Stroke Care in Conflict and War Zones -Peace Saves Lives!

Organised inpatient (stroke unit) care for stroke: network meta-analysis.

See related article, pages 18–23. Stroke unit (SU) care is the only treatment option for acute stroke with proven reduction of death.1 It is also the only intervention that has shown a reduction in long-term dependency, and the majority of stroke patients benefit from this intervention.1 Hence, SU care is by far the most important treatment for stroke patients and the only treatment of acute stroke that has a major impact on the burden of stroke.1–3 It is important to recognize that the organization of stroke services per se plays a key role in improving the overall outcome after a stroke. Despite impressive results, the implementation of SU care is remarkably slow in many countries. A hospital survey from the United States showed that SU care was established at only 38% of the hospitals.4 In a registry of the Canadian Stroke Network, only 31% of stroke patients received care in an SU.5 Similar problems in translating knowledge into practice are also present in many other regions and countries worldwide.6,7 It is mainly the Scandinavian countries that have implemented SUs on a large scale,8 especially Sweden, where >80% of all patients with acute stroke are offered SU care. The positive effects of SU care not only are found in randomized trials but also persist when SUs are implemented in routine clinical practice.9 Hence, the consequences of the lack of a wide implementation of SUs are probably that many stroke patients will die unnecessarily or will become dependent and require long-term institutional …

Protecting health-care workers in the firing line

Organised stroke unit care is provided by multidisciplinary teams that exclusively manage stroke patients in a ward dedicated to stroke patients, with a mobile stroke team or within a generic disability service (mixed rehabilitation ward). To assess the effect of stroke unit care compared with alternative forms of care for people following a stroke. We searched the trials registers of the Cochrane Stroke Group (January 2013) and the Cochrane Effective Practice and Organisation of Care (EPOC) Group (January 2013), MEDLINE (2008 to September 2012), EMBASE (2008 to September 2012) and CINAHL (1982 to September 2012). In an effort to identify further published, unpublished and ongoing trials, we searched 17 trial registers (January 2013), performed citation tracking of included studies, checked reference lists of relevant articles and contacted trialists. Randomised controlled clinical trials comparing organised inpatient stroke unit care with an alternative service. After formal risk of bias assessment, we have now excluded previously included quasi-randomised trials. Two review authors initially assessed eligibility and trial quality. We checked descriptive details and trial data with the co-ordinators of the original trials. We included 28 trials, involving 5855 participants, comparing stroke unit care with an alternative service. More-organised care was consistently associated with improved outcomes. Twenty-one trials (3994 participants) compared stroke unit care with care provided in general wards. Stroke unit care showed reductions in the odds of death recorded at final (median one year) follow-up (odds ratio (OR) 0.87, 95% confidence interval (CI) 0.69 to 0.94; P = 0.005), the odds of death or institutionalised care (OR 0.78, 95% CI 0.68 to 0.89; P = 0.0003) and the odds of death or dependency (OR 0.79, 95% CI 0.68 to 0.90; P = 0.0007). Sensitivity analyses indicated that the observed benefits remained when the analysis was restricted to securely randomised trials that used unequivocally blinded outcome assessment with a fixed period of follow-up. Outcomes were independent of patient age, sex, initial stroke severity or stroke type, and appeared to be better in stroke units based in a discrete ward. There was no indication that organised stroke unit care resulted in a longer hospital stay. Stroke patients who receive organised inpatient care in a stroke unit are more likely to be alive, independent, and living at home one year after the stroke. The benefits were most apparent in units based in a discrete ward. We observed no systematic increase in the length of inpatient stay.

Organised stroke unit care is provided by multidisciplinary teams that exclusively manage stroke patients in a dedicated ward (stroke, acute, rehabilitation, comprehensive), with a mobile stroke team or within a generic disability service (mixed rehabilitation ward). To assess the effect of stroke unit care compared with alternative forms of care for patients following a stroke. We searched the Cochrane Stroke Group trials register (last searched April 2006), the reference lists of relevant articles, and contacted researchers in the field. Randomised and prospective controlled clinical trials comparing organised inpatient stroke unit care with an alternative service. Two review authors initially assessed eligibility and trial quality. Descriptive details and trial data were then checked with the co-ordinators of the original trials. Thirty-one trials, involving 6936 participants, compared stroke unit care with an alternative service; more organised care was consistently associated with improved outcomes. Twenty-six trials (5592 participants) compared stroke unit care with general wards. Stroke unit care showed reductions in the odds of death recorded at final (median one year) follow up (odds ratio (OR) 0.86; 95% confidence interval (CI) 0.76 to 0.98; P = 0.02), the odds of death or institutionalised care (OR 0.82; 95% CI 0.73 to 0.92; P = 0.0006) and death or dependency (OR 0.82; 95% CI 0.73 to 0.92; P = 0.001). Sensitivity analyses indicated that the observed benefits remained when the analysis was restricted to trials that used formal randomisation procedures with blinded outcome assessment. Outcomes were independent of patient age, sex or stroke severity, but appeared to be better in stroke units based in a discrete ward. There was no indication that organised stroke unit care resulted in a longer hospital stay. Stroke patients who receive organised inpatient care in a stroke unit are more likely to be alive, independent, and living at home one year after the stroke. The benefits were most apparent in units based in a discrete ward. No systematic increase was observed in the length of inpatient stay.

Essential Workflow and Performance Measures for Optimizing Acute Ischemic Stroke Treatment in India.

Notable advances have been made in stroke policy and outcomes research over the past year. Policy-relevant gray and published research is included in this review. The advances selected are organized under 3 areas: stroke policy and related evidence, predictive modeling, and quality improvement. ### The Role of Evidence in Stroke Policy Investments Different types of evidence are required at each stage in the development and implementation of large scale stroke strategies. The role of evidence was examined in the development of the Ontario Stroke System (a $30 million per year health policy initiative to improve stroke care in Ontario, Canada). Researchers identified key stages in the implementation process and the various types of evidence mobilized at each stage.1 The value of this research for stroke knowledge translation and policy is that evidence can be systematically organized and shared strategically to achieve policy commitments. ### Strategies for Improving Stroke Care The Helsingborg Declaration 2006 on European Stroke Strategies2 is a consensus document with substantial potential for influencing stroke policy in Europe. The Declaration states that by 2015 all persons in Europe with stroke should have access to a continuum of care in the acute phase including rehabilitation and secondary prevention. Clear goals for improving outcomes, the means to achieve them, and evaluation are outlined. The document also calls for a system to be established to incorporate new research into stroke care. In Canada, work continues on implementing the Canadian Stroke Strategy. The Canadian Stroke Network, a national center of excellence, has been a major contributor in developing research and knowledge translation toward improved policy and care.3 The policy challenge for Canada is that health is a provincial responsibility with substantially different health resources and commitments to stroke in each province. During 2007, several gains were made. For example, the Alberta Provincial Stroke Strategy was developed and a commitment of $1.1 million CDN was …

PurposeAlthough scholars have investigated how social entrepreneurs create and develop social enterprises in the penurious stable environment, how they are created in the penurious unstable environment has yet been overlooked. The purpose of this paper is to address this research gap by exploring how internally displaced individuals, despite the lack of resources, create and develop a social enterprise to serve the other displaced population in the war and conflict zones.Design/methodology/approachUnderpinned by a biographical research design, in-depth interviews with internally displaced individuals who have created social enterprises in the war and conflict zones were undertaken. Three social entrepreneurs were chosen for this study from three different social enterprises that are created by internally displaced individuals to serve the other internally displaced people of three different countries, namely, Pakistan, Afghanistan and Syria.FindingsThe single and cross-case analysis found that internally displaced individuals deploy bricolage strategy, for example, reconfiguration of pre-existing resources and competencies (both internal and external), to start up a social venture in the war and conflict zones. They utilise pre-existing internal resources, mainly human capital, and external resources, through a frugal approach towards resources acquisitions. The authors also found that the displaced social entrepreneurs utilise resources of other displaced individuals, for example, networks, volunteers, local knowledge and financial supports mainly from older arrivals, and develop their own enterprise ecosystem within the host location to co-create and co-develop social enterprise and social values for all of them.Research limitations/implicationsThe findings show that internally displaced individuals utilise bricolage strategies to create and develop socially entrepreneurial venture to serve other internally displaced individuals in the war and conflict zones. As the findings are based on three case studies, for confirmatory approach, a quantitative study with a large sample size is necessary. Furthermore, as the differences in economic, cultural and linguistic in between the home and host locations can have impact on the creation and the development of a social venture, they should be considered in the future studies.Originality/valueThis study contributes to the limited literature and studies on social entrepreneurship, specifically, to the context of unstable penurious environment. It also contributes to the literature on bricolage by extending its application from penurious stable environment to the penurious unstable environment. By exploring what and how internal and external resources are utilised to create and develop a socially entrepreneurial venture in a war and conflict zones, this study has added value to the literature on not only bricolage but also entrepreneurship in war and conflict zones.

Costs of acute stroke care on regular neurological wards: A comparison with stroke unit setting

Organised stroke unit care is provided by multidisciplinary teams that exclusively manage stroke patients in a dedicated ward (stroke ward), with a mobile team (stroke team) or within a generic disability service (a mixed rehabilitation ward). The objective of this review was to assess the effect of stroke unit care compared with alternative forms of care for patients following a stroke. We searched the Cochrane Stroke Group trials register, reference lists of articles and contacted researchers in the field. Randomised and quasi-randomised trials comparing organised inpatient stroke unit care with an alternative service. Two reviewers independently assessed eligibility and trial quality. The principal reviewer conducted a structured interview with the coordinators of unpublished trials. Twenty three trials were included. Compared with alternative services, stroke unit care showed reductions in the odds of death recorded at final (median one year) follow-up (odds ratio 0.86; 95% confidence interval 0.71 to 0.94; P=0.005), the odds of death or institutionalised care (0.80; 0.71 to 0.90; P=0.0002) and death or dependency (0.78; 0.68 to 0.89; P=0.0003). Subgroup analyses indicated that the observed benefits remained when the analysis was restricted to truly randomised trials with blinded outcome assessment. Outcomes were independent of patient age, sex and stroke severity but appeared to be better in stroke units based in a discrete ward. There was no indication that organised stroke unit care resulted in increased hospital stay. Stroke patients who receive organised inpatient care in a stroke unit are more likely to be alive, independent, and living at home one year after the stroke. The benefits were most apparent in units based in a discrete ward. No systematic increase was observed in the length of inpatient stay.

Background: Stroke is a leading cause of death and disability in sub-Saharan Africa with increasing incidence. In Kenya, it is a neglected condition with a paucity of evidence despite its need for urgent care and hefty economic burden. Therefore, we reviewed studies on stroke epidemiology, care, and outcomes in Kenya to highlight existing evidence and gaps on stroke in Kenya.Methods: We reviewed all published studies on epidemiology, care, and outcomes of stroke in Kenya between 1 January 1990 to 31 December 2020 from PubMed, Web of Science, EBSCOhost, Scopus, and African journal online. We excluded case reports, reviews, and commentaries. We used the Newcastle-Ottawa scale adapted for cross-sectional studies to assess the quality of included studies.Results: Twelve articles were reviewed after excluding 111 duplicates and 94 articles that did not meet the inclusion criteria. Five studies were of low quality, two of medium quality, and five of high quality. All studies were hospital-based and conducted between 2003 and 2017. Of the included studies, six were prospective and five were single-center. Stroke patients in the studies were predominantly female, in their seventh decade with systemic hypertension. The mortality rate ranged from 5 to 27% in-hospital and 23.4 to 26.7% in 1 month.Conclusions: Our study highlights that stroke is a significant problem in Kenya, but current evidence is of low quality and limited in guiding policy development and improving stroke care. There is thus a need for increased investment in hospital- and community-based stroke care and research.

Stroke disease is associated with considerable morbidity and mortality. In the UK an estimated 150 000 people suffer from stroke each year and stroke is the third most common cause of death in England and Wales after heart disease and cancer.1 In Ireland there are approximately 10 000 acute strokes annually and it is estimated that there are 30 000 people living with disability post stroke. The population of people over 65 years is set to increase (15% of population over 65 by 2021) and total stroke costs in 2021 are estimated to increase by 50% in comparison with 2007. This increase in the number of people suffering from strokes will place additional pressure on an already over-burdened healthcare system. In these economically challenging times it is crucial that stroke care is delivered in an efficient and cost effective manner. Stroke care alone contributes between 2% and 4% to the total health budget; of which 40% is spent on nursing home care. Improvements in the acute delivery of stroke care and rehabilitation could have a significant impact by reducing the number of nursing home placements.2 In the UK National Sentinel Stroke Audit 2006 a stroke unit was defined as a multidisciplinary team including specialist nursing staff based in a discrete ward that has been designated for stroke patients.3 Studies evaluating stroke units in the 1960s in the UK showed that they did not meet their primary outcome measure of decreased mortality for stroke patients. Thus many evolved as rehabilitation units or were subsumed into another ward.4,5 In 1993 Langhorne et al. 6 looked at all randomized control trials on stroke unit care between 1962 and 1993 and found that there was a significant reduction in mortality for patients treated in stroke units versus care on general wards. …

BackgroundStroke is a leading cause of death and disability but there is little information on the longer-term needs of patients and those of different ethnic groups.ObjectivesTo estimate risk of stroke, longer-term needs and outcomes, risk of recurrence, trends and predictors of effective care, to model cost-effective configurations of care, to understand stakeholders’ perspectives of services and to develop proposals to underpin policy.DesignPopulation-based stroke register, univariate and multivariate analyses, Markov and discrete event simulation, and qualitative methods for stakeholder perspectives of care and outcome.SettingSouth London, UK, with modelling for estimates of cost-effectiveness.ParticipantsInner-city population of 271,817 with first stroke in lifetime between 1995 and 2012.Outcome measuresStroke incidence rates and trends, recurrence, survival, activities of daily living, anxiety, depression, quality of life, appropriateness and cost-effectiveness of care, and qualitative narratives of perspectives.Data sourcesSouth London Stroke Register (SLSR), qualitative data, group discussions.ResultsStroke incidence has decreased since 1995, particularly in the white population, but with a higher stroke risk in black groups. There are variations in risk factors and types of stroke between ethnic groups and a large number of strokes occurred in people with untreated risk factors with no improvement in detection observed over time. A total of 30% of survivors have a poor range of outcomes up to 10 years after stroke with differences in outcomes by sociodemographic group. Depression affects over half of all stroke patients and the prevalence of cognitive impairment remains 22%. Survival has improved significantly, particularly in the older black groups, and the cumulative risk of recurrence at 10 years is 24.5%. The proportion of patients receiving effective acute stroke care has significantly improved, yet inequalities of provision remain. Using register data, the National Audit Office (NAO) compared the levels of stroke care in the UK in 2010 with previous provision levels and demonstrated that improvements have been cost-effective. The treatment of, and productivity loss arising from, stroke results in total societal costs of £8.9B a year and 5% of UK NHS costs. Stroke unit care followed by early supported discharge is a cost-effective strategy, with the main gain being years of life saved. Half of stroke survivors report unmet long-term needs. Needs change over time, but may not be stroke specific. Analysis of patient journeys suggests that provision of care is also influenced by structural, social and personal characteristics.Conclusions/recommendationsThe SLSR has been a platform for a range of health services research activities of international relevance. The programme has produced data to inform policy and practice with estimates of need for stroke prevention and care services, identification of persistent sociodemographic inequalities in risk and care despite a reduction in stroke risk, quantification of the effectiveness and cost-effectiveness of care and development of models to simulate configurations of care. Stroke is a long-term condition with significant social impact and the data on need and economic modelling have been utilised by the Department of Health, the NAO and Healthcare for London to assess need and model cost-effective options for stroke care. Novel approaches are now required to ensure that such information is used effectively to improve population and patient outcomes.FundingThe National Institute for Health Research Programme Grants for Applied Research programme and the Department of Health via the National Institute for Health Research Biomedical Research Centre award to Guy’s and St Thomas’ NHS Foundation Trust in partnership with King’s College London.

To (1) investigate the organisation, provision and practice of oral care in typical UK stroke units; (2) explore stroke survivors', carers' and healthcare professionals' experiences and perceptions about the barriers and facilitators to receiving and undertaking oral care in stroke units. Cerebrovascular disease and oral health are major global health concerns. Little is known about the provision, challenges and practice of oral care in the stroke unit setting, and there are currently no evidence-based practice guidelines. Cross-sectional survey of 11 stroke units across Greater Manchester and descriptive qualitative study using focus groups and semi-structured interviews. A self-report questionnaire was used to survey 11 stroke units in Greater Manchester. Data were then collected through two focus groups (n = 10) with healthcare professionals and five semi-structured interviews with stroke survivors and carers. Focus group and interview data were recorded, transcribed verbatim and analysed using framework approach. Eleven stroke units in Greater Manchester responded to the survey. Stroke survivors and carers identified a lack of oral care practice and enablement by healthcare professionals. Healthcare professionals identified a lack of formal training to conduct oral care for stroke patients, inconsistency in the delivery of oral care and no set protocols or use of formal oral assessment tools. Oral care post-stroke could be improved by increasing healthcare professionals' awareness, understanding and knowledge of the potential health benefits of oral care post-stroke. Further research is required to develop and evaluate the provision of oral care in stroke care to inform evidence-based education and practice. Development of staff training and education, and evidence-based oral care protocols may potentially benefit patient care and outcomes and be implemented widely across stroke care.

BackgroundWith an increasing burden of stroke, it is essential to minimize the incidence of stroke and improve stroke care by emphasizing areas that bring out the maximum impact. The care situation remains unclear in the absence of a national stroke care registry and a lack of structured hospital-based data monitoring. We conducted this systematic review and meta-analysis to assess the status of stroke care in Nepal and identify areas that need dedicated improvement in stroke care.MethodsA systematic literature review was conducted to identify all studies on stroke epidemiology or stroke care published between 2000 and 2020 in Nepal. Data analysis was done with Statistical Package for Social Sciences (SPSS) and Comprehensive Meta-analysis (CMA-3).ResultsWe identified 2533 studies after database searching, and 55 were included in quantitative and narrative synthesis. All analyses were done in tertiary care settings in densely populated central parts of Nepal. Ischemic stroke was more frequent (70.87%) than hemorrhagic (26.79%), and the mean age of stroke patients was 62,9 years. Mortality occurred in 16.9% (13-21.7%), thrombolysis was performed in 2.39% of patients, and no studies described thrombectomy or stroke unit care.ConclusionThe provision of stroke care in Nepal needs to catch up to international standards, and our systematic review demonstrated the need to improve access to quality stroke care. Dedicated studies on establishing stroke care units, prevention, rehabilitation, and studies on lower levels of care or remote regions are required.