Background/Objectives: Gaps in care due to the movement of patients between health settings and/or practitioners, known as transitions of care (TOC), may contribute to second stroke or TIA events. The elements that impact TOC in the stroke/TIA population have not been fully elucidated. The purpose of this study is to identify key elements of a Doctor of Nursing Practice-led TOC model that could be used to develop and evaluate a TOC program for the stroke/TIA population. Design: A descriptive study was performed to 1) identify elements that may affect transitions of care using a stroke database and post-discharge phone surveys and 2) based on information from Aim 1, propose a DNP-led TOC model specific to the stroke/TIA. Setting: An urban primary stroke center in the southwest United States. Participants: All patients in the GWTG®-stroke database from May 1 - December 31st, 2012 and patients who consented at discharge from the stroke unit following a stroke or TIA. Measurements: Patient demographics including: length of stay (LOS), age, race, ethnicity, comorbidities, insurance, discharge status, thirty-day readmission rate, and follow up survey. Results: Patient data (n=276) from GWTG®-stroke database was obtained. Average LOS was 7.81 +/- 11.15 days. The majority of patients were greater than age 65 (59%); 53% relied on Medicare support; those age 50-59 (21%) were most likely to be uninsured (47%). Fifty-one percent were discharged directly home, 48% of those were referred to outpatient rehab services. Two-thirds received rehabilitation services during hospitalization. Eight patients experienced a subsequent hospital readmission; two of those had a repeat stroke event. Although patients reported understanding their discharge instructions, their perception of ongoing care was poor. Conclusion: Key elements of a TOC model specific to the stroke and TIA patient population could include: patient surveillance, comprehensive care planning, follow-up, stroke education and point of contact. Advanced practice nurses have been successful in leading such programs, and a DNP-led model providing continuity of care would support the transition of an effective model into clinical practice.

The latest evidence indicates that 50,000 Canadians will experience a stroke in 2013. The hospital care, rehabilitation, and long term care associated with a stroke places a significant burden on our health care system. Lost productivity and premature death have an immeasurable impact on communities in our province as well as the rest of the country. Small, less populated regions such as Saskatchewan may be underrepresented in national data utilized in the development of national prevention and treatment strategies across the country. The absence of local research has necessitated the use of national information to guide prevention, treatment education and programming in Saskatchewan. The goals of this study was to provide a descriptive profile of stroke and transient ischemic attack cases admitted to Royal University Hospital over the period of April 1, 2009 to March 31st, 2010 and to assess the acute management of these cases as defined in the Canadian Best Practice Recommendations for Stroke Care (Strategy, 2010). A randomized sample of 200 cases 55 years and older was selected for a retrospective descriptive study involving review of adult stroke case records. Personal demographics and healthcare performance through the use of measures provided in The Canadian Best Practice Recommendations for Stroke Care (Canadian Stroke Network (CSN) and Heart and Stroke Foundation of Canada (HSFC), 2010) were evaluated. The results indicated many similarities to available national information on type of stroke, risk factors, gender, and age. Hospital adherence to national guidelines comparing selected indicators was exceeded in some areas, and met in most. The remaining indicators provide an opportunity for improvement and possibly more research. This regional information supplements the available Canadian information and could be used to guide planning and care strategically targeting Saskatchewan residents and increasing their potential for success.

The purpose of this study was to investigate how patients who had undergone Hallberg's  TIA-school at Enköpings Lasarett rate their physical and mental health 18 months after participation. Another purpose was to examine whether they re-diagnosed with a TIA or suffered a stroke. The design of the quantitative study was longitudinal and descriptive. In the study 16 patients participated and to measure their mental and physical health the questionnaire SF36 was used. The results showed that none of the participants suffered a new TIA or stroke since participation in the TIA-school. The participants' self-rated health measured with SF36 showed the highest values ​​in the areas of social function, emotional role function and physical role function. Which indicates a good self-rated health in these areas. Participants were asked how their physical and mental health limited them in everyday life. The majority of participants was not limited at all during the day, either physically (50%) or psychologically (62.5%). Our results demonstrate that a TIA-school like the one at Enköpings Lasarett may have long-term effects on an individual basis, but this effect can not be demonstrated in all off the patients.

The latest evidence indicates that 50,000 Canadians will experience a stroke in 2013. The hospital care, rehabilitation, and long term care associated with a stroke places a significant burden on our health care system. Lost productivity and premature death have an immeasurable impact on communities in our province as well as the rest of the country. Small, less populated regions such as Saskatchewan may be underrepresented in national data utilized in the development of national prevention and treatment strategies across the country. The absence of local research has necessitated the use of national information to guide prevention, treatment education and programming in Saskatchewan. The goals of this study was to provide a descriptive profile of stroke and transient ischemic attack cases admitted to Royal University Hospital over the period of April 1, 2009 to March 31st, 2010 and to assess the acute management of these cases as defined in the Canadian Best Practice Recommendations for Stroke Care (Strategy, 2010). A randomized sample of 200 cases 55 years and older was selected for a retrospective descriptive study involving review of adult stroke case records. Personal demographics and healthcare performance through the use of measures provided in The Canadian Best Practice Recommendations for Stroke Care (Canadian Stroke Network (CSN) and Heart and Stroke Foundation of Canada (HSFC), 2010) were evaluated. The results indicated many similarities to available national information on type of stroke, risk factors, gender, and age. Hospital adherence to national guidelines comparing selected indicators was exceeded in some areas, and met in most. The remaining indicators provide an opportunity for improvement and possibly more research. This regional information supplements the available Canadian information and could be used to guide planning and care strategically targeting Saskatchewan residents and increasing their potential for success.

Background Patients who experience a stroke or transient ischemic attack (TIA) are at high risk of recurrent stroke, but little is known about temporal trends in unselected populations. Reports of low adherence to recommended treatments indicate a need for enhanced secondary preventive follow-up to achieve the full potential of evidence-based treatments. In addition, socioeconomic factors have been associated with poor health outcomes in a variety of contexts. Therefore, it is important to assess the implementation and results of secondary prevention in different socioeconomic groups. Aims The aims of this thesis were to assess temporal trends in ischemic stroke recurrence and evaluate the implementation and results of a nurse-led, telephone-based follow-up program to improve blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) levels after stroke/TIA. Methods In study I, we collected baseline data for unique patients with an ischemic stroke event between 1998 and 2009 (n=196 765) from the Swedish Stroke Register (Riksstroke). Recurrent ischemic stroke events within 1 year were collected from the Swedish National Inpatient Register (IPR) and the cumulative incidence was compared between four time periods using the Kaplan-Meier survival analysis and the logrank test. Implementation (study II) and 1-year results (study III-IV) for the secondary preventive follow-up were studied in the NAILED (Nurse-based Age-independent Intervention to Limit Evolution of Disease) study. Between 1 Jan 2010 and 31 Dec 2013, the baseline characteristics of consecutive patients admitted to Östersund Hospital for acute stroke or TIA were collected prospectively (n=1776). Consenting patients in a condition permitting telephone-based follow-up were randomized to nurse-led, telephone-based follow-up or follow-up according to usual care. Follow-up was cunducted at 1 and 12 months after discharge and the intervention included BP and LDL-C measurements, titration of medication, and lifestyle counseling. In study II, we analyzed factors associated with non-participation in the randomized phase of the NAILED study, including association with education level. In addition, we compared the 1-year prognosis in terms of cumulative survival between participants and non-participants. In study III, we compared differences in BP and LDL-C levels between the intervention and control groups during the first year of follow-up and, in study IV, in relation to level of education (low, ≤10 years; high, >10 years). Results The cumulative 1-year incidence of recurrent ischemic stroke decreased from 15.0% to 12.0%. Among surviving stroke and TIA patients, 53.1% were included for randomization, 35.7% were excluded mainly due to physical or cognitive disability, and 11.2% declined participation in the randomized phase. A low level of education was independently associated with exclusion, as well as the patient’s decision to abstain from randomization. Excluded patients had a more than 12-times higher risk of death within 1 year than patients who were randomized. After 1 year of follow-up, the mean systolic BP, diastolic BP, and LDL-C levels were 3.3 mmHg (95% CI 0.3 to 6.3), 2.3 mmHg (95% CI 0.5 to 4.2), and 0.3 mmol/L (95% CI 0.1 to 0.4) lower in the intervention group than among controls. Among participants with values above the treatment goal at baseline, the differences in systolic BP and LDL-C levels were more pronounced (8.0 mmHg, 95% CI 4.0 to 12.1; 0.6 mmol/L, 95% CI 0.4 to 0.9). In the intervention group, participants with a low level of education achieved similar or larger improvements in BP and LDL-C than participants with a high level of education. In the control group, BP remained unaltered and the LDL-C levels increased among participants with a low level of education. Conclusion The 1-year risk of ischemic stroke recurrence decreased in Sweden between 1998 and 2010. Nurse-led, telephone-based secondary preventive follow-up is feasible in just over half of the survivors of acute stroke and TIA and achieve better than usual care in terms of BP and LDL-C levels, and equality in BP improvements across groups defined by education level. However, a large proportion of stroke survivors are in a general condition precluding this form of follow-up, and their prognosis in terms of 1-year survival is poor. Patients with a low education level are over-represented within this group and among patients declining randomization for secondary preventive follow-up.

Thesis (Ph.D.)--Indiana University, 2009. / Title from screen (viewed on December 1, 2009). Department of Anatomy and Cell Biology, Indiana University-Purdue University Indianapolis (IUPUI). Advisor(s): Zao C. Xu, Feng C. Zhou, Charles R. Yang, Theodore R. Cummins. Includes vitae. Includes bibliographical references (leaves 115-135).

Context: As one of the major causes of death and disability in Canada, research into the treatment and prevention of acute cerebrovascular syndrome (ACVS) remains a priority for clinicians, researchers and the general public. Understanding the relationship between current treatment practices of a rapid stroke clinic and patient outcomes is an essential part of measuring success and considering opportunities for quality improvement. Objective: This study compared the 90-day and 1-year hospital admission and mortality outcomes of patients who were referred to and seen in a rapid stroke clinic (the shows) following an initial transient neurological event (TNE) with those who were referred to but not seen in the same clinic (the no-shows). The specific outcomes examined were stroke events, cardiovascular events and all other hospital events. Methods: In this post-test only non-equivalent group design, data on patient outcomes was collected in the Victoria-based Stroke Rapid Assessment Unit (SRAU) between 2007 and 2013. Analysis included an assessment of group equivalency for possible confounders (age, sex and severity score) and two sets of multivariate logistic regressions were conducted on nine outcomes. Results: An independent t-test revealed there was a statistically significant difference between the mean age of the shows (mean= 68.26) and no-shows (mean= 69.90) (p<0.01). While the proportion of males and females in each of the groups was similar (Fisher’s Exact test, p = 0.831, ns), the severity score of the treatment group (mean= 3.64) was statistically more severe in the show group than the no-show group (mean= 3.50; t = 2.137, p<0.05). Controlling for age, sex and severity score, the odds ratios (ORs) were calculated to compare the odds of various outcomes in the treated (shows) versus the untreated (no-shows) patients groups. ORs for the 90-day and 1-year hospital admissions for stroke-related events were 0.071 (p<0.01) and 0.091 (p<0.01), respectively; the OR for 1-year stroke deaths was 0.167 (p<0.01), indicating a strong protective factor related to attending the clinic appointment. For the cardiovascular outcomes, the ORs for hospitalizations were 0.967 (ns) at 90-days and 0.978 (ns) within 1-year and the OR for the 1-year cardiac-related deaths was 0.391 (ns). For all other outcomes, the ORs were 0.525 (p<0.01) for hospitalizations within 90-days, 0.579 (p<0.01) for hospitalizations within 1-year and 0.299 (p<0.01) for deaths within 1-year. These findings remained consistent with re-analysis excluding subjects who had an event within 5.4 days of their initial TNE. These latter finding largely rules out the possibility that the primary reason the no-shows did not make their clinic appointment, was due to a subsequent hospital event. Conclusion: The ORs for the outcomes show a protective effect of stroke and all other hospital outcomes (but not cardiac events) for patients treated in the rapid assessment clinic. The exclusion of patients who experienced an outcome while waiting for a clinic appointment, lowered the protective effect of the treatment and emphasized the need for rapid assessment but did not alter the main study conclusions. Future research that explores factors influencing appointment adherence and patient attitudes towards acute treatment of TNEs might reveal strategies that could help to reduce the number of patients that remain untreated and at a higher risk for poor outcomes. / Graduate

The goal of this study was to derive a clinical prediction rule for transient ischemic attack (TIA) and non-disabling stroke to predict a treatment change based on echocardiogram. Methods: We conducted a cohort sub-study for TIA and non-disabling stroke patients collected over five years from 8 Emergency Departments. We compiled a list of 27 potential predictors to look for treatment change based on echocardiogram findings. We used a univariate, logistic regression and recursive partitioning analysis to develop the final prediction model. Results: The frequency of treatment change was seen in 87 (3.1%) of 2804 cases. The final model contains six predictors: age less than 50 years old, coronary artery disease history, history of heart failure, any language deficit, posterior circulation infarct and middle cerebral artery infarct on neuroimaging. Conclusions: We have developed a highly sensitive clinic prediction rule to guide in the use of echocardiogram in TIA and non-disabling stroke.

Large aspiny neurons are the only non-GABAergic neurons in the striatum. After transient cerebral ischemia, large aspiny neurons survive while medium spiny neurons die. Previous studies have shown that differential changes in the intrinsic membrane properties and excitatory synaptic transmission play a role in this selective vulnerability. However, the role of inhibitory synaptic transmission in this selective vulnerability is still unknown. Since inhibitory tone is very important in the control of neuronal excitability, the present study is aimed at examining if there are any changes in inhibitory synaptic transmission in striatal neurons after ischemia and the possible mechanisms. We also examined if facilitation of inhibitory synaptic transmission by muscimol could attenuate ischemic neuronal injury in the striatum after ischemia. Results from this study will improve the understanding of the mechanisms underlying selective neuronal injury after transient cerebral ischemia. We hope this study could contribute to the translational studies for the stroke patients after cardiac arrest. / Indiana University-Purdue University Indianapolis (IUPUI) / In the striatum, large aspiny (LA) interneurons survive transient cerebral ischemia while medium spiny (MS) neurons die. Excitotoxicity is believed to be the major cause for neuronal death after ischemia. Since inhibitory tone plays an important role in the control of neuronal excitability, the present study is aimed at examining if there are any changes in inhibitory synaptic transmission in striatal neurons after ischemia and the possible mechanisms. Transient forebrain ischemia was induced in male Wistar rats using the four-vessel occlusion method. Inhibitory postsynaptic currents (IPSCs) were evoked intrastriatally and whole-cell voltage-clamp recording was performed on striatal slices. The expression of glutamate decarboxylase65 (GAD65) was analyzed using immunohistochemical studies and Western blotting. Muscimol (a specific GABAA receptor agonist) was injected intraperitoneally to the rats (1 mg/kg) to observe ischemic damage, evaluated by counting the survived cells in the striatum after hematoxylin & eosin (HE) staining. The amplitudes of evoked IPSCs were significantly increased in LA neurons while depressed in MS neurons after ischemia. This enhancement was due to the increase of presynaptic release. Muscimol (1 μM) presynaptically facilitated inhibitory synaptic transmission in LA neurons at 24 h after ischemia. The optical density of GAD65-positive terminals and the number of GAD65-positive puncta was significantly increased in the striatum at both 1 day and 3 days after ischemia. Consistently, data from western blotting suggested an increased expression of GAD65 in the striatum after ischemia. For the rats treated with muscimol, the number of survived cells in the striatum was greatly increased compared to the non-treatment group. The present study demonstrates an enhancement of inhibitory synaptic transmission in LA neurons after ischemia, which is contributed by two mechanisms. One is the increased presynaptic release of GABA mediated by presynaptic GABAA receptors. The other is the increased expression of GAD. Facilitation of inhibitory synaptic transmission by muscimol protects striatal neurons against ischemia. Therefore, the enhancement of inhibitory synaptic transmission might reduce excitotoxicity and contribute to the selective survival of LA neurons after ischemia.

INTRODUCTION: The association of Sleep-Related Movement Disorders (SRMDs) such as Restless Legs Syndrome (RLS) and Periodic Limb Movements (PLMs) with cerebrovascular disease is underexplored. Emerging evidence links them to vascular disease, for which white matter hyperintensities (WMHs) are a well-recognized biomarker. METHODS: We conducted a cross-sectional hospital-based observational study in which high-risk TIA and minor stroke patients were assessed for vascular risk factors, WMHs and polysomnography-determined sleep variables. RESULTS: Ninety-seven patients were enrolled, of whom 44 completed polysomnography. Twenty-five percent had RLS, which was associated with lower quality of life. Independent of the effect of classical vascular risk factors, PLMs (but not RLS) were associated with WMHs on linear regression analyses (p=0.016). CONCLUSIONS: SRMDs are prevalent after minor stroke/TIA. RLS is associated with poor quality of life, while PLMs are associated with WMHs. Whether PLMs are implicated in the pathogenesis of WMHs or whether WMHs exacerbate PLMs remains uncertain.