End Of Scheduled Follow-up Research Articles

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

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

Very early versus delayed mobilisation after stroke.

Very early versus delayed mobilisation after stroke.

Abstract CT138: Open-label personalized targeted intervention to maximize TTFields intensity in recurrent GBM (OptimalTTF Trial)

Abstract Introduction Tumor Treating Fields (TTFields) is approved for the treatment of recurrent glioblastoma (rGBM). Skull remodeling surgery involves formation of strategically placed craniectomies, burr holes or skull thinning, in order to facilitate electric current flow into the tumor region. Preclinical studies have indicated that these procedures provide a marked and focal enhancement (~100%) of TTFields intensity without significantly compromising patient safety. In this open-label phase 1 investigator-initiated interventional trial, we test the safety, feasibility and efficacy of TTfields plus personalized targeted skull remodeling surgery and best choice chemotherapy. We believe this study has high-impact potential at a low clinical risk and may advance current state-of-the-art therapy of GBM therapy. Methods The trial will include fifteen patients. Major eligibility criteria include age > 18 years, first recurrence of supratentorial GBM, Karnofsky performance score (KPS) > 60, focal tumor < 2 cm to cortical surface, and lack of uncontrollable epilepsy or significant co-morbidity. Upon inclusion, personalized field calculations will be performed to validate TTFields enhancement > 25% due by skull remodeling surgery. The primary endpoint is toxicity assessed by CTCAEv4.0. Secondary endpoints include overall survival, progression free survival (PFS), PFS at six months (PFS6), objective response rate, quality of life (EORTC QLQ-C30 and BN20), KPS, and steroid dose. Follow-up is 18 months and includes regular toxicity assessment (6-week intervals) as well as quality of life and response assessments (3-month intervals). Endpoint data will be collected at the end of scheduled follow-up, occurrence of suspected unexpected serious adverse reactions (SUSARs) or unacceptable serious adverse events (SAEs), withdrawal of consent, or loss to follow-up. Interim analysis will be performed upon endpoint registration for the first five-10 patients. Citation Format: Nikola Mikic, Anders Rosendal Korshøj. Open-label personalized targeted intervention to maximize TTFields intensity in recurrent GBM (OptimalTTF Trial) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr CT138.

Treadmill training and body weight support for walking after stroke.

Treadmill training, with or without body weight support using a harness, is used in rehabilitation and might help to improve walking after stroke. This is an update of the Cochrane review first published in 2003 and updated in 2005 and 2014. To determine if treadmill training and body weight support, individually or in combination, improve walking ability, quality of life, activities of daily living, dependency or death, and institutionalisation or death, compared with other physiotherapy gait-training interventions after stroke. The secondary objective was to determine the safety and acceptability of this method of gait training. We searched the Cochrane Stroke Group Trials Register (last searched 14 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Reviews of Effects (DARE) (the Cochrane Library 2017, Issue 2), MEDLINE (1966 to 14 February 2017), Embase (1980 to 14 February 2017), CINAHL (1982 to 14 February 2017), AMED (1985 to 14 February 2017) and SPORTDiscus (1949 to 14 February 2017). We also handsearched relevant conference proceedings and ongoing trials and research registers, screened reference lists, and contacted trialists to identify further trials. Randomised or quasi-randomised controlled and cross-over trials of treadmill training and body weight support, individually or in combination, for the treatment of walking after stroke. Two review authors independently selected trials, extracted data, and assessed risk of bias and methodological quality. The primary outcomes investigated were walking speed, endurance, and dependency. We included 56 trials with 3105 participants in this updated review. The average age of the participants was 60 years, and the studies were carried out in both inpatient and outpatient settings. All participants had at least some walking difficulties and many could not walk without assistance. Overall, the use of treadmill training did not increase the chances of walking independently compared with other physiotherapy interventions (risk difference (RD) -0.00, 95% confidence interval (CI) -0.02 to 0.02; 18 trials, 1210 participants; P = 0.94; I² = 0%; low-quality evidence). Overall, the use of treadmill training in walking rehabilitation for people after stroke increased the walking velocity and walking endurance significantly. The pooled mean difference (MD) (random-effects model) for walking velocity was 0.06 m/s (95% CI 0.03 to 0.09; 47 trials, 2323 participants; P < 0.0001; I² = 44%; moderate-quality evidence) and the pooled MD for walking endurance was 14.19 metres (95% CI 2.92 to 25.46; 28 trials, 1680 participants; P = 0.01; I² = 27%; moderate-quality evidence). Overall, the use of treadmill training with body weight support in walking rehabilitation for people after stroke did not increase the walking velocity and walking endurance at the end of scheduled follow-up. The pooled MD (random-effects model) for walking velocity was 0.03 m/s (95% CI -0.05 to 0.10; 12 trials, 954 participants; P = 0.50; I² = 55%; low-quality evidence) and the pooled MD for walking endurance was 21.64 metres (95% CI -4.70 to 47.98; 10 trials, 882 participants; P = 0.11; I² = 47%; low-quality evidence). In 38 studies with a total of 1571 participants who were independent in walking at study onset, the use of treadmill training increased the walking velocity significantly. The pooled MD (random-effects model) for walking velocity was 0.08 m/s (95% CI 0.05 to 0.12; P < 0.00001; I2 = 49%). There were insufficient data to comment on any effects on quality of life or activities of daily living. Adverse events and dropouts did not occur more frequently in people receiving treadmill training and these were not judged to be clinically serious events. Overall, people after stroke who receive treadmill training, with or without body weight support, are not more likely to improve their ability to walk independently compared with people after stroke not receiving treadmill training, but walking speed and walking endurance may improve slightly in the short term. Specifically, people with stroke who are able to walk (but not people who are dependent in walking at start of treatment) appear to benefit most from this type of intervention with regard to walking speed and walking endurance. This review did not find, however, that improvements in walking speed and endurance may have persisting beneficial effects. Further research should specifically investigate the effects of different frequencies, durations, or intensities (in terms of speed increments and inclination) of treadmill training, as well as the use of handrails, in ambulatory participants, but not in dependent walkers.

Early supported discharge services for people with acute stroke.

People with stroke conventionally receive a substantial part of their rehabilitation in hospital. Services have now been developed that offer people in hospital an early discharge with rehabilitation at home (early supported discharge: ESD). To establish if, in comparison with conventional care, services that offer people in hospital with stroke a policy of early discharge with rehabilitation provided in the community (ESD) can: 1) accelerate return home, 2) provide equivalent or better patient and carer outcomes, 3) be acceptable satisfactory to patients and carers, and 4) have justifiable resource implications use. We searched the Cochrane Stroke Group Trials Register (January 2017), Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 1) in the Cochrane Library (searched January 2017), MEDLINE in Ovid (searched January 2017), Embase in Ovid (searched January 2017), CINAHL in EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to December 2016), and Web of Science (to January 2017). In an effort to identify further published, unpublished, and ongoing trials we searched six trial registries (March 2017). We also performed citation tracking of included studies, checked reference lists of relevant articles, and contacted trialists. Randomised controlled trials (RCTs) recruiting stroke patients in hospital to receive either conventional care or any service intervention that has provided rehabilitation and support in a community setting with an aim of reducing the duration of hospital care. The primary patient outcome was the composite end-point of death or long-term dependency recorded at the end of scheduled follow-up. Two review authors scrutinised trials, categorised them on their eligibility and extracted data. Where possible we sought standardised data from the primary trialists. We analysed the results for all trials and for subgroups of patients and services, in particular whether the intervention was provided by a co-ordinated multidisciplinary team (co-ordinated ESD team) or not. We assessed risk of bias for the included trials and used GRADE to assess the quality of the body of evidence. We included 17 trials, recruiting 2422 participants, for which outcome data are currently available. Participants tended to be a selected elderly group of stroke survivors with moderate disability. The ESD group showed reductions in the length of hospital stay equivalent to approximately six days (mean difference (MD) -5.5; 95% confidence interval (CI) -3 to -8 days; P < 0.0001; moderate-grade evidence). The primary outcome was available for 16 trials (2359 participants). Overall, the odds ratios (OR) for the outcome of death or dependency at the end of scheduled follow-up (median 6 months; range 3 to 12) was OR 0.80 (95% CI 0.67 to 0.95, P = 0.01, moderate-grade evidence) which equates to five fewer adverse outcomes per 100 patients receiving ESD. The results for death (16 trials; 2116 participants) and death or requiring institutional care (12 trials; 1664 participants) were OR 1.04 (95% CI 0.77 to 1.40, P = 0.81, moderate-grade evidence) and OR 0.75 (95% CI 0.59 to 0.96, P = 0.02, moderate-grade evidence), respectively. Small improvements were also seen in participants' extended activities of daily living scores (standardised mean difference (SMD) 0.14, 95% CI 0.03 to 0.25, P = 0.01, low-grade evidence) and satisfaction with services (OR 1.60, 95% CI 1.08 to 2.38, P = 0.02, low-grade evidence). We saw no clear differences in participants' activities of daily living scores, patients subjective health status or mood, or the subjective health status, mood or satisfaction with services of carers. We found low-quality evidence that the risk of readmission to hospital was similar in the ESD and conventional care group (OR 1.09, 95% CI 0.79 to 1.51, P = 0.59, low-grade evidence). The evidence for the apparent benefits were weaker at one- and five-year follow-up. Estimated costs from six individual trials ranged from 23% lower to 15% greater for the ESD group in comparison to usual care.In a series of pre-planned analyses, the greatest reductions in death or dependency were seen in the trials evaluating a co-ordinated ESD team with a suggestion of poorer results in those services without a co-ordinated team (subgroup interaction at P = 0.06). Stroke patients with mild to moderate disability at baseline showed greater reductions in death or dependency than those with more severe stroke (subgroup interaction at P = 0.04). Appropriately resourced ESD services with co-ordinated multidisciplinary team input provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as reducing the length of hospital stay. Results are inconclusive for services without co-ordinated multidisciplinary team input. We observed no adverse impact on the mood or subjective health status of patients or carers, nor on readmission to hospital.

Interference of blood pressure control within 24 hours in acute ischemic stroke: systematic review protocol

Stroke is the third most common cause of death in most industrialized countries, with an estimated global mortality of 4.7 million yearly. A stroke occurs every 53 seconds in North America and by 2002 was projected to become the fourth leading burden of disease worldwide. Stroke killed 283,000 people in 2000 and accounted for about one in every 14 deaths in the United States. Each year, about 700,000 people suffer a new or recurrent stroke. It is the major cause of serious, long-term disability, with more than 1,100,000 American adults reporting functional limitations resulting from stroke. Review of the evidence on how acute variation in blood pressure (BP) during the first 24 hours of acute ischemic stroke can influence outcome, considering interesting preliminary evidence that without intervening medications may be superior to some use of drugs in modifying an acute rise in BP, and suggesting that the blood pressure decline spontaneously without administration of medication may also have an influence on the acquired disabilities. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 12), MEDLINE (1954-July 2013), EMBASE (1980-July 2013), CINAHL (1982-July 2013), Database of Research in Stroke (DORIS) (2008-2013), Latin American and Caribbean Health Sciences Literature (LILACS) (1982-December 2013) and reference lists of articles. We contacted researchers in the field. We did a grey literature search for articles published until July 2013. We also searched Dissertation Abstracts International via Dissertation Express, and the metaRegister of Controlled Trials. In an effort to identify further published, unpublished and ongoing trials, we searched ongoing trials registers and SCOPUS. Inclusion criteria: 1, age 18-75 years; 2, clinical signs consistent with the diagnosis of ischemic stroke; 3, treatment onset within 3-9 hours after stroke onset; 4, no prior neurologic event that would obscure the interpretation of the signal and current presenting neurologic deficits (modified Rankin scale = 1); 5, National Institutes of Health Stroke Scale (NIHSS) score >4 and at least moderate limb weakness; 6, MRI screening to be started within 7.5 hours after stroke onset; 7, perfusion abnormality of >2 cm in diameter involving hemispheric gray matter; 8, perfusion/diffusion mismatch of 20; 9, magnetic resonance angiography shows TICI grade 0 or 1. Exclusion criteria: 1, prestroke score on the modified Rankin Scale >2 or on the Barthel Index. Review authors will work independently to assess risk of bias using criteria described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011) to assess trial quality. This set of criteria is based on evidence of associations between overestimate of effect and high risk of bias of the article such as sequence generation, allocation concealment, blinding, incomplete outcome data and selective reporting. If the raters disagreed, the final rating was made by consensus, with the involvement of another member of the review group. Where inadequate details of randomization and other characteristics of trials were provided, authors of the studies were contacted in order to obtain further information. Nonconcurrence in quality assessment was reported, but if disputes arose as to in which category a trial was to be allocated, again, resolution was made by discussion. The level of risk of bias was noted in both the text of the review and in the Summary of findings tables. Primary outcomes: death or dependency at the end of scheduled follow-up. Dependency is defined as being severely dependent on others in activities of daily living, or being significantly disabled; this corresponds to a Barthel Index score or a modified Rankin Scale grade 3-6 at 3-month follow-up. Secondary outcomes: 1, standardized nondisease-specific instrument for describing and valuating health-related quality of life; EQ-5D (EuroQol) questionnaire. 2, NIHSS measure of neurologic deficit; the Barthel Index measure of activities of daily living; the Modified Rankin Scale measure of the degree of disability or dependence in daily activities for 90 days follow-up. 3, average time of hospital discharge. 4, time to discharge from the neuro ICU or neuro critical care unit. 5, assessment of systolic and diastolic blood pressure control. 6, causality assessment of adverse events following blood pressure reduction within 24 hours of acute ischemic stroke.

Occupational therapy for care home residents with stroke.

Stroke is a worldwide problem and is a leading cause of adult disability, resulting in dependency in activities of daily living (ADL) for around half of stroke survivors. It is estimated that up to 25% of all care home residents in the USA and in the UK have had a stroke.Stroke survivors who reside in care homes are likely to be more physically and cognitively impaired and therefore more dependent than those able to remain in their own home. Overall, 75% of care home residents are classified as severely disabled, and those with stroke are likely to have high levels of immobility, incontinence and confusion, as well as additional co-morbidities. It is not known whether this clinically complex population could benefit from occupational therapy in the same way as community-dwelling stroke survivors. The care home population with stroke differs from the general stroke population living at home, and a review was needed to examine the benefits of occupational therapy provided to this specific group. This review therefore focused on occupational therapy interventions for ADL for stroke survivors residing in care homes. To measure the effects of occupational therapy interventions (provided directly by an occupational therapist or under the supervision of an occupational therapist) targeted at improving, restoring and maintaining independence in ADL among stroke survivors residing in long-term institutional care, termed collectively as 'care homes'. As a secondary objective, we aimed to evaluate occupational therapy interventions for reducing complications such as depression and low mood. We searched the Cochrane Stroke Group Trials Register (August 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, September 2012), MEDLINE (1948 to September 2012), EMBASE (1980 to September 2012), CINAHL (1982 to September 2012) and 10 additional bibliographic databases and six trials registers. We also handsearched seven journals, checked reference lists and obtained further information from individual trialists. Randomised controlled trials investigating the impact of an occupational therapy intervention for care home residents with stroke versus standard care. The lead review author performed all searches. Two review authors then independently assessed all titles and abstracts of studies and selected trials for inclusion, with a third review author resolving any discrepancies. The same two review authors independently extracted data from all included published sources to ensure reliability. Primary outcomes were performance in ADL at the end of scheduled follow-up and death or a poor outcome. Secondary outcomes aimed to reflect the domains targeted by an occupational therapy intervention. We included in the review one study involving 118 participants. We found one ongoing study that also met the inclusion criteria for the review, but the data were not yet available. We found insufficient evidence to support or refute the efficacy of occupational therapy interventions for improving, restoring or maintaining independence in ADL for stroke survivors residing in care homes. The effectiveness of occupational therapy for the population of stroke survivors residing in care homes remains unclear, and further research in this area is warranted.

Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials

Objective To evaluate the effectiveness of comprehensive geriatric assessment in hospital for older adults admitted as an emergency.Search strategy We searched the EPOC Register, Cochrane’s Controlled Trials Register, the Database...

Services for Reducing the Duration of Hospital Care for Acute Stroke Patients

In most developed countries, stroke patients are admitted to hospital for a period of acute care and rehabilitation. Services have been developed to try and accelerate discharge home and reduce the duration of hospital stay. These have been termed early supported discharge (ESD) services. This review tested whether ESD services could reduce length of stay and improve patient outcome compared with conventional hospital care and discharge arrangements. We searched the Cochrane Specialist Register of Controlled Trials (to August 2004). The contact trialist of all eligible studies was then contacted and asked to provide details of their intervention and control services and to provide individual patient data. We included randomized controlled trials (RCTs) that compared an ESD service with conventional care for hospitalized stroke …

Early supported discharge services for stroke patients: a meta-analysis of individual patients' data

Stroke patients conventionally undergo a substantial part of their rehabilitation in hospital. Services have been developed that offer patients early discharge from hospital with rehabilitation at home (early supported discharge [ESD]). We have assessed the effects and costs of such services. We did a meta-analysis of data from individual patients who took part in randomised trials that recruited patients with stroke in hospital to receive either conventional care or any ESD service intervention that provided rehabilitation and support in a community setting with the aim of shortening the duration of hospital care. The primary outcome was death or dependency at the end of scheduled follow-up. Outcome data were available for 11 trials (1597 patients). ESD services were mostly provided by specialist multidisciplinary teams to a selected group (median 41%) of stroke patients admitted to hospital. There was a reduced risk of death or dependency equivalent to six (95% CI one to ten) fewer adverse outcomes for every 100 patients receiving an ESD service (p=0.02). The hospital stay was 8 days shorter for patients assigned ESD services than for those assigned conventional care (p<0.0001). There were also significant improvements in scores on the extended activities of daily living scale and in the odds of living at home and reporting satisfaction with services. The greatest benefits were seen in the trials evaluating a coordinated multidisciplinary ESD team and in stroke patients with mild to moderate disability. Appropriately resourced ESD services provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as shortening hospital stays.

Percutaneous US-guided radiofrequency ablation with perfused needle applicators: improved survival with the VX2 tumor model in rabbits.

To evaluate survival, metastases, tumor necrosis, and prediction of local recurrence after percutaneous ultrasonographically (US) guided radiofrequency (RF) thermal ablation with electrodes perfused continuously with isotonic saline. VX2 liver tumors were implanted in 31 rabbits according to a standardized protocol. After 21 days, 16 animals were treated percutaneously with RF ablation. Four animals died of complications related to anesthesia, and 12 animals were evaluated. All animals were followed for 110 days and monitored with computed tomography (CT) and US at 1, 7, and 30 days. A control group of 15 animals did not receive treatment. Autopsy was performed at the end of scheduled follow-up or immediately after death. For survival analysis, the Kaplan-Meier method was used; for nominal data, the Fisher exact test was used. In comparison to controls, animals in the treatment group showed significantly prolonged survival (P <.001). Eight of 12 animals (67%) treated with RF ablation survived to 110 days, while none of the controls did so. Metastases developed in all controls (100%) and in eight of 12 treated animals (67%) (P =.001). In comparison with controls, animals that developed metastases despite treatment also showed significantly prolonged survival (P =.02). Local recurrence was observed in three of 12 animals (25%) in the treatment group. CT and US performed 1 week after treatment did not allow prediction of local recurrence. RF ablation of liver tumors with perfused needle applicators prolongs survival in the VX2 rabbit liver tumor model, regardless of whether complete remission is achieved. In comparison with controls, RF ablation results in a lower frequency of metastases.