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Biomedical subjects

L Kalra

Publications and source records attributed to L Kalra.

At least 37 records · Page 2Linked to original sources
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.

Aged↗
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.

Aged↗
PubMed1999

Use of antithrombotic measures for stroke prevention in atrial fibrillation.

OBJECTIVE: To evaluate appropriateness of antithrombotic use to prevent stroke in atrial fibrillation. DESIGN, PATIENTS: 344 patients with atrial fibrillation, stratified by age, were assessed clinically for contraindications to anticoagulation and stroke risk. The use of warfarin and aspirin was compared with recommendations for anticoagulation derived from pooled clinical trial data. RESULTS: Low risk of stroke was seen in 47 (14%) patients, moderate risk in 213 (62%), and high risk in 84 (24%) patients included in the sample (mean (SD) age 68.4 (17.2) years, 42% men). The proportion of patients requiring anticoagulation varied from 258/344 (75%) to 72/344 (21%) depending upon criteria used, of whom 86/258 (33%) and 36/72 (50%) were receiving warfarin, respectively. Warfarin or aspirin were not being used in 124/297 (42%) patients with moderate to high risk, whereas anticoagulation was being undertaken in 13/47 (27%) patients at low risk of stroke. Antithrombotic use (warfarin or aspirin) was significantly less common in patients over 75 years of age, regardless of absence of contraindications and eligibility according to various criteria (p < 0.001). CONCLUSIONS: A clear need for anticoagulation using clinical criteria existed in about 25% of patients in atrial fibrillation presenting to medical clinics who were at high risk of stroke. Of these, only 50% of eligible patients were being anticoagulated. Appropriate anticoagulation needs to be based on risk assessment rather than age. Consensus is therefore needed on appropriate antithrombotic use in clinical practice.

Aged↗
PubMed1999

Risk assessment and anticoagulation for primary stroke prevention in atrial fibrillation.

BACKGROUND AND PURPOSE: Risk assessment before anticoagulation is important for effective stroke prevention in atrial fibrillation (AF). METHODS: A study was undertaken in patients with AF to investigate the contribution of clinical and echocardiography (ECHO) criteria to treatment decisions on anticoagulation. Patients were stratified by age and stroke risk; contraindications to anticoagulation and warfarin use were assessed. The value of ECHO in treatment decisions, effect of age, and existing anticoagulation practice were evaluated. RESULTS: The mean+/-SD age of 234 patients was 67.1+/-11.8 years, and 122 (52%) were women. Clinical risk factors were present in 74 of 80 patients (92%) aged >75 years compared with 99 of 154 patients (64%) </=75 years (P<0.01). ECHO risk was identified in 94 of 154 patients (61%) </=75 years, 16 (17%) of whom had no clinical risk factors. ECHO risk was present in 71 patients (88%) >75 years of age, and was associated with clinical risk factors in all patients. Eligibility for anticoagulation was seen in 72 of 154 (47%) to 105 of 154 (68%) patients aged </=75 years, depending on the criteria used, and in 66 of 80 patients (83%) >75 years, regardless of criteria used (P<0.01). Warfarin was being used in 55 of 105 patients (51%) </=75 years and 8 of 66 patients (12%) >75 years (P<0.001). Anticoagulation was being undertaken in 7 of 49 patients (14%) </=75 years despite no clinical or ECHO risks. CONCLUSIONS: Accurate assessments of eligibility and appropriateness of anticoagulation in AF can be made on clinical criteria alone, especially in older people. The value of ECHO in treatment decisions is limited to patients </=75 years of age with no clinical risk factors.

Aged↗
PubMed1998

Pharmacological treatment of dysphagia in stroke.

The pharynx is important for a normal swallow and it has been suggested that pharmacological agents may play a role in the management of pharyngeal dysphagia, but none have been formally evaluated. A pilot double-blind, placebo-controlled study was undertaken in 17 hospitalized patients with persistent dysphagia 2 weeks after stroke. Patients were randomized to treatment with slow-release nifedipine 30 mg orally (n = 8) or placebo (n = 9) following specialist swallowing assessment and videofluoroscopy to exclude severe dysphagia. Videofluoroscopy was repeated after 4 weeks of treatment. Fourteen patients (active 6, placebo 8) completed the study. Two patients died (active 1, placebo 1) and 1 patient in the active group had to be withdrawn because of progressive heart failure. Initial assessment showed impairment in the pharyngeal phase with delayed triggering of swallow, poor laryngeal elevation, and prolonged pharyngeal transit times in all patients. Silent aspiration was seen in 4 patients (active 2, placebo 2). Improvement in swallowing was seen in 8 patients (active 5, placebo 3) at the end of 4 weeks. There were significant changes in the pharyngeal transit time (mean -1.34 second; 95% C.I. -2.56, -0.11) and swallow delay (mean -1.91 seconds; 95% C.I. -3.58, -0.24) in the active group suggesting improvement in the initiation of pharyngeal contractions and reduction in the time taken for the bolus to transverse the pharynx. A similar change was not seen in the placebo group. It is suggested that pharmacological agents such as nifedipine may have a role in the management of stroke-related dysphagia and merit further investigation.

Aged↗
PubMed1998

Stroke risk management: changes in mainstream practice.

BACKGROUND: Research shows that identification and control of risk factors reduces ischemic stroke. The impact of this evidence and health initiatives on mainstream practice remains unknown. METHODS: The purpose of this observational study was to investigate prior management of risk factors (hypertension, atrial fibrillation, previous stroke/transient ischemic attacks) in patients with acute cerebral infarction. Data were collected on the frequency of known risk factors before the incident stroke and their management compared with predefined criteria for appropriateness. The proportion of patients receiving treatment for risk factors before the acute episode was studied over 3 years. RESULTS: One thousand seventy-four patients (median age, 76 years; 60% women) were included in the study over 3 years. The proportion of patients with known hypertension (41% to 46%), diabetes (12% to 13%), previous stroke or transient ischemic attack (TIA) (21% to 31%), and atrial fibrillation (16% to 21%) remained stable. Overall, approximately 45% patients with atrial fibrillation, 60% patients with hypertension, and 70% with cerebrovascular disease were being actively managed. Time trends analysis showed a significant increase in the proportion of patients being treated for risk due to known cerebrovascular disease (59% to 85%), atrial fibrillation (18% to 59%), ischemic heart disease (35% to 72%), and carotid disease (13% to 85%) between the first and third year. The proportion of patients receiving treatment for hypertension remained unchanged. Patients with preexisting symptomatic vascular disease were more likely to receive appropriate risk management compared with asymptomatic patients (72% versus 46%, P<.001). CONCLUSIONS: Although a significant number of ischemic events remain potentially preventable, there appears to be a positive trend in improved control of stroke risk.

Acute Disease↗
PubMed1998

The process of rehabilitation and discharge planning in stroke: a controlled comparison between stroke units.

BACKGROUND AND PURPOSE: Stroke units improve outcome for stroke patients. Comparative controlled studies between stroke units are required to determine which components of stroke unit rehabilitation influence outcome and which may be investigated further in randomized controlled trials. This study compares 2 stroke units with regard to the effect differences in practice have on functional recovery (Barthel Index score) and discharge planning (length of stay). METHODS: Stroke unit patients with moderate disability (Barthel score of 4 to 10 at week 1) admitted over 18 months were studied. Barthel measurements were obtained weekly from week 1 to discharge. Details of stroke unit function were recorded. The core features of stroke units were in place in both units. Rehabilitation was impairment focused (theoretically driven) on one unit and disability oriented (pragmatic) on the other. RESULTS: Numbers of patients were comparable (85 versus 99). Median Barthel score at week 1 (6 versus 6), time to maximal Barthel score (14 versus 14 weeks), discharge Barthel score (14 versus 14), and institutionalization (32% versus 28%) were similar in both units. Median lengths of stay differed (68 versus 49 days; P<0.001). CONCLUSIONS: Comparisons with regard to the rehabilitation process can be made between stroke units. Differences in rehabilitation process between 2 units showed no effect on the rate of functional recovery. Length of stay was significantly different between units, an effect that cannot be attributed to functional recovery and therefore reflects differences in discharge planning, including postdischarge support.

Aged↗
PubMed1997

The role of a specialist team in implementing continuing health care guidelines in hospitalized patients.

BACKGROUND: Assessment of continuing health care needs is unstandardized and often undertaken by professionals not trained in the management of complex disability. METHODS: A 6 month prospective study to evaluate the role of a specialist team in implementing continuing care guidelines in hospitalized patients. The team was responsible for assessment and facilitation of access to continuing health care throughout the hospital between hospital and community on a non-age-related basis. It had access to six inpatient beds and a budget to purchase health care after discharge for 7 days. Patients with complex disability were referred to the team if their continuing health care needs could not be assessed, improved or provided within routine practice. RESULTS: Of the 93 patients included in the study, 34 (37%) were from geriatric wards and 59 (63%) from other specialties. Twenty-six (44%) of the patients from other specialties had been inappropriately referred (no continuing health care needs) and 24 (41%) appropriate patients had not been referred because of inadequate assessments. It was possible to facilitate discharge and continuing care provision in 26 patients without transfer to dedicated beds. Thirty-two patients were transferred for further management (median length of stay 17 days). Three (9%) patients died, 20 (63%) were discharged home and six (19%) were discharged to institutional care. Three patients had to be transferred to acute care. A high level of satisfaction with support and post-discharge arrangements was reported by 26 (81%) patients, 25 (78%) carers and 26 (81%) general practitioners for patients transferred to specialist beds. CONCLUSIONS: Specialist intervention, using a team approach, facilitates effective implementation of continuing care guidelines in hospitalized patients.

Aged↗
PubMed1997

The influence of visual neglect on stroke rehabilitation.

BACKGROUND AND PURPOSE: The poor outcome observed in stroke patients with visual neglect may be due to greater stroke severity or nonspecialist management. METHODS: The effects of visual neglect were studied prospectively in 150 consecutive stroke patients with comparable stroke pathology and motor severity managed on a stroke unit. A randomized study was subsequently undertaken in 50 stroke patients with visual neglect to evaluate the effectiveness of spatial cueing during motor activity on functional outcome and resource use in these patients. RESULTS: Visual neglect was present in 47 (32%) of a selected group of 146 patients (mean age, 77.0 +/- 8.2 years; 42% men) with moderate stroke severity. There were no differences in demography, prestroke function, or motor power in the arm (2.6 +/- 1.7 versus 2.3 +/- 2.1) or the leg (3.2 +/- 1.4 versus 3.0 +/- 1.6) on the affected side compared with 99 patients with no visual neglect. Although patients with visual neglect had lower median initial (4 versus 5, P < .01) and discharge (14 versus 16, P < .01) Barthel Index scores, equal proportions of patients were discharged home (60% versus 65%) or to institutions (34% versus 33%) in both groups. The durations of hospitalization (64 versus 36 days, P < .001) and therapy input (47.7 versus 27.8 hours; P < .01), however, were significantly greater in patients with visual neglect. The randomized controlled study showed a trend toward higher Barthel scores at 12 weeks (14 versus 12.5, P = NS) and significant reduction in median length of hospital stay (42 versus 66 days) in patients receiving spatiomotor cueing and early emphasis on functional rehabilitation. CONCLUSIONS: Patients with visual neglect managed on a stroke unit have similar destination of discharge despite lower Barthel Index scores compared with patients of equal stroke severity who do not have this deficit. Spatiomotor cueing and early emphasis on function can improve outcome and reduce resource use in these patients.

Activities of Daily Living↗
PubMed1995

Role of stroke rehabilitation units in managing severe disability after stroke.

BACKGROUND AND PURPOSE: Stroke unit rehabilitation tends to be directed toward stroke patients with moderately severe disabilities ("the middle group"). Data collected on a stroke rehabilitation unit, however, showed improving outcome over 3 years in patients with a poor prognosis (discharge home: 48% versus 16%, P < .02; discharge Barthel Index score: 9 versus 6, P < .05). The hypothesis that stroke rehabilitation units may improve outcome in severely disabled stroke patients was tested in this study. METHODS: A randomized controlled study was undertaken in 71 patients with a poor prognosis who were treated either on a stroke rehabilitation unit (n = 34) or on general wards (n = 37) to compare outcome between the two groups. Data collected were also compared with those from a methodologically similar study undertaken 3 years ago. RESULTS: Severe stroke patients treated on the stroke rehabilitation unit had a significantly better outcome compared with general wards (mortality: 21% versus 46%, P < .05; discharge home 47% versus 19%, P < .01; median length of hospital stay: 43 versus 59 days, P < .02). The number of stroke unit patients being discharged home had increased significantly from the previous study, with a trend toward improvement in median discharge Barthel Index score. CONCLUSIONS: Stroke rehabilitation units may improve outcome in severe stroke patients. This improvement appears to be due to the development of innovative management strategies that reduce mortality and institutionalization and enable caregivers to support more disabled stroke patients at home.

Aged↗