covariance: fibrinogen-HT, P = 2.45 × 10. Multitrait analysis between fibrinogen-HT revealed 3 loci that simultaneously regulate circulating levels of fibrinogen and risk of HT: rs56026866 (PLXND1), P = 8.80 × 10; rs1421067 (CHD9), P = 1.81 × 10; and rs34780449, near ROBO1 gene, P = 1.64 × 10. Multitrait analysis between VWF-HT showed a novel common association regulating VWF and risk of HT after r-tPA at rs10942300 (ZNF366), P = 1.81 × 10. Mendelian randomization analysis did not find significant causal associations, although a nominal association was observed for FXI-HT (inverse-variance weighted estimate [SE], 0.07 [−0.29 to 0.00]; odds ratio, 0.87; 95% CI, 0.75-1.00; raw P =.05). We identified 4 shared loci between hemostatic factors and HT after r-tPA treatment, suggesting common regulatory mechanisms between fibrinogen and VWF levels and HT. Further research to determine a possible mediating effect of fibrinogen on HT risk is needed

Safety and Outcome of Revascularization Treatment in Patients With Acute Ischemic Stroke and COVID-19: The Global COVID-19 Stroke Registry.

BACKGROUND AND OBJECTIVES COVID-19 related inflammation, endothelial dysfunction and coagulopathy may increase the bleeding risk and lower efficacy of revascularization treatments in patients with acute ischemic stroke. We aimed to evaluate the safety and outcomes of revascularization treatments in patients with acute ischemic stroke and COVID-19. METHODS Retrospective multicenter cohort study of consecutive patients with acute ischemic stroke receiving intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) between March 2020 and June 2021, tested for SARS-CoV-2 infection. With a doubly-robust model combining propensity score weighting and multivariate regression, we studied the association of COVID-19 with intracranial bleeding complications and clinical outcomes. Subgroup analyses were performed according to treatment groups (IVT-only and EVT). RESULTS Of a total of 15128 included patients from 105 centers, 853 (5.6%) were diagnosed with COVID-19. 5848 (38.7%) patients received IVT-only, and 9280 (61.3%) EVT (with or without IVT). Patients with COVID-19 had a higher rate of symptomatic intracerebral hemorrhage (SICH) (adjusted odds ratio [OR] 1.53; 95% CI 1.16-2.01), symptomatic subarachnoid hemorrhage (SSAH) (OR 1.80; 95% CI 1.20-2.69), SICH and/or SSAH combined (OR 1.56; 95% CI 1.23-1.99), 24-hour (OR 2.47; 95% CI 1.58-3.86) and 3-month mortality (OR 1.88; 95% CI 1.52-2.33).COVID-19 patients also had an unfavorable shift in the distribution of the modified Rankin score at 3 months (OR 1.42; 95% CI 1.26-1.60). DISCUSSION Patients with acute ischemic stroke and COVID-19 showed higher rates of intracranial bleeding complications and worse clinical outcomes after revascularization treatments than contemporaneous non-COVID-19 treated patients. Current available data does not allow direct conclusions to be drawn on the effectiveness of revascularization treatments in COVID-19 patients, or to establish different treatment recommendations in this subgroup of patients with ischemic stroke. Our findings can be taken into consideration for treatment decisions, patient monitoring and establishing prognosis

Safety and Outcome of Revascularization Treatment in Patients With Acute Ischemic Stroke and COVID-19: The Global COVID-19 Stroke Registry

BACKGROUND AND OBJECTIVES: COVID-19 related inflammation, endothelial dysfunction and coagulopathy may increase the bleeding risk and lower efficacy of revascularization treatments in patients with acute ischemic stroke. We aimed to evaluate the safety and outcomes of revascularization treatments in patients with acute ischemic stroke and COVID-19. METHODS: Retrospective multicenter cohort study of consecutive patients with acute ischemic stroke receiving intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) between March 2020 and June 2021, tested for SARS-CoV-2 infection. With a doubly-robust model combining propensity score weighting and multivariate regression, we studied the association of COVID-19 with intracranial bleeding complications and clinical outcomes. Subgroup analyses were performed according to treatment groups (IVT-only and EVT). RESULTS: Of a total of 15128 included patients from 105 centers, 853 (5.6%) were diagnosed with COVID-19. 5848 (38.7%) patients received IVT-only, and 9280 (61.3%) EVT (with or without IVT). Patients with COVID-19 had a higher rate of symptomatic intracerebral hemorrhage (SICH) (adjusted odds ratio [OR] 1.53; 95% CI 1.16-2.01), symptomatic subarachnoid hemorrhage (SSAH) (OR 1.80; 95% CI 1.20-2.69), SICH and/or SSAH combined (OR 1.56; 95% CI 1.23-1.99), 24-hour (OR 2.47; 95% CI 1.58-3.86) and 3-month mortality (OR 1.88; 95% CI 1.52-2.33).COVID-19 patients also had an unfavorable shift in the distribution of the modified Rankin score at 3 months (OR 1.42; 95% CI 1.26-1.60). DISCUSSION: Patients with acute ischemic stroke and COVID-19 showed higher rates of intracranial bleeding complications and worse clinical outcomes after revascularization treatments than contemporaneous non-COVID-19 treated patients. Current available data does not allow direct conclusions to be drawn on the effectiveness of revascularization treatments in COVID-19 patients, or to establish different treatment recommendations in this subgroup of patients with ischemic stroke. Our findings can be taken into consideration for treatment decisions, patient monitoring and establishing prognosis