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Biomedical subjects

L Kalra

Publications and source records attributed to L Kalra.

At least 19 recordsLinked to original sources
PubMed2001

Should stroke subtype influence anticoagulation decisions to prevent recurrence in stroke patients with atrial fibrillation?

BACKGROUND AND PURPOSE: Long-term anticoagulation is routinely used for secondary stroke prevention in atrial fibrillation, often regardless of stroke subtype. Although the role of warfarin in cardioembolic stroke is established, it may not prevent recurrence in other stroke subtypes, even in the presence of atrial fibrillation. METHODS: This was a 2-year, prospective, intervention study conducted in a district general hospital. Participants included 386 acute stroke patients with atrial fibrillation. Subjects were characterized for stroke subtype on clinical, neuroimaging, carotid ultrasonographic, and echocardiographic criteria. Eligible patients were treated with adjusted-dose warfarin (international normalized ratio, 2.0 to 3.0). Aspirin (75 to 300 mg/d) was used in patients with contraindications or those who refused anticoagulation. The main outcome measures were rate of recurrent stroke by subtype and major and minor bleeding complications. RESULTS: The aspirin group (n=172) was comparable to the warfarin group (n=214) in terms of age, sex, risk factors, and initial stroke subtype. The rate of recurrent stroke was higher (9.5% versus 4.9%, P<0.02) but that of major bleeding was lower (0.6% versus 2.5%, P<0.05) with aspirin. The increased stroke rate with aspirin was due predominantly to cardioembolic recurrence in patients presenting initially with cardioembolic stroke (8.4% versus 1.9%, P<0.01). The recurrence rate in aspirin-treated patients who presented with lacunar stroke and atrial fibrillation was similar to that seen in patients receiving warfarin (8.8% versus 8.9%). CONCLUSIONS: In this cohort of stroke patients with atrial fibrillation, anticoagulation was superior to aspirin in preventing cardioembolic but not lacunar recurrence. Determination of stroke subtype may be important in anticoagulation decisions for secondary prevention, and further studies are required.

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PubMed2001

Can differences in management processes explain different outcomes between stroke unit and stroke-team care?

BACKGROUND: Stroke units reduce mortality and dependence, but the reasons are unclear. We have compared differences in management and complications of patients with acute stroke who were admitted to a stroke unit or to a general ward as part of a previously reported randomised trial. METHODS: 304 patients had been randomly assigned to stroke units (n=152) or to general wards supported by a specialist stroke team (152). We used a structured format to gather prospective data on the frequency of prespecified interventions in each of the major aspects of stroke care. Observations were undertaken daily for the first week and every week for the next 3 months by independent observers. The effect of differences in management on outcome at 3 months was assessed with the modified Rankin score, dichotomised to good (0-3) and poor (4-6) outcome. FINDINGS: Patients in the stroke unit were monitored more frequently (odds ratio 2.1 [1.3-3.4]) and more patients received oxygen (2.0 [1.3-3.2]), antipyretics (6.4 [1.5-27.5]), measures to reduce aspiration (6.0 [2.3-15.5]), and early nutrition (14.4 [5.1-40.9]) than those in general wards. Complications were less frequent in patients in the stroke unit than those in general wards (0.6 [0.2-0.7]), with fewer patients having progression of stroke, chest infection, or dehydration. Measures to prevent aspiration, early feeding, stroke unit management, and frequency of complications independently affected outcome. INTERPRETATION: Differences in management and complications between the stroke unit and general wards differ substantially, even when specialist support is provided. Such differences could be responsible for the more favourable outcome seen in patients on stroke units than those on general wards.

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PubMed2001

Are the results of randomized controlled trials on anticoagulation in patients with atrial fibrillation generalizable to clinical practice?

BACKGROUND: Randomized trials demonstrate a clear benefit of anticoagulation in patients with atrial fibrillation at risk of stroke, but the proportion of eligible patients who are treated with anticoagulants remains low. The reluctance to treat all eligible patients with anticoagulants may be due to studies in clinical practice showing variable risk-benefit, raising concerns about application to general medical practice. METHODS: A systematic review of published medical literature was performed to identify studies of patients with atrial fibrillation who were treated with warfarin in actual clinical practice. Data from these studies were compared with pooled data from randomized controlled trials. RESULTS: Three studies met the predefined criteria, each in a different health care setting, totaling 410 patients with 842 patient-years of follow-up. Patients in clinical practice were older and had more comorbid conditions compared with trial participants. However, the ischemic stroke rate was similar between clinical practice and randomized studies (1.8% [95% confidence interval (CI), 0.9%-2.7%] vs 1.4% [95% CI, 0.9%-2.0%]). Intracranial hemorrhage (0.1% [95% CI, 0%-0.3%] vs 0.3% [95% CI, 0.06%-0.5%]) and major bleeding (1.1% [95% CI, 0.4%-1.8%] vs 1.3% [95% CI, 0.8%-1.8%]) rates were also similar. There was a higher rate of minor bleeding in clinical practice than in trials (12.0% [95% CI, 9.7%-14.3%] vs 7.9% [95% CI, 6.6%-9.2%]). CONCLUSIONS: Patients who undergo anticoagulation for atrial fibrillation in actual clinical practice differ from those in randomized trials, but have similar rates of stroke and major bleeding. The risk of minor bleeding is higher and may require more intensive monitoring in practice.

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PubMed2000

Alternative strategies for stroke care: a prospective randomised controlled trial.

BACKGROUND: Organised specialist care for stroke improves outcome, but the merits of different methods of organisation are in doubt. This study compares the efficacy of stroke unit with stroke team or domiciliary care. METHODS: A single-blind, randomised, controlled trial was undertaken in 457 acute-stroke patients (average age 76 years, 48% women) randomly assigned to stroke unit, general wards with stroke team support, or domiciliary stroke care, within 72 h of stroke onset. Outcome was assessed at 3, 6, and 12 months. The primary outcome measure was death or institutionalisation at 12 months. Analyses were by intention to treat. FINDINGS: 152 patients were allocated to the stroke unit, 152 to stroke team, and 153 to domiciliary stroke care. 51 (34%) patients in the domiciliary group were admitted to hospital after randomisation. Mortality or institutionalisation at 1 year were lower in patients on a stroke unit than for those receiving care from a stroke team (21/152 [14%] vs 45/149 [30%]; p<0.001) or domiciliary care (21/152 [14%] vs 34/144 [24%]; p=0.03), mainly as a result of reduction in mortality. The proportion of patients alive without severe disability at 1 year was also significantly higher on the stroke unit compared with stroke team (129/152 [85%] vs 99/149 [66%]; p<0.001) or domiciliary care (129/152 [85%] vs 102/144 [71%]; p=0.002). These differences were present at 3 and 6 months after stroke. INTERPRETATION: Stroke units are more effective than a specialist stroke team or specialist domiciliary care in reducing mortality, institutionalisation, and dependence after stroke.

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PubMed2000

Prospective cohort study to determine if trial efficacy of anticoagulation for stroke prevention in atrial fibrillation translates into clinical effectiveness.

OBJECTIVE: To determine whether trial efficacy of prophylaxis with warfarin for patients with atrial fibrillation at high risk of stroke translates into effectiveness in clinical practice. DESIGN: Two year prospective cohort study. SETTING: District general hospital. PARTICIPANTS: 167 patients with atrial fibrillation and at high stroke risk who were eligible for anticoagulation. INTERVENTIONS: Long term anticoagulation with warfarin at adjusted doses to maintain an international normalised ratio of 2.0-3.0. MAIN OUTCOME MEASURES: Comparison of patient characteristics, comorbidity, anticoagulation control, stroke rate, and haemorrhagic complications with pooled data from five randomised controlled trials. RESULTS: Patients in the study group were seven years older (95% confidence interval 4 to 10) and comprised 33% more women than patients in the pooled trials. The international normalised ratio was in the target range for 61% of the time (range 37%-85%), below for 26% of the time (range 8%-32%), and above for 13% of the time (range 6%-26%). The time that patients in the study group spent in the target range was significantly less than in the pooled analysis. The incidence of stroke in the study group (2.0% per year, 0.7% to 4. 4%) was comparable to that of patients receiving warfarin in pooled studies (1.4%, 0.8% to 2.3%). Per year the incidence of major (1.7% v 1.6%) and minor (5.4% v 9.2%) bleeding complications was also similar. CONCLUSION: Rates of stroke and major haemorrhage after anticoagulation in clinical practice were comparable to those obtained from pooled data from randomised controlled studies for patients with atrial fibrillation at high risk of stroke.

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PubMed2000

Does prior use of aspirin affect outcome in ischemic stroke?

BACKGROUND: Large intervention studies suggest that aspirin may reduce mortality when given to patients who present with strokes or transient ischemic attacks. We sought to determine whether patients who were already using aspirin at the time of an ischemic stroke had a lower mortality than those who were not. METHODS: A prospective cohort study was undertaken in patients (mean age 76 +/- 15 years) with acute ischemic stroke. Detailed information on demography, stroke characteristics, and aspirin use prior to the stroke was collected from patients, medical records, and other sources. Patients were classified by cause and subtype of stroke using standard criteria. Mortality was measured 4 weeks after the initial episode. RESULTS: Of the 1,457 patients, 650 (45%) were using aspirin (median dose 75 mg; range 75 to 300 mg) prior to the stroke. Prior use of aspirin was associated with lower 4-week mortality (14% versus 20%, P <0.01 ). Beneficial effects of prior aspirin use on mortality were seen in patients with atherosclerotic strokes (15% versus 21%, P <0.05) and with cardioembolic strokes (21% versus 34%, P <0.05), but not among patients with strokes due to small vessel occlusion (10% versus 11%, P = 0.8). Prior aspirin use was also associated with lower mortality in patients in whom the cause of ischemic stroke could not be determined (15% versus 22%, P <0.01). The effect of prior aspirin use on mortality was independent of age, gender, other risk factors, and use of other medication. CONCLUSIONS: Prior use of low-dose aspirin may be associated with a small but significant reduction in stroke mortality.

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PubMed2000

Services for helping acute stroke patients avoid hospital admission.

BACKGROUND: Stroke patients are usually admitted to hospital for their acute care and rehabilitation. Services to help acute stroke patients avoid admission to hospital ("hospital-at-home") have now been developed. OBJECTIVES: The objective of this review was to establish the costs and effects of such services compared with conventional services. SEARCH STRATEGY: The Stroke Group Specialist Register of Controlled Trials was searched and supplemented by discussion with colleagues and trialists. This was last updated in March 1999. SELECTION CRITERIA: Controlled clinical trials recruiting stroke patients who have not been admitted to hospital and compare; a) services which provided support with an aim of helping prevent admission to hospital with b) conventional services (which could include hospital admission). DATA COLLECTION AND ANALYSIS: Two independent reviewers determined the eligibility and methodological quality of trials. Trialists were then contacted to obtain standardised descriptive and outcome data. MAIN RESULTS: Four trials are included in the review of which three currently have outcome data available (921 patients; 857 from one controlled trial, 64 from two randomised trials). There were no statistically significant differences between the patient and carer outcomes of the intervention and control groups either within individual trials or in pooled analyses. There was a trend toward greater hospital bed use and increased costs in the intervention groups. REVIEWER'S CONCLUSIONS: There is currently no evidence from clinical trials to support a radical shift in the care of acute stroke patients from hospital-based care.

Home Care Services↗
PubMed2000

Integrated care pathways in stroke management.

BACKGROUND: an organized, goal-defined and time-specified plan of management as envisaged by the integrated care pathway approach can achieve quality outcomes at lower cost. Integrated care pathways may have applications to stroke management because diagnosis is well defined, complex interdisciplinary inputs are required and there is good evidence on best practice. METHOD: we reviewed medical, nursing, rehabilitation and health services databases to identify studies on integrated care pathways in stroke management. Criteria for inclusion were: use of a care pathway or similar methods in acute or rehabilitation settings, randomized studies or non-randomized comparisons with concurrent or historical controls and some form of outcome assessment. RESULTS: we identified six non-randomized studies of acute stroke. One used concurrent controls; the rest used historical controls. Only one study investigated stroke rehabilitation and this used a quasi-randomized controlled design. Five studies in the acute setting demonstrated reduced hospital stay. A reduction in costs of care was reported in all five studies that examined costs. Two studies reported improved uptake of medical interventions. No difference in length of hospital stay, costs or functional status was seen in the rehabilitation study. CONCLUSIONS: integrated care pathway methodology may facilitate quality and cost improvements in stroke care, but evidence is weak and uncertainty exists. Further evidence is needed before implementation in practice.

Delivery of Health Care, Integrated↗
PubMed2000

Secular trends in the management of hypertension and atrial fibrillation in patients presenting with stroke.

We studied changes in stroke prevention in 2000 ischaemic stroke patients using prospectively collected data from an incident stroke register over 3 years. Patients were divided into those with risk factors but no previous history of a vascular event (asymptomatic vascular disease) and those with risk factors and a previous history of stroke or TIAs, ischaemic heart disease, angina, myocardial infarction or peripheral vascular disease (symptomatic vascular disease). Time trends were analysed for the use of aspirin, management of hypertension and atrial fibrillation prior to the presenting episode. Median age of those with known risk factors included in the study was 75 years (range 44-99 years); 60% were women. Year-by-year analysis showed no differences in demography, stroke characteristics or vascular risk profile. The use of aspirin for symptomatic vascular disease increased with time (28% to 72%) (p<0.001), but did not increase for asymptomatic vascular disease, despite risk factors being present. The proportion of patients receiving antihypertensive treatment for symptomatic vascular disease was unchanged with time (66% to 64%) but there was a significant increase in the number of patients receiving antihypertensive treatment for asymptomatic vascular disease (28% to 44%) (p<0.05). The proportion of patients with atrial fibrillation receiving antithrombotic treatment did not increase for asymptomatic vascular disease (23% to 21%) (p=0.54) but did increase for symptomatic vascular disease (19.5% to 37%) (p<0.01) over 3 years. The use of warfarin in atrial fibrillation increased both in the case of asymptomatic (4.5% to 42%) (p<0.01) and symptomatic vascular disease (12.5% to 33.0%) (p<0.01).

Adult↗
PubMed2000

Randomized controlled trial of integrated (managed) care pathway for stroke rehabilitation.

BACKGROUND AND PURPOSE: Integrated Care Pathway (ICP) is an organized, goal-defined, and time-managed plan that has the potential of facilitating timely interdisciplinary coordination, improving discharge planning, and reducing length of hospital stay. METHODS: An ICP for stroke rehabilitation based on evidence of best practice, professional standards, and existing infrastructure was developed. Its effectiveness was tested in 152 stroke patients undergoing rehabilitation who were randomized to receive ICP care coordinated by an experienced nurse (n=76) or conventional multidisciplinary care (n=76). RESULTS: The age, sex, premorbid functional ability, and stroke characteristics of the 2 groups were comparable. There were no differences in mortality rates (10 [13%] versus 6 [8%]), institutionalization (10 [13%] versus 16 [21%]), or length of hospital stay (50+/-19 versus 45+/-23 days) between patients receiving ICP or multidisciplinary care. Patients receiving conventional multidisciplinary care improved significantly faster between 4 and 12 weeks (median change in Barthel Activities of Daily Living Index 6 versus 2; P<0.01) and had higher Quality of Life scores at 12 weeks (65 versus 59; P=0.07) and 6 months (72 versus 63; P<0.005). There were no significant differences in the mean duration of physiotherapy (42.8+/-41.2 versus 39.4+/-36.4 hours) or occupational therapy (8.5+/-7.5 versus 8.0+/-7.5 hours) received between the 2 groups. CONCLUSIONS: ICP management offered no benefit over conventional multidisciplinary care on a stroke rehabilitation unit. Functional recovery was faster and Quality of Life outcomes better in patients receiving conventional multidisciplinary care.

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PubMed2000

Secondary stroke prevention in atrial fibrillation: lessons from clinical practice.

BACKGROUND AND PURPOSE: Secondary prevention trials do not distinguish outcomes according to stroke cause. The purpose of the study was to determine whether trial efficacy of anticoagulation for secondary prevention could be replicated in clinical practice in strokes of different etiology. METHODS: A 2-year observation study was undertaken in 288 stroke patients with atrial fibrillation (mean age 76 years; 55% women) who were receiving anticoagulation therapy to maintain an international normalized ratio of 2.0 to 3.0. Comparisons were made of (1) patient characteristics, anticoagulation control, and annual stroke/hemorrhage rates with those of the European Atrial Fibrillation Trial and (2) cause of recurrent stroke by initial stroke subtype. RESULTS: Subjects were 5 years older (95% CI 3 to 7 years), and more patients had small-vessel stroke (26% versus 14%; 95% CI 3% to 17%) compared with corresponding trial data. The duration spent in the target anticoagulation range (55% versus 59%), recurrent stroke rate (5.1% versus 3.6% per year), and major (2.3% versus 2.2% per year) or minor (9.5% versus 11.8% per year) hemorrhage rates were comparable with those in patients receiving warfarin in the randomized study. Ten of 14 (71%) of embolic recurrences occurred in patients with a previous cardioembolic episode, and 8 of 11 (73%) lacunar recurrences occurred in patients with previous lacunar stroke as the qualifying event for anticoagulation (P:=0.025). Only 3 of 14 cardioembolic compared with 8 of 11 lacunar recurrences occurred during adequate anticoagulation. CONCLUSIONS: Anticoagulation for secondary stroke prevention in clinical practice achieves outcomes comparable with those of randomized trials. Nearly 26% of qualifying strokes and 40% of recurrences were nonembolic; stroke subtype should be considered when making treatment decisions.

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