Welcome to the WSC 2022 Interactive Program

Background and Aims

Background: stroke patients are in higher risk of multiple impairments (cognitive, chronic fatigue, mood disorders) which may lead to effect their mental health physical wellbeing. Mindfulness has been theoretically and empirically linked psychological well-being. The use of mindfulness-based interventions brings about various positive psychological effects, including increased well-being, reduced psychological distress.

AIM: A systematic review was conducted to determine the effectiveness of mindfulness based interventions (MBI) reducing depression among stroke survivors

Methods

Methodology: A search protocol was conducted using three databases (PubMed, Scopus and PsycINFO), Eligible studies were identified on the basis of SPIO criteria – Study, Population, Intervention, Outcome. Articles were required to meet the following criteria to be included: (1) describe mindfulness interventions, (2) published in the last ten years and include depression as an outcome, (3) study population was limited to patients with history of acute ischemic stroke (age>18 years), (4) published in English in a peer-reviewed journal.

Results

Results :

We identified 5RCTs as eligible for inclusion in the systematic review (including 170 stroke survivors). MBIs included manualized and tailored interventions, treatment duration 4-12 weeks, delivered face-to-face and online in groups and also individually.

figure will be attached later

Conclusions

Conclusion:

Evidence supports that mindfulness-based interventions improves mental health in stroke survivors by reducing depression. More research and future work with longer term follow-up are needed in order to understanding of how mindfulness-based interventions affect depression among stroke survivors.

Background and Aims

Worldwide, and especially in Latin America, stroke centers are usually located in capitals and metropolitan regions, creating gaps in stroke care coverage. Outside these regions, some general hospitals may be potential stroke centers. Health managers and decision-makers may benefit from this information to know the gaps in coverage and where to set up a new stroke center.

We aim to develop an open-access web-based system that will present the acute stroke care coverage in Latin America and the gaps in coverage and also suggest the optimal location for new stroke centers.

Methods

Data from the location and types of stroke centers will be gathered from the WSO Roadmap initiative in Latin America and the Certification of Stroke Centers database in Latin America. Data from current potential hospitals will be retrieved by a structured search on the internet and contacting neurologists in the countries. Geolocation of the stroke centers and potential stroke centers will be performed using open-access databases. The optimal location for implementing stroke centers will be obtained using meta-heuristics, machine learning methods, and data science strategies.

Results

The project is in progress, currently in the phase of optimization of the isochrone map for enhanced visualization of the coverage stratified by travel time. Also, the geolocation data for current and potential stroke centers are being collected.

Conclusions

The project will provide a tool for healthcare managers and decision-makers to understand their acute stroke care coverage and to plan the implementation of new stroke centers.
This project is funded by the World Stroke Organization via the Pilot Research Proposal Grant Program 2022.

Background and Aims

It is unclear whether early identification and interventions for poststroke depression (PSD) will modify long-term stroke outcomes.

Effective Mood Management After Stroke (EMMAS) was a hospital initiative since 2010 for screening and interventions for PSD to improve the rehabilitation potential and quality of life for stroke patients.

We aim to measure the impact of EMMAS on long-term stroke outcomes.

Methods

Chronic stroke survivors (stroke > 5 years) who participated in EMMAS (n=366) were compared with stroke survivors who did not (n=127), using propensity score matching.

Poor outcome was a composite of death, institutionalisation, overall health decline or having PSD at time of study participation.

Covariates used for matching were demographics, vascular risk factors, stroke characteristics and baseline stroke severity.

Results

60% of study sample were classified as having poor outcome. 115 matched pairs were identified. In the fully adjusted logistic regression for poor outcomes, non-EMMAS patients were 3 times more likely to suffer from poor outcomes, odds ratio for EMMAS group 0.37, 95% confidence interval 0.203 - 0.654, p<0.001.

Conclusions

Regardless of the presence of PSD, a model of stroke care that is integrated with proactive identification of PSD has an important protective effect on long-term stroke outcomes. This translates to value-added and cost-effective care.

Background and Aims

Caring for stroke survivors results in significant care-burden and strain on the informal caregivers. Caregiver-burden also poses risk to the care-recipient as it can substantially reduce quality of care giving. There is dearth of literature on interventional programmes that ameliorate burden in informal-caregivers of stroke survivors, therefore this study developed a culturally and environmentally friendly digital-assisted learning of implementing prescribed home-programmes intervention and investigate its efficacy on burden of care and quality of life (QoL) of informal-caregivers of stroke survivors

Methods

Study was conducted in 2-phases: Phase-one developed digital-assisted programme while phase-two used the programme given in digital format as intervention on 33 informal caregivers of stroke survivors. WHO-BREF and Preparedness for Care-giving Scale were used to assess burden, QoL and preparedness for caregiving respectively, before and one-month after intervention. Data was analysed using Wilcoxon Signed Rank Test.

Results

Thirty-two (72.7% females) participants completed the phase- of the study. They were aged 18years to 75years (mean=39.8±10.2years. More (63.6 %) were family members. More (48.5%) provided care for 6-12hours daily while 18% for at least 12hours daily with 54% providing care for not less than one-year. At baseline, 53.6% had mid-to-moderate while 46.4% had moderate-to-severe. Post-intervention, 68.8% had little while 31.3% had mid-moderate burden. there was significant improvement (p<0.001) in both domains and overall QoL and preparedness for caregiving between pre-intervention and post-intervention.

Conclusions

The study provided a digital-assisted learning of implementing prescribed home-programmes that effective in ameliorating burden of caregiving, improve QoL and preparedness to handle demands of caregiving on informal-caregivers of stroke survivors.

Background and Aims

Ischemic stroke is treatable with intravenous alteplase and/or endovascular thrombectomy (EVT) treatment. Both treatments are highly time dependent, as faster treatment results in better outcomes. Utilization of both of these treatments is less than optimal, and treatment times remain over the recommended benchmarks.

Methods

An improvement intervention was launched across Atlantic Canada through the ACTEAST (Atlantic Canada Together Enhancing Acute Stroke Treatment) Project. Atlantic Canada has four provinces: Nova Scotia (NS), New Brunswick (NB), Prince Edward Island (PEI), and Newfoundland and Labrador (NL). The improvement intervention was a 6-month virtual Improvement Collaborative that consisted of each stroke centre assembling an interdisciplinary team, 2 full-day Learning Sessions, four to six 1-hour webinars, and a site visit. The intervention was implemented using a Stepped-Wedge design, where the intervention is carried out in 3 phases (Figure). The first phase was with NS, followed by NB and PEI, and the final phase was with NL. Data collected during the green periods will be compared to the data collected in the orange periods of the Figure.

Results

The study is still on-going, but engagement results are available. The number of healthcare participants enrolled across all 34 hospitals were 98, 86, and 72 for NS, NB/PEI, and NL respectively. The Learning Sessions had a mean attendance rate of 63.7% (SD: 13.2%). Site visits were completed with each hospital and attendance ranged from 4-20 people.

Conclusions

High level of engagement is possible in an Improvement Collaborative Intervention when implemented using a stepped-wedge design.

Background and Aims

A subset of ischemic stroke patients is prone to receive inadequate treatment due to the highly constrained nature of MR (magnetic resonance) imaging, which leads them to have poor functional outcomes and poses a higher economic burden on the health system and those patients.

We aim to evaluate the impact of Synaptive 0.5T Evry MRI on functional outcomes in such patients and the impact on the cost to health systems and those patients.

Methods

We plan a single-center, ambidirectional case-control study; including profiles of stroke patients with diagnostic uncertainty on CT (computed tomography), which arrived beyond 4.5 hours window, or with an unknown time of onset. Retrospective chart reviews and interviews of the patients treated using the current system of stroke care (controls) and of the patient treated using the prospective use of Evry MRI (cases) will be considered for capturing data related to timelines, use of various imaging modalities, choice of treatment, and for costs to the health system and patients. Recorded data will be used to model both functional and economic outcomes. The most appropriate statistical tools will be used to develop three separate models for functional independence, the cost to the health system, and patients.

Results

Retrospective chart reviews and prospective patient recruitment will start after obtaining ethical approvals.

Conclusions

This study will bridge the gap in knowledge with respect to the impact of a readily accessible MR imaging system optimization on the functional outcomes in a subset of stroke patients and on cost-effectiveness for the health system and those patients.

Background and Aims

The World Stroke Organization Certification of stroke centers was created to ensure that hospitals implement and monitor all priority evidence-based strategies in stroke care. We present the certification program structuring strategy implemented in Latin America.

Methods

The WSO/SIECV certification is based on the WSO Roadmap for Quality Stroke Care that classifies the services in 3 levels: 2 stroke centers and 1 Minimal healthcare service for areas with low access to doctors and infrastructure. It suggests resources and protocols to be implemented in each level. For the WSO/SIECV Certification the executive committee of the program defined the criteria to certify each level of stroke center.

Results

The steps:1.To fill the self-assessment form to evaluate the status of the hospital; 2.If the hospital meets the criteria, to fill the online Application for Certification Form; 3.If approved (all mandatory elements and 75% of recommended in each level are required for certification ), to submit the supporting documents; 4.An onsite visit is scheduled; 6. After onsite visit an international board review gives the final approval; 7.The committee suggests actions to improve the services.

The program was structured in 5 months, launched in March 2021 and joined Ministries of Health and Scientific Societies from 13 countries. 14 hospitals were certified (9 Brazil, 1 Uruguay, 4 Colombia) and 20 are in process of certification.

Conclusions

In was feasible to create and implement a good quality certification program with a continuous improvement of services. The program will be expanded now to another regions.

Background and Aims

The stroke code system aims to provide efficient responses for hyper-acute stroke patients. Universitas Indonesia (UI) hospital established in 2019 and is the 83^rd hospital out of 2925 in Indonesia that has stroke code system. After 6 months of implementing the stroke code system, it is necessary to evaluate the system.

Methods

A cross-sectional study performed by taking secondary data from electronic medical records from September 2021 to March 2022. Subjects inclusion criteria were stroke patients which had onset less than 6 hours. Analysis of data will be carried out by analysing each stage of the stroke code timestamp.

Results

A total of 32 patients used the stroke code system. There were no records regarding ER arrival time and when the radiological interpretation was completed. The initiation of radiological examination should have a timestamp after system activation but there were 11 cases which showed the opposite, and 2 cases showed the timestamp occurred in the same minute. In 19 cases with the correct timestamp sequence, only 3 cases met the standard. Thrombolysis was administered to 6 patients, in which all cases did not meet the timestamp standard. In these 6 cases, the mean duration from system activation was 80 minutes. The data obtained in this study is quite limited, probably because RSUI and the stroke code system has just been established.

Conclusions

Timestamp recording in UI hospital code stroke system is not properly done. Knowledge related to timestamps is beneficial in increasing effectivity of handling stroke cases moving forward.

Background and Aims

National registries or audit programmes are recognised methods of assessing quality of healthcare delivery. The Sentinel Stroke National Audit Programme in England has historically focused on acute and hospital-based care. Whilst evidence suggests the audit has been successful in driving improvements in hospital-based care, this has yet to be established in the community setting. This study explores how the audit is perceived by community stakeholders and how audit-data is currently used.

Methods

An online survey distributed through social media and established clinical networks. Participants included individuals working in, commissioning or managing community stroke rehabilitation.

Results

A national sample from a broad group of stakeholders was achieved (n=206). Participants describe using data to support a range of service improvement activities such as: securing funding for additional staff / equipment and service reorganisation. However, concerns were raised regarding the audits ability to accurately reflect the post-acute stroke population, or the variety of services delivered. Participants identified a number of barriers that prevent audit leading to service improvement. These include insufficient skills to interpret audit reports, a lack of administrative support for data collection and competing demands on clinical time.

Conclusions

Stakeholders are engaged with the post-acute audit and report using data to support a variety of service improvements. Further investigation of the barriers identified are required in order to realise the potential of national clinical audit as a tool for quality improvement in the post-acute stroke setting.

Acknowledgement: Study supported by THIS Institute award: PHD-2020-01-003

Background and Aims

In the UK, over 20% of stroke survivors leave hospital severely disabled. Limited evidence-based clinical guidance is available to support the rehabilitation of these individuals. Our research has focussed on establishing consensus regarding the core components of home-based rehabilitation for this population. This study explores the challenges of providing that rehabilitation and identifies strategies to overcome them.

Methods

A multiple-case study design examined three multi-disciplinary rehabilitation teams providing home-based rehabilitation to this population. Data was collected from focus group transcripts with team representatives (n=20) and publicly available information such as national stroke audit data.

Results

High levels of need were reported for these patients across multiple domains such as continence, communication and motor control. There was lack of agreement relating to who was ultimately responsible for providing rehabilitation for this group. Teams have evolved to include this population but are insufficiently commissioned to fully meet their needs. In-complete and disjointed pathways with resultant healthcare inequalities were commonly reported.

Teams have adopted multiple strategies in attempts to overcome these challenges, including upskilling a diverse range of partners. Exploiting available multi-disciplinary expertise, skills and resources across health, social care and voluntary sector boundaries enabled rehabilitation opportunities, focused interventions and optimised outcomes.

Conclusions

Collaboration and partnership working are essential for commissioning and delivery of rehabilitation for severely disabled stroke-survivors. Multidisciplinary expertise is required, relying on coordinated multiagency rehabilitation opportunities to be realised to address existing health inequalities.

Acknowledgement: This work was supported by NIHR ARC East Midlands, grant number: NIHR-200171

Background and Aims

Lower-middle income countries (LMICs), including Southeast Asian region has over 11 millions strokes cases in 2016 according to World Health Organization, with mortality is high at more than 4 million annually and 87% of these deaths happened in LMICs. Along with advanced therapy in acute ischemic stroke like thrombolysis and endovascular therapy, there are financial problems especially to LMICs. We want to review healthcare, financing system and problems of Southeast Asian countries to cover acute ischemic stroke therapies.

Methods

We searched from PUBMED, PROQUEST and Scopus until July 2022 to identify articles containing combinations: (a) Systems of Care OR Healthcare System ; AND (b) Acute ischemic stroke ; AND (c) Indonesia OR Philippines OR Malaysia OR Singapore OR Laos OR Brunei OR Myanmar OR Thailand OR Cambodia OR Vietnam OR Southeast Asia; AND (d) Burdens OR Problems.

Results

Mainly among Southeast Asian countries, the healthcare coverage for acute ischemic stroke therapies financed by private sector, nongovernmental section and mostly by public sector, meanwhile thrombectomy devices have to be paid as an out-of-pocket expense and become a major obstacle for many patients, therefore it's infrequently performed except in tertiary or national referral hospitals. For some nations there are scarcity of neurologist especially in rural area.

Conclusions

Stroke services have improved steadily in Southeast Asian countries given that thrombolysis and endovascular therapy already implemented throughout the region. However, it is also important to improve the quality and quantity of human resources, distribution of physicians, healthcare system and financing to continue reducing mortality and morbidity from acute ischemic stroke.

Background and Aims

Sri Lanka has a complex health system where a significant number of people utilize non-western alternative treatment systems such as Ayurveda, Traditional indigenous Medicine, Unani etc. These systems have statutory recognition. Therefore, treatment of conditions like strokes which need long term care often is a mix of these systems. Particularly in strokes, as these systems are used for long term care and rehabilitation, western medical practitioners will often experience their patients using alternative treatments. The aim of this study is to describe the perception of health professions on using alternative therapies for stroke recovery.

Methods

Descriptive cross sectional study among conveniently selected Doctors, Nurses and Physiotherapists from Western Province of Sri Lanka, using an online questionnaire.

Results

Majority of the sample (95%) have come across patients who have used alternative therapies for their stroke recovery. Most common type of alternative therapy was Ayurveda (95%). Most experienced (45%) that alternative therapies were used when patients reach the maximum possible improvements through western medicine. 41% professionals thought that there are both motor and sensory improvements through alternative medicine. 64% believed that alternative therapies are beneficial in stroke recovery.

Conclusions

Alternative therapies can be suggested as an adjunct with western medicine for patients to reach their maximum potentials.

Background and Aims

The benefits of stroke management is time-sensitive. However, healthcare service disruptions and fears related to the COVID-19 pandemic have resulted in reduced stroke admissions. We aim to compare variables associated with early versus late time-to-admissions following acute stroke and transient ischemic attack (TIA) during the pandemic.

Methods

We conducted a prospective cross-sectional study in a 5-month period. Data was collected via questionnaire and guided interview. Descriptive and bivariate chi-square analyses was conducted comparing variables between early and late admission (cut-off 4.5 hours).

Results

137 patients were included. Most were male (59.1%) with a mean age of 61.12 (SD ±13.52). Diagnoses were ischemic stroke (83.2%), hemorrhagic stroke (9.5%), and TIA (7.3%). Median time-to-admission was 7 hours (IQR 2.00-23.00). 60.6% of patients experienced delayed time-to-admission exceeding 4.5 hours. Factors associated with early arrival include a diagnosis of hemorrhagic stroke (p<0.001), symptoms of altered mentation (p<0.001) and visual dysfunction (p=0.001), routine anti-hypertensive usage (p=0.015), higher education level (p=0.004), perceptions of seriousness (p<0.001) and urgency (p<0.001), and recognition of stroke (p<0.001). Being alone during onset of symptoms was significantly associated with delayed arrival (p<0.001).

Conclusions

A majority of stroke patients were admitted after the golden period, due to failure in recognizing symptoms of stroke and low perceptions of seriousness and urgency. Other factors such as perceived severity of symptoms (i.e., altered mental status, visual dysfunction), a higher education, and routine use of hypertensives, contributes to early arrival. This study can be used to inform future public health intitiatives and campaigns.

Background and Aims

Active patient participation involving engagement and meaningful activities promotes the neuroplastic basis for functional recovery after a stroke, yet, participation is, along with levels of physical activity often low, regardless of stroke severity. The reasons behind this are unclear. The purpose of this study was to explore how stroke survivors perceive the transition from being an independent individual to one in need of help and if their role in post-stroke rehabilitation and the subsequent influence of these on active participation in their life and in society.

Methods

In-depth interviews with 17 stroke survivors were conducted. Data were analyzed using systematic text condensation informed by the term autonomy from enactive theory.

Results

Two categories emerged. The first describes how the stroke and the admission to hospital cause a shift from being an autonomous person to “an object on an assembly line”. In hospital, protocol-based investigations, inactivity and lack of patient involvement dominate. The second category illuminates how the stroke survivors passively adapt to the hospital system in contrast to participatory enablement in the community. Patients are more prepared for the transition to home after in-patient rehabilitation than following direct discharge from hospital. When discharged directly to their home many felt unprepared for difficulties such as fatigue or cognitive problems that surfaced only after discharge.

Conclusions

Bodily changes, the traditional patient role and the hospital context mutually reinforce a reduction in individual autonomy and actualize how partnership in interactions with multidisciplinary professionals may strengthen autonomy and promote participation after a stroke. There is an underutilized potential for promoting participation.

Background and Aims

Stroke is a major cause of death and disability globally, and has been associated with poor functional outcomes, leading to diminished quality of life. Evidence suggests certain factors such as age, functional level at admission, severity of stroke and previous stroke can predict functional outcomes, however the role of other factors such as mood, resilience levels, cognition are less clear. There is also a paucity of studies looking at factors that could predict quality of life in these survivors. Hence, we aim to establish the association of these factors with functional outcomes and quality of life of stroke survivors.

Methods

We will conduct a prospective cohort study in a Singapore Community Hospital, where we will recruit 192 participants transferred to the community hospital for rehabilitation after a stroke. We will collect data relating to their functional status using the Modified Barthel Index (MBI), quality of life using EQ-5D-5L, mental health using the Patient Health Questionnaire (PHQ-2) and Conner Davidson Resilience Scale (CD-RISC 10), cognition using Abbreviated Mental Test (AMT), medical history and sociodemographic factors.

Results

We will perform data analysis using the IBM SPSS Statistics for Windows, Version 23.0. We will summarize the demographic variables using descriptive statistics and will use univariate and multivariate analyses to study the associations between the various factors with functional outcomes and quality of life measures.

Conclusions

Our research aims to identify factors from the biopsychosocial domains that are associated with functional outcomes and quality of life in stroke survivors, to guide future research in targeting modifiable factors.

Background and Aims

Stroke is a cause of high morbidity and mortality. The implementation of code stroke system in Indonesia has only been running for the past 7-8 years. The Education Hospital of University of Indonesia is a hospital that has been operating for 3 years and has been running the code stroke system since September 2021. After 6 months of implementation, evaluation was carried out for further improvements.

Methods

Cross-sectional study was employed in which secondary data were collected from 32 patients who came to the ER and were taken from electronic medical records between September 2021 to March 2022. Data analysis was carried out from the description of patient management, used imaging, and factors that influenced thrombolysis decisions and outcomes.

Results

The study found out 32 patients presented with hemiparesis in less than 6 hours after the onset. The imaging was carried out using CT scan on 11 patients and MRI on 21 patients. The result revealed 9 patients with mimic stroke, 19 patients with ischemic stroke, and 4 hemorrhagic stroke patients. There were 8 eligible candidates for thrombolysis, 2 patients had contraindications with thrombocytopenia and bleeding. Therefore, thrombolysis was performed on 6 patients. NIHSS scores were improved on 5 patients. Neurologist decision to cancel the code stroke due to the normal imaging results at the age of > 70 years and with NIHSS score < 4.

Conclusions

This study concluded an evaluation is required to undertake certain types of medical imaging in order to obtain the effective flow of code stroke.