Acute Hospital Treatment Research Articles

Effect of comprehensive geriatric assessment on hospitalizations in older adults with frailty initiating curatively intended oncologic treatment: The PROGNOSIS-RCT study

IntroductionFrailty constitutes a risk for unplanned hospitalizations in older adults with cancer. This study examines whether comprehensive geriatric assessment (CGA) as an add-on to standard oncologic care can prevent unplanned hospitalizations in older adults with frailty and cancer who initiate curative oncological treatment. Materials and MethodsThis randomized controlled trial included older adults aged ≥70 with frailty (Geriatric 8 [G8] ≤14), and solid cancers who initiated curative oncological treatment. Participants were randomized 1:1 to either standard oncologic care (control) or standard oncologic care supplemented with CGA-guided interventions (intervention). Baseline characteristics were retrieved prior to randomization. The primary endpoint, the between-group rate ratio of unplanned hospitalizations within six months of treatment initiation, was analyzed using negative binominal regression. Analyses were performed using an intention-to-treat approach, followed by per-protocol analysis, including participants receiving CGA within 30 days of randomization, and preplanned subgroup analyses based on treatment modality and Geriatric 8 screening. Secondary endpoints included acute hospital contacts, treatment adherence, and toxicity. ResultsFrom November 1, 2020 to May 31, 2023, 173 participants were enrolled. Median age was 75 (interquartile range 72–79), 51.5% were female, 58% had a G8 score > 12, and 84% had Eastern Cooperative Oncology Group performance status 0–1. The most common cancer sites were lung (23%), upper gastrointestinal (15%), and breast (13%). The rate (per person-years) of unplanned hospitalization was 1.32 in the intervention group and 1.81 in the control group, with a between-group rate ratio of 0.74 (95% confidence interval [CI] 0.45–1.23, P = 0.25) favoring the intervention. The between-group rate ratio increased in the per-protocol analysis (0.64 [95% CI 0.37–1.10, P = 0.10]). Similarly, no significant between group differences were found in treatment adherence, rate of acute hospital contacts, or toxicity. DiscussionIn this study, CGA did not significantly reduce the rate of unplanned hospitalizations. Furthermore, no between-group differences were found in treatment adherence, toxicity lead hospitalizations, or treatment completion in older adults with cancer and frailty. However, per-protocol analysis suggests that increasing adherence to CGA may improve the outcome. Larger studies ensuring higher CGA adherence are warranted to confirm our findings.

Acute Valproate-Induced Encephalopathy in Status Epilepticus: A Registry-Based Assessment.

Valproate-induced encephalopathy (VIE) affects between 0.1% and 2.5% of patients under long-term epilepsy treatment. Its frequency and characteristics in adults with status epilepticus (SE) is, however, unknown. The aim of this study was to characterize the frequency and the clinico-biological characteristics of VIE in adult SE patients. We reviewed all patients included in our institutional SE registry who were treated for an SE episode between November 2021 and February 2023 and identified 39 patients who received valproate for their SE treatment. Acute VIE was defined by worsening of consciousness having led to the discontinuation of valproate, and improvement of consciousness within 96 hours after discontinuation of valproate during acute hospital treatment. Patients had a mean valproate intravenous loading dose of 34.5mg/kg and a mean maintenance dose of 15.3mg/kg/d (1078mg/d). Four out of 29 patients with measured ammonium had hyperammonemia. We identified four (10%) patients fulfilling acute VIE criteria. Median time from administration of valproate to the occurrence of VIE, and to resolution of VIE after cessation of valproate treatment, was 2 days for each. Three of the four VIE patients had no associated hyperammonemia. Patients who developed VIE more frequently had a history of liver disease (p=0.023), and tended to be younger, but other clinical variables did not differ significantly from patients without VIE, including valproate loading or maintenance doses, SE cause, duration or severity, other concomitant antiseizure medications (none received topiramate, phenobarbital, or primidone). Pending larger studies, VIE in SE seems relatively frequent and difficult to foresee; clinical alertness to symptoms is mandatory, even without hyperammonemia, and valproate withdrawal should be considered in suspected cases.

A proposed clinical pathway for the patients with Borderline Personality Disorder presenting to Emergency Departments.

Emergency Department (ED) care of repeated self-injury, intensive affective lability, and interpersonal dysfunction associated with borderline personality disorder (BPD) is challenging. We propose an evidence-based acute clinical pathway for people with BPD. Our standardised evidence-based short-term acute hospital treatment pathway includes structured ED assessment, structured short-term hospital admission when clinically indicated, and immediate short-term (4-sessions) clinical follow-up. This approach could be adopted nationally to reduce iatrogenic harm, acute service overdependence and negative healthcare system impacts of BPD.

Physical Rehabilitation and Mental Health Care After Burn Injury: A Multinational Study.

While remarkable improvements have been made to acute hospital burn care in recent decades, it is not matched by improvements in post-acute care, including physical rehabilitation and mental health. Progress in acute hospital treatment of burn survivors now highlights the next important step-addressing care once a patient leaves intensive treatment and is discharged to the community. Long-term physical rehabilitation and mental health services are vital to improving quality of life for burn survivors. Using qualitative methods, we apply an adapted Reeve framework to assess and compare post-acute physical rehabilitation and mental health care across 13 countries on 6 continents. Twenty semistructured interviews were conducted with burn surgeons and rehabilitation specialists. One major theme that emerged was the importance of training and resources to the quality of post-acute care. This exploratory study suggests the value of investing scarce resources in a range of low-cost interventions to improve follow-up burn care. One intervention identified here is short-term training in post-acute rehabilitation and mental health to upgrade and standardize best clinical practices to address as-yet unmet post-discharge needs of burn survivors.

Psychiatric disorders during acute hospital treatment of COVID-19 - a case series

IntroductionCoronavirus disease (COVID-19) has been associated with the development mental and behavioural symptoms and psychiatric disorders. This association is stronger in severe cases of the disease and in those needing inpatient treatment, particularly in intensive care units (ICU).ObjectivesTo determine the incidence of psychiatric disorders in a Portuguese hospital-based sample of patients with COVID-19. To describe relevant demographic and clinical data.MethodsWe reviewed all COVID-19 inpatients assessed by liaison psychiatry at our hospital between April and September 2020. Patients admitted due to a psychiatric disorder were excluded from the analysis. We reviewed medical records and retrieved relevant clinical data. ICD-10 was used to classify diagnoses.ResultsWe identified 36 cases with a mean age of 62.64 years-old (SD 19.23). The most common disorder was delirium, which occurred in 41.7% of our sample (15 patients), followed by adjustment disorder (22.2%, n=8), and depressive episode (16.7%, n=8). Most patients had no personal (61.1%, n=22) nor family (75%, n=27) history of a psychiatric disorder. Mean length of admission was 36.89 days (SD 28.91). Seventeen cases (47.22%) had at least one risk factor for severe COVID-19 disease and 14 (38.89%) were admitted at some point to the ICU.ConclusionsIn our sample, delirium was the main cause for mental or behavioural symptoms in COVID-19 patients. However, we observed a wide array of presentations in our center. A larger sample would allow to better characterize this often-overlooked symptoms and identify risk factors to psychiatric syndromes.DisclosureNo significant relationships.

Prehospital stratification in acute chest pain patient into high risk and low risk by emergency medical service: a prospective cohort study

ObjectivesTo describe contemporary characteristics and diagnoses in prehospital patients with chest pain and to identify factors suitable for the early recognition of high-risk and low-risk conditions.DesignProspective observational cohort study.SettingTwo centre...

PMH3 Effects of ART Therapy on Depression and Anxiety in Patients Undergoing Medical Treatment: A Systematic Review

Art therapy has been proposed as an alternative to pharmacological treatment to help relieve symptoms of depression and anxiety in patients undergoing medical treatment. The current systematic review (SR) was conducted to evaluate whether art therapy was beneficial in these patients. MEDLINE, EMBASE and the Cochrane Library were interrogated in April 2020. Eligibility criteria included full publications enrolling patients undergoing medical treatment (no restriction on underlying condition) who received visual art therapy. Outcomes of interest included change in depression and/or anxiety symptoms. Of the 1857 publications screened, 90 were evaluated by full text and 27 met the inclusion criteria (4 randomised controlled trials (RCTs), 15 single-arm, and 8 comparative studies; patient number ranged from 6 to 195). Art therapy included colouring, painting, animation, clay modelling and plastic art workshops. Publications reported data from patients with a range of underlying conditions: cancer (n=11), depression and/or anxiety (n=5), post-traumatic stress disorder (PTSD; n=5), psychiatric inpatients (n=2), and one each of Alzheimer’s Disease, stroke, undergoing an allogenic hemopoietic stem cell transplant or receiving acute hospital treatment. Considerable inter-study heterogeneity was evident with regard to enrolled patients, study follow-up, and tools administered to measure symptom response. Use of art therapy resulted in a statistically significantly reduction in anxiety and/or depression symptoms in 18/27 studies (including 3/4 of the RCTs) either versus baseline or versus control treatment. The statistically significant beneficial effect was observed across multiple indications: cancer (in 8/11 studies), PTSD (3/5 studies), and anxiety and/or depression (5/5 in studies). This SR provides evidence that art therapy can be beneficial as to relieve symptoms of depression and/or anxiety in patients with a wide range of disorders. Further comparative evidence and data from larger cohort studies with sufficient follow up and well defined outcome measures are required to confirm these findings.

Integrating intravenous frusemide treatment into the community for heart failure patients

Abstract Background A structured pathway was developed to allow patients to safely receive intravenous (i/v) frusemide at home. This pathway was implemented by an integrated team consisting of primary and tertiary care. This allowed the traditional acute hospital treatment to be now delivered in the community. Purpose This concept has been used on an individual case basis by a minority of acute hospitals. Previously there was no structured pathway that would allow this treatment to become a standard part of heart failure treatment by acute hospitals. The pathway would ensure that the treatment would be delivered safely to a cohort of patients who meet certain criteria. Methods A pathway was developed by a consultant cardiologist, heart failure (HF) nurses and the Community Intervention Team (CIT)/CareDoc. The Caredoc Community Intervention Team (CIT) is a nurse led professional team that provides acute nursing care to patients in the community setting. The HF nurse would identify the suitable patient for i/v frusemide as per pathway. A referral would be sent to the CIT team who would administer the frusemide at the patients home. The CIT team would take a renal profile daily, check vital signs, check symptoms of HF and check daily weight on the patient while they were receiving i/v frusemide. The bloods results would be reviewed daily by the HF nurse. The HF nurse would liaise daily with the CIT team and patient for symptoms, daily weights and vital signs. The patient would then be reviewed in the HF clinic post treatment. Results Single centre retrospective analysis was undertaken of the patients who received i/v frusemide at home over a 3 year period. 83 patients meet the inclusion criteria and received the treatment. 70 male and 13 female. Average age 78 years old. Average length of treatment 3 days. Treatment was given twice daily, average daily dose was 137 mg. Majority of treatment was 80mg bd or 60 mg bd. No failure cannulating any patient as CIT had high cannulation skills due to regular cannulation as part of workload. 3 episodes of hypokalaemia, lowest potassium was 3.1 mmols, all 3 episodes were effectively treated with oral potassium supplements. No significant acute kidney injury was noted that required change to treatment. 6 patients required heart failure associated admission to hospital, 3 had hypotension, 1 has fast A-flutter and 2 remained resistance to i/v frusemide and required inotropes. Both patient and carers reported a high satisfaction rate with the service. Conclusion National length of stay for a HF patient in Ireland is 11 days.This novel structured pathway successfully selected appropriate patients who can safely receive i/v frusemide at home. 93% avoided hospital admission.This reduces the need for acute hospital admission and significant associated costs. Patients and carers rated 95% satisfaction with service.Sustainability of the project is driven by an integration team approach. Funding Acknowledgement Type of funding source: None

Sekundäre Fehlbelegung und B - C Lücke

Placement errors in neurological early rehabilitation Out of 252 patients in neurological intensive care rehabilitation at the BDH Clinic Elzach who progressed to further rehabilitation treatment, 24 did not fulfill the criteria for acute hospital treatment in the last week(s) before beginning further rehabilitation. We argue that health insurance should be obligated to pay for in-patient treatment despite this gap.

Post-acute geriatric rehabilitation outcomes in fracture patients treated in an orthogeriatric trauma center-Aprospective investigation with historical control

Despite the increasing amount of positive evidence with respect to mortality for the orthogeriatric co-management in a center for geriatric traumatology (CGT), effects on the course after the acute inpatient hospital treatment have been insufficiently investigated. Patients over 75 years old who needed rehabilitation following acute inpatient treatment before (retrospective, n = 90) and after (prospective, n = 99) the introduction of a certified CGT were investigated. The two groups were compared with respect to the frequency of discharge into an indication-specific (AHB) and geriatric rehabilitation, mobility performance including the five times sit-to-stand test, short physical performance battery (SPPB) and competence in activities of daily living with the Barthel index (BI). After introduction of a CGT 17.2% (95 % confidence interval [95 % CI]: 10-25%; p < 0.027) of the patients were discharged to a specialized orthopedic inpatient rehabilitation (AHB) vs. 6.7% (95 % CI: 1-12%) before the introduction. Correspondingly less patients needed geriatric rehabilitation (before CGT 93.3 %, 95 % CI: 88.1-98.6 vs. CGT 82.8 %, 95 % CI: 75-90; p < 0.001). The overall outcome of post-acute geriatric inpatient rehabilitation improved in both groups but did not differ. Patients who needed two therapy sessions in the CGT were clearly poorer than those with one therapy session with respect to activities of daily living (BI: 34.1, 95 % CI: 30-37.2 vs. 41.2, 95 % CI: 30.9-51.4) and mobility performance (SPPB: 1.2, 95 % CI: 0.7-1.8 vs. 2.2, 95 % CI: 0.9-3.4; p = 0.048). The differences remained despite improvement of both groups during geriatric rehabilitation. The establishment of aCGT enables more patients to be discharged into a less cost-intensive AHB. The more intensive treatment in the CGT offers more severely affected patients the chance for further functional improvement through post-acute inpatient geriatric rehabilitation. A predominantly closing treatment of patients in a CGT is not conceivable in the CGT model presented.

Predictors of Outcome of Acute Partial Hospitalization: An Exploratory Study.

To identify predictors of outcome of acute partial hospital (PH) treatment, patients admitted during a 15-month period were studied. Outcomes were change in the Behavior and Symptom Identification Scale and readmission within 30 days. Predictors were clinical and demographic variables obtained on all patients. Most patients (92%) improved during acute PH treatment, only 5% were readmitted, and average changes were moderate to large. However, many patients still had significant symptoms and behavioral problems at discharge, 56.5% missed at least 1 day, and 16.5% dropped out. Less acute improvement was associated with greater long-term impairment, worse treatment attendance, more previous treatment episodes, and fewer medication changes. Readmission was associated with less acute improvement and its predictors, and with nonattendance. In summary, acute outcome in PH was predicted by functioning more generally. Factors that affect patients' acute PH responses may also affect functioning in other areas. These findings suggest possible modifications of PH practices and programs.

Apilot observational study to analyze (in)activity and reasons for sedentary behavior of cognitively impaired geriatric acute inpatients.

Background and objectiveMobility decline and worsening of the cognitive status are all too often the result of acute hospital treatment in older patients. This is particularly pronounced in patients with pre-existing cognitive impairment. This study strived to analyze the routines of geriatric acute care and identify reasons and triggers for sedentary behavior during acute hospitalization of cognitively impaired inpatients.Methods and patientsA sample of 20 moderately cognitively impaired geriatric inpatients (average age 84 years) were recruited on an acute care ward. Information on persons attending the patient, daytime, location, context, patient’s activity behavior and difficulty of action were collected by behavioral mapping over a period of 35 1‑min timeslots and extrapolated to a period of 525 min. Routines were further analyzed via semi-structured interviews with five healthcare professionals (HCP).ResultsRelevant relations between various categorical and ordinal variables, such as patients’ activity behavior, persons attending the patient, daytime, location, difficulty of action and contextual factors were found. Extrapolated data showed that patients spent 396.9 min (75%) in their room, 342.0 min (65%) were spent alone and 236.2 min (45%) lying in bed. The time patients spent alone was grossly underestimated by HCP.ConclusionTime spent without company, lacking meaningful activities and continuous bedridden periods due to missing demands to leave the room might have led to time spent inactive and alone. These seem to be strong predictors for sedentariness. Routines of acute care should be reorganized to increase physical activity and thereby reduce sedentary behavior of this patient group.

Legal Capacity in patients with post-stroke-aphasia

Aphasia is a frequent cognitive disorder after stroke. Despite a high prevalence, there is comparatively little medical literature or high court jurisdiction concerning the question if aphasia impairs patients in their legal capacity.Imaging studies allow a detailed understanding of the underlying pathology of aphasia, the resulting clinical pictures and potential mechanisms of recovery. Based on functional-anatomical models of language and associated concepts of inner speech, the impact of language disorders on legal capacity is evaluated. A phase model for the assessment of patients with aphasia is proposed, accounting for different stages of potential recovery after stroke.In practice, evaluation of the prerequisites for legal capacity or incapacity in patients with aphasia requires an interdisciplinary cooperation between neurologists, psychiatrists and speech language therapists. In cases of ex-post assessment, the evaluation of legal incapacity at a specific date, however, relies on a detailed documentation of the patient's language impairment and its recovery. To overcome the current limitations standardized and test-based assessment of neuropsychiatric and language capacities after acute hospital treatment and rehabilitation treatment is desirable.

PCV55 - ECONOMIC BURDEN OF STROKE IN GERMANY: A SYSTEMATIC REVIEW

Despite substantial improvements in prevention and acute treatment, stroke is still one of the leading causes of death worldwide. In Europe, more than 1 million people suffer from stroke each year. The purpose of this systematic review is to provide a comprehensive overview of previously published cost-of-illness studies of stroke (including transient ischemic attack) in Germany. A PubMed search was conducted to identify studies providing estimates of the economic burden of stroke in Germany published before June 2018. A study was included if it reported total costs of stroke or costs of a specific stroke treatment phase (e.g. acute inpatient care) per patient in Germany. Studies that considered stroke only as a consequence of other diseases (e.g. diabetes) and therefore did not focus on the detailed description of stroke-related costs were excluded. To ensure comparability between the included studies, all cost estimates were inflated to 2017 values using consumer price indices obtained from the German Federal Statistical Office. Fourteen articles met the predefined inclusion criteria. Twelve studies applied a bottom-up approach with sample sizes varying from 53 to 18,106 patients. The remaining two studies used a top-down approach based on registry data. Type of stroke, treatment phase, time horizon, and included cost components varied widely across studies. Mean direct medical costs per year ranged from €11,400 to €43,200. Inpatient costs for acute hospital treatment varied between €3,700 and €23,900. From a societal perspective, costs for the first year after stroke ranged from €11,500 to €42,400. Discounted direct lifetime costs for ischemic stroke were €51.800. One study estimated the mean per patient cost of informal care per month at about €2,500. Results of the included studies emphasise the high economic burden of stroke in Germany. The amount of costs was considerably influenced by the type of stroke.

Acute Ischemic Stroke Hospital Admissions, Treatment, and Outcomes in Poland in 2009-2013.

Ischemic stroke (IS) still constitutes a serious problem for public health worldwide. The data on its burden in Poland before 2009 is limited and came only from a few metropolitan areas. To assess temporal trends in the hospital admissions, treatment, and outcomes of IS in Poland in 2009-2013, to identify risk factors for IS mortality and to compare the results with other countries. The data from the Polish Stroke Registry were analyzed. The data concerned all subjects hospitalized due to IS (classified according to the ICD10 classification as I63.0-I63.9) as primary diagnosis in Poland in 2009-2013. Temporal trends in treatment and outcome were analyzed. Hospital admissions rates as well as case fatality and 12-month mortality rates were calculated. Altogether, 360,556 patients (47.5% of males) were hospitalized due to IS in Poland in 2009-2013. The median of age was 75 years, IQR 18 (Women 78, IQR 14 vs. Men 70, IQR 17; p < 0.001). The hospital admissions age-standardized annual rate for IS in Poland in 2013 was 8% lower than in 2009 (169 vs. 157/100,000; p for trend < 0.001). In-hospital case fatality has slightly decreased (from 13.6% in 2009 to 12.9% in 2013; p for trend < 0.001). One-year posthospital mortality rate has not changed (19.3% in 2009 and 2013). The percentage of IS subjects treated with intravenous thrombolysis was low but increased from 1.7% in 2009 to 6.3% in 2013 (p for trend <0.001). Since 2009, Poland has had national epidemiological data on the hospital admissions, treatment, and outcomes in IS. The data indicate a slow improvement of in-hospital survival and suggest the need for better stroke prevention and further dissemination of reperfusion therapy.

Art therapy improves mood, and reduces pain and anxiety when offered at bedside during acute hospital treatment

Art therapists can engage medical inpatients in the creation of art to encourage emotional and physical healing. Utilizing a chart review, the impact of art therapy sessions at the bedside with patients (N=195) in a large urban teaching hospital was reviewed. The sample was predominantly female (n=166) as more women than men agreed to participate in an art therapy session. As a routine part of regular clinical practice patients were asked to rate their perception of mood, anxiety, and pain using a 5-point faces scale before and after an art therapy session conducted by a registered art therapist. Multiple diagnoses were included in this chart review, making this study more representative of the variety of medical issues leading to hospitalization. Analysis of pre and post results demonstrated significant improvements in pain, mood, and anxiety levels of art therapy sessions for all patients regardless of gender, age, or diagnosis (all p<0.001).

Patient experiences and predictors in an acute geriatric ward: A cross-sectional study.

To investigate older peoples' experiences with acute hospital treatment and care, and variables that may influence these experiences. In the Nordic countries, research on older peoples' experiences with hospital care is sparse. Participants were recruited from an acute geriatric ward in a hospital in Norway during a 1-year period (n=189). Patient experience was assessed using the Picker Patient Experience Questionnaire, self-rated health by Euro-QoL 5-dimension, three-level version and comorbidity by Charlson comorbidity index. Responders' median age was 79years, 48.7% male. Most of the problems were related to continuity and transition, while fewest problems were related to respect for patient preferences. Charlson comorbidity index score and the variables "still working," "in a relationship" and "living alone" negatively influenced patient experience. A high amount of problems were identified among patients hospitalised in an acute geriatric ward. Findings from this study may provide important information about issues that need focus to increase the care experiences of older people. Results from this study adds to existing knowledge, and emphasize the need for increased focus on discharge and continuity of care processes.

Optimizing polypharmacy among elderly hospital patients with chronic diseases--study protocol of the cluster randomized controlled POLITE-RCT trial.

BackgroundTreatment of patients with multimorbidity is challenging. A rational reduction of long-term drugs can lead to decreased mortality, less acute hospital treatment, and a reduction of costs. Simplification of drug treatment schemes is also related to higher levels of patient satisfaction and adherence. The POLITE-RCT trial will test the effectiveness of an intervention aiming at reducing the number of prescribed long-term drugs among multimorbid and chronically ill patients. The intervention focuses on the interface between primary and secondary health care and includes a pharmacist-based, patient-centered medication review prior to the patient’s discharge from hospital.MethodsThe POLITE-RCT trial is a cluster randomized controlled trial. Two major secondary health care providers of Mecklenburg-Western Pomerania, Germany, take part in the study. Clusters are wards of both medical centers. All wards where patients with chronic diseases and multimorbidity are regularly treated will be included. Patients aged 65+ years who take five or more prescribed long-term drugs and who are likely to spend at least 5 days in the participating hospitals will be recruited and included consecutively. Cluster-randomization takes place after a six-month baseline data collection period. Patients of the control group receive care as usual. The independent two main primary outcomes are (1) health-related quality of life (EQ-5D) and (2) the difference in the number of prescribed long-term pharmaceutical agents between intervention and control group. The secondary outcomes are appropriateness of prescribed medication (PRISCUS list, Beers Criteria, MAI), patient satisfaction (TSQM), patient empowerment (PEF-FB-9), patient autonomy (IADL), falls, re-hospitalization, and death. The points of measurement are at admission to (T0) and discharge from hospital (T1) as well as 6 and 12 months after discharge from the hospital (T2 and T3). In 42 wards, 1,626 patients will be recruited.DiscussionIn case of positive evaluation, the proposed study will provide evidence for a sustainable reduction of polypharmacy by enhancing patient-centeredness and patient autonomy.Trial registrationCurrent Controlled Trials ISRCTN42003273

Evaluation of a new person-centered integrated care model in psychiatry.

The present study evaluated a new integrated treatment concept offering inpatient care, acute psychiatric day hospital and outpatient treatment by the same therapeutic team. 178 patients participated in this randomized controlled trial. Data on psychopathology, global and social functioning, patient satisfaction, continuity of care and administrative data was gathered on admission, throughout the course of treatment, upon discharge and at 1-year follow-up. In addition, the physicians in charge rated the therapeutic relationship. The data analysis consists of group-wise comparisons and regression analyses (cross-tabulations and χ(2) test statistics for categorical data and Mann-Whitney U tests for continuous data). Differences between groups over time were analyzed with a series of generalized linear mixed model. The integrated care group showed a significant reduction in psychopathological impairment (20.7%) and an improvement of psychosocial functioning (36.8%). The mean number of days before re-admission was higher in the control group when compared to the integrated care group (156.8 vs. 91.5). There was no difference in the number of re-admissions and days spent in psychiatric institutions. This new approach offers a treatment model, which facilitates continuity of care. Beside it improves psychopathological outcome measures and psychosocial functioning in patients with mental illness.

Risk factors and cerebrovascular disease

Worldwide stroke and other cerebrovascular diseases (CVD) are a leading cause of physical disability. They are the second commonest cause of mortality (accounting for 10.8 % of all deaths; WHO, 2011) and the primary reason for admission in a large proportion of hospital inpatients. As a result, it is perhaps not surprising that the financial and social costs arising from CVD, which predominantly relate to subsequent physical care needs, are substantial. The outlook is also far from encouraging, since incidence of CVD is highest in the elderly and the morbidity and costs associated with age-related disorders such as these are likely to continue to mount with the pattern of extended life expectancy observed in Western populations. Although recent attention has focused on the acute hospital treatment of CVD, and in particular intravenous thrombolysis, even the most effective immediate interventions for ischemic stroke have little impact on overall disability and dependency within the general population when compared to primary prevention. In order to apply primary prevention strategies more effectively and efficiently across relevant populations we need to improve our understanding of constituent disease phenotypes and individualized risk factors (genetic and environmental), so that risks are more comprehensively assessed and informed interventional programs developed. An example of how effective targeted primary prevention can be in ischemic stroke relates to atrial fibrillation (AF), where aspirin confers an approximately 22 % absolute risk reduction (ARR) for ischemic stroke, but warfarin confers a much greater (66 %) ARR, albeit with an increased risk of bleeding. The recently revised CHA2DS2-VASc score now enables straightforward stratification of stroke risk for patients with documented AF to balance the risk benefits for specific patients. Newer anticoagulants and left atrial appendage closure devices are now coming into more widespread clinical practice and may have less associated risks (e.g., bleeding), so that treatment options for AF continue to improve and expand. It is also widely considered that a significant proportion of the 25 % of strokes that are ‘‘unexplained’’ (cryptogenic) have undocumented AF as the primary etiology, but the management of this group of patients and how to identify them remains unclear. However, for the majority of patients, the etiology of their cerebrovascular disease is less well defined and although there have been successful campaigns tackling public understanding of stroke symptoms, to facilitate rapid treatment, perhaps the biggest challenge for the future will be to identify all at risk patients and apply effective individualized strategies to prevent these devastating disorders. In this month’s journal club we review some current concepts of the underlying etiologies of CVD. The first two of the three papers are retrospective studies that examine risk factors outside of those given mainstream attention (namely psycho-physical stress and genetic polymorphisms), while the third is a prospective study tackling the issue of sub-clinical AF and stroke. A common and timeless theme emerges from these studies, which is that if we are to be successful in unraveling the diverse causes of these disorders, clinical phenotyping will be an essential tool. J. T. Anderson N. P. Robertson (&) Department of Neurology, University Hospital of Wales, Cardiff, UK e-mail: robertsonnp@cardiff.ac.uk