Abstract
3
Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
Stroke is the second leading cause of death and a major cause of disability worldwide. Two-thirds of stroke deaths worldwide occur in developing countries. Hypertension and diabetes are the two major risk factors for stoke in India. There is a positive trend in the development of stroke units and stroke care services in the major cities of the country. Thrombolysis for stroke is given in many centers across the nation. The stroke units are more in the private sector hospitals than in the public hospitals. The key issues in India in developing a stroke program are a) Convincing the local hospital/government policy makers b) Creating a stroke team due to lack of personnel c) Availability of infrastructure etc. The above issues are the important factors which hinder the development of stroke care services in the government sector hospitals. A very small segment of the eligible patients receive thrombolysis due to non-affordability of the drug. There is a lack of awareness among the public and the patient regarding stroke warning symptoms and signs. Lack of ambulance services cause a delay in the hospital arrival of the patients. Organized stroke rehabilitation is very scarce in the country. The use of alternative medicine by the stroke patients is very high. Very often it interferes with the implementation of secondary prevention strategies. The local sociocultural factors, diet and the joint family system can be used to improve the care of the stroke patients.
4
Cerebrovascular Disease Department, Ho Chi Minh City, Vietnam
Intravenous (IV) thrombolysis is a proven therapy in acute ischaemic stroke (IS), but its use is relatively rare in developing countries such as Vietnam. Ho Chi Minh (HCM) city is the largest city in Vietnam with a population of more than 8 million people. The major obstacles are the cost of the drug, unawareness of stroke signs, and poor organization of emergency response and ambulance services. They result in a large number of patients being excluded from potential treatment because of late presentation to hospital, with only 8.7% of arriving within 3 h. Since 2006, IV-tPA has been provided at three Stroke Centers in HCM city for acute stroke. We conducted an observational study of outcomes after IV-tPA in these 3 hospitals and the preliminary results just have been published recently. An important finding of this study was that 43% of patients receiving IV-tPA had a mRS 0–1 at 3 months. Importantly, low-dose IV-tPA was associated with a low mortality rate of 2.1% and a high 3-month functional independence rate of 56.3%. Consequently, raising the awareness of the public and enhancing organizational aspects of acute stroke management have enabled better outcomes. There has been a dramatic increase in the number of stroke patients received IV-tPA in our center for years, with 59 patients in 2009 and 40 patients in the first 6 months of 2010. At the same time, we have begun to offer endovascular intervention with intra-arterial thrombolysis and mechanical thrombectomy for patients who failed IV thrombolysis or who presented within 3 and 6 h. In conclusion, our preliminary results provide further confirmatory evidence of the safety and feasibility of IV-tPA for treatment in Vietnamese patients with acute IS.
5
1The George Institute for International Health, Royal Prince Alfred Hospital and University of Sydney, NSW, Australia; 2Department of Neurology, Peking University First Hospital, Beijing, China; 3Centre for Epidemiological Studies and Clinical Trials, Rui Jin Hospital, Shanghai Jiaotong University, Shanghai, China; 4Sydney Medical School (Western), Sydney, NSW, Australia; 5Department of Neurology and Clinical Research Unit, Lariboisière Hospital, APHP, Paris, France; 6INSERM Unit 708, APHP, Paris; 7John Hunter Hospital and the Hunter Medical Research Institute, University of Newcastle, Australia
6
Vascular Biology & Immunopharmacology Group, Department of Pharmacology, Monash University, VIC, Australia
Early reperfusion is the preferred treatment strategy in ischaemic stroke, but the effects of circulating immune cells on stroke outcome are still poorly understood. Differing temporal profiles of infiltration of various leukocyte types occur in the post-ischaemic brain, with some populations of innate or adaptive immune cells likely to be beneficial and others detrimental. These influences are further complicated by differences between genders in the underlying mechanisms. We have recently examined aspects of T lymphocyte function in a mouse model of 0.5 hour middle cerebral artery occlusion using an intraluminal monofilament followed by reperfusion. We found evidence that salvage of cerebral tissue following reperfusion was limited by the damaging effects of infiltrating Nox2-containing (i.e. superoxide-generating) leukocytes. Most of the Nox2-expressing cells in the infarct at 24 hours were found to be T lymphocytes. Moreover, stroke resulted in a marked increase in superoxide production by circulating, but not spleen-derived, T-lymphocytes, and all these effects of stroke were profoundly greater in males in comparison to females. Our findings provide novel insights into mechanisms that could be therapeutically targeted in acute ischemic stroke patients who receive thrombolysis therapy to induce cerebral reperfusion.
7
Cerebrovascular Disease Department, Ho Chi Minh City, Vietnam
Intravenous (IV) thrombolysis is a proven therapy in acute ischaemic stroke (IS), but its use is relatively rare in developing countries such as Vietnam. Ho Chi Minh (HCM) city is the largest city in Vietnam with a population of more than eight million people. The major obstacles are the cost of the drug, unawareness of stroke signs, and poor organization of emergency response and ambulance services. They result in a large number of patients being excluded from potential treatment because of late presentation to hospital, with only 8.7% of arriving within 3 h. Since 2006, IV-tPA has been provided at three Stroke Centers in HCM city for acute stroke. We conducted an observational study of outcomes after IV-tPA in these three hospitals and the preliminary results just have been published recently. An important finding of this study was that 43% of patients receiving IV-tPA had an mRS 0–1 at 3 months. Importantly, low-dose IV-tPA was associated with a low mortality rate of 2.1% and a high 3-month functional independence rate of 56.3%. Consequently, raising the awareness of the public and enhancing organizational aspects of acute stroke management have enabled better outcomes. There has been a dramatic increase in the number of stroke patients received IV-tPA in our center for years, with 59 patients in 2009 and 40 patients in the first 6 months of 2010. At the same time, we have begun to offer endovascular intervention with intra-arterial thrombolysis and mechanical thrombectomy for patients who failed IV thrombolysis or who presented within 3 and 6 h. In conclusion, our preliminary results provide further confirmatory evidence of the safety and feasibility of IV-tPA for treatment in Vietnamese patients with acute IS.
8
Hunter New England Area Health, NSW, Australia
The ischaemic penumbra is the threatened, but potentially salvageable tissue surrounding the infarct core soon after stroke, and salvaging the penumbra is the target of acute stroke treatment. Accurate identification of penumbra has the potential to improve thrombolytic treatment by allowing individualised assessment of potential benefits (and possibly risks). However methods to accurately define penumbra in a timely manner require further improvement. In particular, identifying the optimal thresholds for definition of penumbra using existing perfusion based imaging has been problematic. In part this may be because in patients it is often difficult to accurately define the time of vessel reperfusion relative to imaging. I believe experimental models have a lot to offer in terms of improving understanding of, and more accurately defining the penumbra. This has been shown in studies using MRI, CT perfusion and hypoxia markers in both animals and humans. My interpretation of the existing evidence is that there is a similar duration of penumbra in rodents and humans. New data indicates that there may be multiple dynamic factors, including cortical spreading depressions and the opening of leptomeningeal collateral vessels, which influence the duration of penumbral survival in individuals.
9
Supportive and Palliative Care Unit, McCulloch House, Monash Medical Centre, Southern Health, Clayton VIC, Australia
Eastern Palliative Care, Specialist Palliative Home Care, VIC, Australia
Department of Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton VIC, Australia
The last hours to days of life is defined as the terminal phase of an illness. At this time the focus of care is upon the active management of symptoms whilst maintaining dignity for the patient and caring for and supporting their family. Dying is a clinical diagnosis that some clinicians seem to struggle with, it is suggested by: the patient becoming increasingly weak, bed bound and drowsy; difficulty with swallowing is common; and appetite and intake decrease, and patients may become withdrawn and less communicative. Once diagnosed the common symptoms should be anticipated and these include delirium, restlessness, dyspnoea, pain and excessive respiratory secretions. Understanding the clinical course of dying, appropriate and timely symptom management, both pharmacological and non-pharmacological, and addressing family/carers fears and concerns should minimise suffering and distress to patients and their families at the end of life. It is important to remember that the majority of Australians die not in a designated palliative care bed, but in an acute general hospital. At Southern Health we have therefore developed a multidisciplinary care plan ‘Pathway for Improving the Care of the Dying (PICD)’ to guide generalist staff in the diagnosis and management of patients dying in general wards1.
10
National Stroke Research Institute (a part of the Florey Neuroscience Institutes), VIC, Australia
A Very Early Rehabilitation Trial (AVERT) is a large international rehabilitation trial currently underway. This trial is used to illustrate the challenges in obtaining high quality clinical data. AVERT aims to recruit 2104 stroke patients from over 30 hospitals in six countries. High data quality requires clear Case Report Forms (CRFs), accurate data collection from the medical record and the patient, consistent data collection procedures, and complete and timely data collection. A skilled trials manager is very important and provides consistent training and ongoing site support. The trial manager provides training in all aspects of the trial protocol, AVERT Online and CRFs. The validity of outcome measures and any differences in culture and language use are identified during site feasibility assessment. Solutions to any differences are then determined. Our AVERT Online clinical trials web site is an essential trial tool. AVERT Online provides a training package to test reliability in outcome measures. AVERT Online also provides an easy tracking system of individual patient data over the 12 month trial period. Hospitals and trial management can check the progress of CRF completion. An automated email system reminds staff when CRFs are due, overdue or incomplete. A data collection manual is used to reinforce a consistent data collection process. Logic checks are run on submitted data and data clarification procedures are used. Regular on-site monitoring is limited due to funding restrictions, so other strategies are required. Data analyses are used to determine data outliers, and these are followed up as required.
11
Brock K1, Hakkennes S2 and
1St Vincent's Hospital Melbourne, Victorian Stroke Clinical Network, VIC, Australia; 2Barwon Health, La Trobe University, Victorian Stroke Clinical Network, VIC, Australia; 3Victorian Stroke Clinical Network, Department of Health, VIC, Australia
Rehabilitation for severe stroke has been an area of interest in Victoria for some years, with a focus on accessibility and provision of rehabilitation resources. Two prospective benchmarking studies have been undertaken. The first study utilised data from eight rehabilitation units to investigate the effect of implementation of casemix based funding for rehabilitation in 2001. The second study addressed discharge destination from the acute hospital setting, with seven hospitals participating. These studies demonstrated changes in practice associated with changes in the funding model and variations in practice with regard to access to rehabilitation. In 2008, the Subacute Committee of the Victorian Stroke Clinic Network sought to develop this work further by commissioning a systematic review of selection for inpatient rehabilitation and through analysis of data routinely reported by rehabilitation units to the Department of Health. The systematic review included three categories of studies; prediction of outcome, prediction of discharge destination from the acute setting and studies directly investigating selection for rehabilitation. Analysis of the Department of Health data focused on number of admissions, admission and discharge function and length of stay for those with severe stroke for each health service. The presentation will outline the outcomes of these activities.