Satu Baylan

Bio: Satu Baylan is an academic researcher from University of Glasgow. The author has contributed to research in topics: Cognition & Mood. The author has an hindex of 6, co-authored 11 publications receiving 205 citations.

Early supported discharge services for people with acute stroke

Abstract: Background People with stroke conventionally receive a substantial part of their rehabilitation in hospital. Services have now been developed that offer people in hospital an early discharge with rehabilitation at home (early supported discharge: ESD). Objectives To establish if, in comparison with conventional care, services that offer people in hospital with stroke a policy of early discharge with rehabilitation provided in the community (ESD) can: 1) accelerate return home, 2) provide equivalent or better patient and carer outcomes, 3) be acceptable satisfactory to patients and carers, and 4) have justifiable resource implications use. Search methods We searched the Cochrane Stroke Group Trials Register (January 2017), Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 1) in the Cochrane Library (searched January 2017), MEDLINE in Ovid (searched January 2017), Embase in Ovid (searched January 2017), CINAHL in EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to December 2016), and Web of Science (to January 2017). In an effort to identify further published, unpublished, and ongoing trials we searched six trial registries (March 2017). We also performed citation tracking of included studies, checked reference lists of relevant articles, and contacted trialists. Selection criteria Randomised controlled trials (RCTs) recruiting stroke patients in hospital to receive either conventional care or any service intervention that has provided rehabilitation and support in a community setting with an aim of reducing the duration of hospital care. Data collection and analysis The primary patient outcome was the composite end-point of death or long-term dependency recorded at the end of scheduled follow-up. Two review authors scrutinised trials, categorised them on their eligibility and extracted data. Where possible we sought standardised data from the primary trialists. We analysed the results for all trials and for subgroups of patients and services, in particular whether the intervention was provided by a co-ordinated multidisciplinary team (co-ordinated ESD team) or not. We assessed risk of bias for the included trials and used GRADE to assess the quality of the body of evidence. Main results We included 17 trials, recruiting 2422 participants, for which outcome data are currently available. Participants tended to be a selected elderly group of stroke survivors with moderate disability. The ESD group showed reductions in the length of hospital stay equivalent to approximately six days (mean difference (MD) -5.5; 95% confidence interval (CI) -3 to -8 days; P < 0.0001; moderate-grade evidence). The primary outcome was available for 16 trials (2359 participants). Overall, the odds ratios (OR) for the outcome of death or dependency at the end of scheduled follow-up (median 6 months; range 3 to 12) was OR 0.80 (95% CI 0.67 to 0.95, P = 0.01, moderate-grade evidence) which equates to five fewer adverse outcomes per 100 patients receiving ESD. The results for death (16 trials; 2116 participants) and death or requiring institutional care (12 trials; 1664 participants) were OR 1.04 (95% CI 0.77 to 1.40, P = 0.81, moderate-grade evidence) and OR 0.75 (95% CI 0.59 to 0.96, P = 0.02, moderate-grade evidence), respectively. Small improvements were also seen in participants' extended activities of daily living scores (standardised mean difference (SMD) 0.14, 95% CI 0.03 to 0.25, P = 0.01, low-grade evidence) and satisfaction with services (OR 1.60, 95% CI 1.08 to 2.38, P = 0.02, low-grade evidence). We saw no clear differences in participants' activities of daily living scores, patients subjective health status or mood, or the subjective health status, mood or satisfaction with services of carers. We found low-quality evidence that the risk of readmission to hospital was similar in the ESD and conventional care group (OR 1.09, 95% CI 0.79 to 1.51, P = 0.59, low-grade evidence). The evidence for the apparent benefits were weaker at one- and five-year follow-up. Estimated costs from six individual trials ranged from 23% lower to 15% greater for the ESD group in comparison to usual care. In a series of pre-planned analyses, the greatest reductions in death or dependency were seen in the trials evaluating a co-ordinated ESD team with a suggestion of poorer results in those services without a co-ordinated team (subgroup interaction at P = 0.06). Stroke patients with mild to moderate disability at baseline showed greater reductions in death or dependency than those with more severe stroke (subgroup interaction at P = 0.04). Authors' conclusions Appropriately resourced ESD services with co-ordinated multidisciplinary team input provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as reducing the length of hospital stay. Results are inconclusive for services without co-ordinated multidisciplinary team input. We observed no adverse impact on the mood or subjective health status of patients or carers, nor on readmission to hospital.

Positive PsychoTherapy in ABI Rehab (PoPsTAR): A pilot randomised controlled trial.

Abstract: Psychological distress is common following acquired brain injury (ABI), but the evidence base for psychotherapeutic interventions is small and equivocal. Positive psychotherapy aims to foster well-being by increasing experiences of pleasure, engagement and meaning. In this pilot trial, we investigated the feasibility and acceptability of brief positive psychotherapy in adults with ABI and emotional distress. Participants were randomised to brief positive psychotherapy plus usual treatment, or usual treatment only. Brief positive psychotherapy was delivered over eight individual out-patient sessions, by one research psychologist. A blinded assessor administered the Depression Anxiety Stress Scales (DASS-21) and the Authentic Happiness Inventory (AHI) at 5, 9 and 20 weeks post-baseline. Of 27 participants randomised (median age 57; 63% male; 82% ischaemic stroke survivors; median 5.7 months post-injury), 14 were assigned to positive psychotherapy, of whom 8 completed treatment. The intervention was feasible to deliver with excellent fidelity, and was acceptable to participants. Retention at 20 weeks was 63% overall. A full-scale trial would need to retain n = 39 per group to end-point, to detect a significant difference in change scores on the DASS-21 Depression scale of 7 points (two-tailed alpha = .05, power = .80). Trials including an active control arm would require larger sample sizes. We conclude that a full-scale trial to investigate efficacy is warranted.

Measuring the effects of listening for leisure on outcome after stroke (MELLO): A pilot randomized controlled trial of mindful music listening:

Abstract: BackgroundCognitive deficits and low mood are common post-stroke. Music listening is suggested to have beneficial effects on cognition, while mindfulness may improve mood. Combining these approache...

The effects of music listening interventions on cognition and mood post-stroke: a systematic review

Abstract: Introduction: Music listening may have beneficial psychological effects but there has been no comprehensive synthesis of the available data describing efficacy of music listening in stroke.Areas covered: We performed a systematic review examining the effects of music listening interventions on cognition and mood post-stroke. We found five published trials (n = 169 participants) and four ongoing trials. All studies demonstrated benefits of music listening on at least one measure of cognition or mood. Heterogeneity precluded meta-analysis and all included studies had potential risk of bias. Common reporting or methodological issues including lack of blinding, lack of detail on the intervention and safety reporting.Expert commentary: It is too early to recommend music listening as routine treatment post-stroke, available studies have been under-powered and at risk of bias. Accepting these caveats, music listening may have beneficial effects on both mood and cognition and we await the results of ongoi...

Action Plan for Stroke in Europe 2018-2030.

Abstract: Two previous pan-European consensus meetings, the 1995 and 2006 Helsingborg meetings, were convened to review the scientific evidence and the state of current services to identify priorities for research and development and to set targets for the development of stroke care for the decade to follow. Adhering to the same format, the European Stroke Organisation (ESO) prepared a European Stroke Action Plan (ESAP) for the years 2018 to 2030, in cooperation with the Stroke Alliance for Europe (SAFE). The ESAP included seven domains: primary prevention, organisation of stroke services, management of acute stroke, secondary prevention, rehabilitation, evaluation of stroke outcome and quality assessment and life after stroke. Research priorities for translational stroke research were also identified. Documents were prepared by a working group and were open to public comments. The final document was prepared after a workshop in Munich on 21-23 March 2018. Four overarching targets for 2030 were identified: (1) to reduce the absolute number of strokes in Europe by 10%, (2) to treat 90% or more of all patients with stroke in Europe in a dedicated stroke unit as the first level of care, (3) to have national plans for stroke encompassing the entire chain of care, (4) to fully implement national strategies for multisector public health interventions. Overall, 30 targets and 72 research priorities were identified for the seven domains. The ESAP provides a basic road map and sets targets for the implementation of evidence-based preventive actions and stroke services to 2030.

What is the evidence on the role of the arts in improving health and well-being?

Abstract: Over the past two decades, there has been a major increase in research into the effects of the arts on health and well-being, alongside developments in practice and policy activities in different countries across the WHO European Region and further afield. This report synthesizes the global evidence on the role of the arts in improving health and well-being, with a specific focus on the WHO European Region. Results from over 3000 studies identified a major role for the arts in the prevention of ill health, promotion of health, and management and treatment of illness across the lifespan. The reviewed evidence included study designs such as uncontrolled pilot studies, case studies, small-scale cross-sectional surveys, nationally representative longitudinal cohort studies, community-wide ethnographies and randomized controlled trials from diverse disciplines. The beneficial impact of the arts could be furthered through acknowledging and acting on the growing evidence base; promoting arts engagement at the individual, local and national levels; and supporting cross-sectoral collaboration.

2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

Abstract: HomeStrokeVol. 53, No. 72022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessReview ArticlePDF/EPUB2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association Steven M. Greenberg, MD, PhD, FAHA, Chair, Wendy C. Ziai, MD, MPH, FAHA, Vice Chair, Charlotte Cordonnier, MD, PhD, Dar Dowlatshahi, MD, PhD, FAHA, Brandon Francis, MD, MPH, Joshua N. Goldstein, MD, PhD, FAHA, J. Claude Hemphill III, MD, MAS, FAHA, Ronda Johnson, MBA, Kiffon M. Keigher, MSN, ACNP-BC, RN, SCRN, William J. Mack, MD, MS, FAHA, J. Mocco, MD, MS, FAHA, Eileena J. Newton, MD, Ilana M. Ruff, MD, Lauren H. Sansing, MD, MS, FAHA, Sam Schulman, MD, PhD, Magdy H. Selim, MD, PhD, FAHA, Kevin N. Sheth, MD, FAHA, Nikola Sprigg, MD, Katharina S. Sunnerhagen, MD, PhD and on behalf of the American Heart Association/American Stroke Association Steven M. GreenbergSteven M. Greenberg Search for more papers by this author , Wendy C. ZiaiWendy C. Ziai Search for more papers by this author , Charlotte CordonnierCharlotte Cordonnier Search for more papers by this author , Dar DowlatshahiDar Dowlatshahi Search for more papers by this author , Brandon FrancisBrandon Francis Search for more papers by this author , Joshua N. GoldsteinJoshua N. Goldstein Search for more papers by this author , J. Claude Hemphill IIIJ. Claude Hemphill III Search for more papers by this author , Ronda JohnsonRonda Johnson Search for more papers by this author , Kiffon M. KeigherKiffon M. Keigher Search for more papers by this author , William J. MackWilliam J. Mack *AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison. Search for more papers by this author , J. MoccoJ. Mocco †AANS/CNS liaison. Search for more papers by this author , Eileena J. NewtonEileena J. Newton Search for more papers by this author , Ilana M. RuffIlana M. Ruff ‡AHA Stroke Council Stroke Performance Measures Oversight Committee liaison. Search for more papers by this author , Lauren H. SansingLauren H. Sansing Search for more papers by this author , Sam SchulmanSam Schulman Search for more papers by this author , Magdy H. SelimMagdy H. Selim Search for more papers by this author , Kevin N. ShethKevin N. Sheth *AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison. Search for more papers by this author , Nikola SpriggNikola Sprigg Search for more papers by this author , Katharina S. SunnerhagenKatharina S. Sunnerhagen Search for more papers by this author and on behalf of the American Heart Association/American Stroke Association Search for more papers by this author Originally published17 May 2022https://doi.org/10.1161/STR.0000000000000407Stroke. 2022;53:e282–e361Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: May 17, 2022: Ahead of Print Top 10 Take-Home Messages for the Management of Patients With Spontaneous Intracerebral Hemorrhage GuidelineThe organization of health care systems is increasingly recognized as a key component of optimal stroke care. This guideline recommends development of regional systems that provide initial intracerebral hemorrhage (ICH) care and the capacity, when appropriate, for rapid transfer to facilities with neurocritical care and neurosurgical capabilities.Hematoma expansion is associated with worse ICH outcome. There is now a range of neuroimaging markers that, along with clinical markers such as time since stroke onset and use of antithrombotic agents, help to predict the risk of hematoma expansion. These neuroimaging markers include signs detectable by noncontrast computed tomography, the most widely used neuroimaging modality for ICH.ICHs, like other forms of stroke, occur as the consequence of a defined set of vascular pathologies. This guideline emphasizes the importance of, and approaches to, identifying markers of both microvascular and macrovascular hemorrhage pathogeneses.When implementing acute blood pressure lowering after mild to moderate ICH, treatment regimens that limit blood pressure variability and achieve smooth, sustained blood pressure control appear to reduce hematoma expansion and yield better functional outcome.ICH while anticoagulated has extremely high mortality and morbidity. This guideline provides updated recommendations for acute reversal of anticoagulation after ICH, highlighting use of protein complex concentrate for reversal of vitamin K antagonists such as warfarin, idarucizumab for reversal of the thrombin inhibitor dabigatran, and andexanet alfa for reversal of factor Xa inhibitors such as rivaroxaban, apixaban, and edoxaban.Several in-hospital therapies that have historically been used to treat patients with ICH appear to confer either no benefit or harm. For emergency or critical care treatment of ICH, prophylactic corticosteroids or continuous hyperosmolar therapy appears to have no benefit for outcome, whereas the use of platelet transfusions outside the setting of emergency surgery or severe thrombocytopenia appears to worsen outcome. Similar considerations apply to some prophylactic treatments historically used to prevent medical complications after ICH. Use of graduated knee- or thigh-high compression stockings alone is not an effective prophylactic therapy for prevention of deep vein thrombosis, and prophylactic antiseizure medications in the absence of evidence for seizures do not improve long-term seizure control or functional outcome.Minimally invasive approaches for evacuation of supratentorial ICHs and intraventricular hemorrhages‚ compared with medical management alone‚ have demonstrated reductions in mortality. The clinical trial evidence for improvement of functional outcome with these procedures is neutral, however. For patients with cerebellar hemorrhage, indications for immediate surgical evacuation with or without an external ventricular drain to reduce mortality now include larger volume (>15 mL) in addition to previously recommended indications of neurological deterioration, brainstem compression, and hydrocephalus.The decision of when and how to limit life-sustaining treatments after ICH remains complex and highly dependent on individual preference. This guideline emphasizes that the decision to assign do not attempt resuscitation status is entirely distinct from the decision to limit other medical and surgical interventions and should not be used to do so. On the other hand, the decision to implement an intervention should be shared between the physician and patient or surrogate and should reflect the patient’s wishes as best as can be discerned. Baseline severity scales can be useful to provide an overall measure of hemorrhage severity but should not be used as the sole basis for limiting life-sustaining treatments.Rehabilitation and recovery are important determinants of ICH outcome and quality of life. This guideline recommends use of coordinated multidisciplinary inpatient team care with early assessment of discharge planning and a goal of early supported discharge for mild to moderate ICH. Implementation of rehabilitation activities such as stretching and functional task training may be considered 24 to 48 hours after moderate ICH; however, early aggressive mobilization within the first 24 hours after ICH appears to worsen 14-day mortality. Multiple randomized trials did not confirm an earlier suggestion that fluoxetine might improve functional recovery after ICH. Fluoxetine reduced depression in these trials but also increased the incidence of fractures.A key and sometimes overlooked member of the ICH care team is the patient’s home caregiver. This guideline recommends psychosocial education, practical support, and training for the caregiver to improve the patient’s balance, activity level, and overall quality of life.PreambleSince 1990, the American Heart Association (AHA)/American Stroke Association (ASA) has translated scientific evidence into clinical practice guidelines with recommendations to improve cerebrovascular health. These guidelines, which are based on systematic methods to evaluate and classify evidence, provide a foundation for the delivery of quality cerebrovascular care. The AHA/ASA sponsors the development and publication of clinical practice guidelines without commercial support, and members volunteer their time to the writing and review efforts.Clinical practice guidelines for stroke provide recommendations applicable to patients with or at risk of developing cerebrovascular disease. The focus is on medical practice in the United States, but many aspects are relevant to patients throughout the world. Although it must be acknowledged that guidelines may be used to inform regulatory or payer decisions, the core intent is to improve quality of care and align with patients’ interests. Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances and should not replace clinical judgment; furthermore, the recommendations set forth should be considered in the context of individual patient values, preferences, and associated conditions.The AHA/ASA strives to ensure that guideline writing groups contain requisite expertise and are representative of the broader medical community by selecting experts from a broad array of backgrounds, representing different sexes, races, ethnicities, intellectual perspectives, geographic regions, and scopes of clinical practice and by inviting organizations and professional societies with related interests and expertise to participate as endorsers. The AHA/ASA has rigorous policies and methods for development of guidelines that limit bias and prevent improper influence. The complete policy on relationships with industry and other entities (RWI) can be found at https://professional.heart.org/-/media/phd-files/guidelines-and-statements/policies-devolopment/aha-asa-disclosure-rwi-policy-5118.pdf?la=en.Beginning in 2017, numerous modifications to AHA/ASA guidelines have been implemented to make guidelines shorter and enhance user-friendliness. Guidelines are written and presented in a modular knowledge chunk format; each chunk includes a table of recommendations, a brief synopsis, recommendation-specific supportive text, and, when appropriate, flow diagrams or additional tables. Hyperlinked references are provided to facilitate quick access and review. Other modifications to the guidelines include the addition of Knowledge Gaps and Future Research segments in some sections and a web guideline supplement (Online Data Supplement) for useful but noncritical tables and figures.Joseph P. Broderick, MD, FAHAChair, AHA Stroke Council Scientific Statement Oversight Committee1. IntroductionApproximately 10% of the 795 000 strokes per year in the United States are intracerebral hemorrhages (ICHs),1 defined by brain injury attributable to acute blood extravasation into the brain parenchyma from a ruptured cerebral blood vessel. The clinical impact of ICH appears disproportionately high among lower-resource populations both in the United States and internationally. In US-based studies, ICH incidence has been reported to be ≈1.6-fold greater among Black than White people2 and 1.6-fold greater among Mexican American than non-Hispanic White people.3 Internationally, ICH incidence is substantially higher in low- and middle-income versus high-income countries, both as a proportion of all strokes and in absolute incidence rates.4,5Several additional features of ICH make it a greater public health threat than conveyed by incidence numbers alone. ICH is arguably the deadliest form of acute stroke, with early-term mortality about 30% to 40% and no or minimal trend toward improvement over more recent time epochs.6–9 Incidence of ICH increases sharply with age and is therefore expected to remain substantial as the population ages, even with counterbalancing public health improvements in blood pressure (BP) control.8 Another growing source of ICH is more widespread use of anticoagulants,10 a trend likely to counterbalance the reduced ICH risk associated with increasing prescription of direct oral anticoagulants (DOACs) relative to vitamin K antagonists (VKAs).11ICH thus remains in need of novel treatments and improved application of established approaches for every aspect of the disease: primary and secondary prevention, acute inpatient care, and poststroke rehabilitation and recovery. This guideline seeks to synthesize data in the ICH field into practical recommendations for clinical practice.1.1. Methodology and Evidence ReviewThe recommendations listed in this guideline are, whenever possible, evidence based and supported by extensive evidence review. A search for literature derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline was conducted between October 2020 and March 2021. Additional trials published between March 2021 and November 2021 that affected the content, Class of Recommendation (COR), or Level of Evidence (LOE) of a recommendation were included when appropriate. For specific search terms used‚ readers are referred to the Online Data Supplement, which contains the final evidence tables summarizing the evidence used by the guideline writing group to formulate recommendations. In addition, the guideline writing group reviewed documents related to subject matter previously published by the AHA/ASA. References selected and published in the present document are representative and not all inclusive.Each topic area was assigned a primary writer and a primary and sometimes secondary reviewer. Author assignments were based on the areas of expertise of the members of the guideline writing group and their lack of any RWI related to the section material. All recommendations were fully reviewed and discussed among the full guideline writing group to allow diverse perspectives and considerations for this guideline. Recommendations were then voted on, and a modified Delphi process was used to reach consensus. Guideline writing group members who had RWI that were relevant to certain recommendations were recused from voting on those particular recommendations. All recommendations in this guideline were agreed to by between 88.9% and 100% of the voting guideline writing group members.1.2. Organization of the Writing GroupThe guideline writing group consisted of vascular neurologists, neurocritical care specialists, neurological surgeons, an emergency physician, a hematologist, a rehabilitation medicine physician, a board-certified acute care nurse practitioner, a fellow-in-training, and a lay/patient representative. The writing group included representatives from the AHA/ASA, the American Association of Neurological Surgeons/Congress of Neurological Surgeons, and the American Academy of Neurology. Appendix 1 of this document lists guideline writing group members’ relevant RWI and other entities. For the purposes of full transparency, the guideline writing group members’ comprehensive disclosure information is available online.1.3. Document Review and ApprovalThis document was reviewed by the AHA Stroke Council Scientific Statement Oversight Committee, the AHA Science Advisory and Coordinating Committee, and the AHA Executive Committee; reviewers from the American Academy of Neurology, the Society of Vascular and Interventional Neurology, and the American Association of Neurological Surgeons/Congress of Neurological Surgeons; and 53 individual content reviewers. Appendix 2 lists reviewers’ comprehensive disclosure information.1.4. Scope of the GuidelineThis guideline addresses the diagnosis, treatment, and prevention of ICH in adults and is intended to update and replace the AHA/ASA 2015 ICH guideline.12 This 2022 guideline is limited explicitly to spontaneous ICHs that are not caused by head trauma and do not have a visualized structural cause such as vascular malformation, saccular aneurysm, or hemorrhage-prone neoplasm. These hemorrhages without a demonstrated structural or traumatic cause are often referred to as primary ICH (see further comment on this terminology in Section 2.1, Small Vessel Disease Types). This guideline thus does not overlap with AHA/ASA guidelines or scientific statements on the treatment of arteriovenous malformations,13 aneurysmal subarachnoid hemorrhage,14 or unruptured saccular aneurysms.13,15 This guideline does, however, address imaging approaches to ICH that help differentiate primary ICH from these secondary causes.This guideline aims to cover the full course of primary ICH (Figure 1), from the location and organization of emergency care (Section 3), initial diagnosis and assessment (Section 4), and acute medical and surgical interventions (Sections 5.1, 5.2, and 6) to further inpatient care of post-ICH complications (Sections 5.3–5.5), goals of care assessment (Section 7), rehabilitation and recovery (Section 8), and secondary prevention of recurrent ICH (Section 9). Because of the substantial differences in pathogenesis and course between ICH and ischemic stroke, the writing group sought, when possible, to base its recommendations on data derived specifically from ICH patient groups. Some aspects of inpatient medical care and post-ICH rehabilitation are likely to be similar between patients with ICH and patients with ischemic stroke, however. Readers are therefore referred to relevant AHA/ASA guidelines and scientific statements for ischemic stroke in these overlapping areas.16,17Table 1 is a list of associated AHA/ASA guidelines and scientific statements that may be of interest to the reader.Table 1. Associated AHA/ASA Guidelines and StatementsTitleOrganizationPublication yearAHA/ASA guidelines 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke AssociationAHA/ASA2021 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice GuidelinesACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA2017 Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke AssociationAHA/ASA2016 Guidelines for the Management of Patients With Unruptured Intracranial Aneurysms: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke AssociationAHA/ASA2015 Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke AssociationAHA/ASA2015 Guidelines for the Primary Prevention of Stroke: A Statement for Healthcare Professionals From the American Heart Association/American Stroke AssociationAHA/ASA2014 Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke AssociationAHA/ASA2012AHA/ASA scientific statements Care of the Patient With Acute Ischemic Stroke (Prehospital and Acute Phase of Care): Update to the 2009 Comprehensive Nursing Care Scientific Statement: A Scientific Statement From the American Heart AssociationAHA/ASA2021 Management of Brain Arteriovenous Malformations: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke AssociationAHA/ASA2017 Prevention of Stroke in Patients With Silent Cerebrovascular Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke AssociationAHA/ASA2017 Palliative and End-of-Life Care in Stroke: A Statement for Healthcare Professionals From the American Heart Association/American Stroke AssociationAHA/ASA2014AAPA indicates American Association of Physician Assistants; ABC, Association of Black Cardiologists; ACC, American College of Cardiology; ACPM, American College of Preventive Medicine; AGS, American Geriatrics Society; AHA, American Heart Association; APhA, American Pharmacists Association; ASA, American Stroke Association; ASH, American Society of Hypertension; ASPC, American Society for Preventive Cardiology; NMA, National Medical Association; and PCNA, Preventive Cardiovascular Nurses Association.Download figureDownload PowerPointFigure 1. Guideline overview for primary ICH. ICH indicates intracerebral hemorrhage. Recommendations on the topics above can be found in the guideline in the sections indicated: *Sections 3 and 5. †Section 4. ‡Sections 5 and 6. §Section 7. ∥Section 5. #Section 8. **Section 9.Another area where this ICH guideline interfaces with prior ischemic stroke guidelines is the challenging area of antithrombotic agent use in patients after ICH who are at risk for both recurrent ICH and ischemic stroke (Section 9.1.3, Management of Antithrombotic Agents). This guideline does not attempt to reassess the extensive literature on assessment of future ischemic stroke risk and instead refers the reader to existing AHA guidelines on primary and secondary ischemic stroke prevention.18,19This ICH guideline has a new section on assessment of ICH risk in individuals with no prior ICH but with neuroimaging findings such as cerebral microbleeds or cortical superficial siderosis suggestive of a hemorrhage-prone microvasculopathy. This topic, which was also previously discussed in an AHA scientific statement on the wider area of silent cerebrovascular disease,20 does not fall strictly under the heading of ICH management. This guideline writing group nonetheless included the section (9.2, Primary ICH Prevention in Individuals With High-Risk Imaging Findings) because of its close relationship to the considerations used for secondary prevention of recurrent ICH (Section 9.1, Secondary Prevention) and the high frequency with which these small hemorrhagic lesions are detected as incidental findings on magnetic resonance imaging (MRI) performed for other indications. Evidence on how to interpret and act on incidental hemorrhagic lesions remains limited but is likely to grow with the widespread incorporation of blood-sensitive MRI methods into research studies and clinical practice.1.5. COR and LOERecommendations are designated with both a COR and an LOE. The COR indicates the strength of recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk. The LOE rates the quality of scientific evidence supporting the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 2).Table 2. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*Table 2. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*AbbreviationsAbbreviationMeaning/PhraseADLactivities of daily livingAFatrial fibrillationAHAAmerican Heart AssociationaPCCactivated prothrombin complex concentrateASAAmerican Stroke AssociationATACH-2Antihypertensive Treatment of Acute Cerebral Hemorrhage IIAVERTA Very Early Rehabilitation TrialBPblood pressureCAAcerebral amyloid angiopathyCLEAR IIIClot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage Phase IIICLOTSClots in Legs or Stockings After StrokeCORClass of RecommendationCPPcerebral perfusion pressureCTcomputed tomographyCTAcomputed tomography angiographyDBPdiastolic blood pressureDIAGRAMDiagnostic Angiography to Find Vascular MalformationsDNARdo not attempt resuscitationDOACdirect oral anticoagulantDSAdigital subtraction angiographyDVTdeep vein thrombosisEDemergency departmentEIBPLearly intensive blood pressure loweringEMSemergency medical servicesERICHEthnic/Racial Variations of Intracerebral HemorrhageEVDexternal ventricular drain/drainageFFPfresh-frozen plasma4-F PCC4-factor prothrombin complex concentrateGCSGlasgow Coma ScaleHEhematoma expansionHRhazard ratioICHintracerebral hemorrhageICPintracranial pressureICUintensive care unitINCHInternational Normalized Ratio (INR) Normalization in Coumadin Associated Intracerebral HemorrhageINRinternational normalized ratioINTERACT2The Second Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage TrialIPCintermittent pneumatic compressionIVCinferior vena cavaIVHintraventricular hemorrhageIVTintraventricular thrombolysisLMWHlow-molecular-weight heparinLOELevel of EvidenceLOSlength of stayLVADleft ventricular assist deviceMISminimally invasive surgeryMISTIE IIIMinimally Invasive Surgery Plus rt-PA for Intracerebral Hemorrhage EvacuationMRAmagnetic resonance angiographyMRImagnetic resonance imagingmRSmodified Rankin ScaleMSUmobile stroke unitNCCTnoncontrast computed tomographyNDneurological deteriorationNICE-SUGARNormoglycemia in Intensive Care Evaluation and Survival Using Glucose Algorithm RegulationNIHSSNational Institutes of Health Stroke ScaleNSAIDnonsteroidal anti-inflammatory drugORodds ratioPCCprothrombin complex concentratePEpulmonary embolismPREVAILEvaluation of the WATCHMAN Left Atrial Appendage [LAA] Closure Device in Patients With Atrial Fibrillation Versus Long Term Warfarin TherapyPRoFESSPrevention Regimen for Effectively Avoiding Second StrokesPROGRESSPerindopril Protection Against Recurrent Stroke StudyPROTECT-AFWATCHMAN Left Atrial Appendage System for Embolic Protection in Patients With Atrial FibrillationQASCQuality in Acute Stroke CareRCTrandomized controlled trialRRTrenal replacement therapyRWIrelationships with industry and other entitiesSAEserious adverse eventSBPsystolic blood pressureSPARCLStroke Prevention by Aggressive Reduction in Cholesterol LevelsSSRIsselective serotonin reuptake inhibitorsSTICHSurgical Trial in Intracerebral HemorrhageTBItraumatic brain injuryTXAtranexamic acidUFHunfractionated heparinVKAvitamin K antagonistVTEvenous thromboembolism2. General Concepts2.1. Small Vessel Disease TypesDespite our use of the term primary ICH to distinguish from ICH with a demonstrated structural cause (Section 1.4, Scope of the Guideline), these seemingly spontaneous hemorrhages are not truly primary but rather represent the consequence of defined underlying (and often co-occurring) vascular pathologies. The 2 common cerebral small vessel pathologies that account for the overwhelming majority of primary ICH are arteriolosclerosis and cerebral amyloid angiopathy (CAA). Each is a common age-related pathology, appearing at autopsy at moderate to severe extents in 30% to 35% of individuals enrolled in a longitudinal study of aging.21 Arteriolosclerosis (also referred to as lipohyalinosis) is detected as concentric hyalinized vascular wall thickening favoring the penetrating arterioles of the basal ganglia, thalamus, brainstem, and deep cerebellar nuclei (collectively referred to as deep territories). Its major associated risk factors are hypertension, diabetes, and age. CAA is defined by deposition primarily of the β-amyloid peptide in the walls of arterioles and capillaries in the leptomeninges, cerebral cortex, and cerebellar hemispheres (lobar territories). The primary risk factors for CAA are age and apolipoprotein E genotypes containing the ε2 or ε4 alleles.ICH occurs in a relatively small subset of those brains with advanced arteriolosclerosis or CAA, typically in deep territories for arteriolosclerosis and lobar territories for CAA, the brain locations favored by the underlying pathologies. Small, often asymptomatic cerebral microbleeds in these compartments are substantially more common, occurring in >20% of population-based individuals >60 years of age scanned with sensitive T2*-weighted MRI methods.22,23 The presence of multiple strictly lobar ICHs, microbleeds, or cortical superficial siderosis (chronic blood products over the cerebral subpial surface) has been pathologically validated as part of the Boston criteria to detect CAA-related hemorrhage with reasonably high specificity and sensitivity.24 Microbleeds associated with arteriolosclerosis tend to occur in deep territories but can appear in lobar territories as well.The underlying small vessel types of ICH have several practical implications for the formulation of ICH guidelines. They establish a hemorrhage-prone environment in which use of antithrombotic agents creates increased risk of ICH.25 It is important to note, however, that the small vessel pathologies that underlie ICH are also associated with increased risk of ischemic stroke,26 highlighting the complexity and importance of balancing the risks versus benefits of antithrombotic treatment. Among the cerebral small vessel diseases, CAA inferred by the Boston criteria appears to confer substantially greater risk for recurrent hemorrhage than arteriolosclerosis (recurrent ICH rates in a pooled analysis of 7.39%/y after CAA-related ICH versus 1.11%/y after non–CAA-related ICH).272.2. Mechanisms for ICH-Related Brain InjuryICH is understood to injure surrounding brain tissue through the direct pressure effects of an acutely expanding mass lesion and through secondary physiological and cel

The Efficacy of Multi-component Positive Psychology Interventions: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Abstract: Recently, we see a sharp increase in the number of multi-component positive psychology interventions (MPPIs). The aim of the current study is to examine the efficacy of MPPIs, through a systematic review and meta-analysis. We included 50 randomized controlled trials that were published in 51 articles between 1998 and August 2018. We found standardized mean differences of Hedges’ g = 0.34 for subjective well-being, Hedges’ g = 0.39 for psychological well-being, indicating small to moderate effects, and Hedges’ g = 0.29 for depression, and Hedges’ g = 0.35 for anxiety and stress, indicating small effects. Removing outliers led to a considerable decrease in effect sizes for subjective well-being and depression, a slight decrease for psychological well-being, and a strong increase in the effect size for stress. Removing low quality studies led to a considerable decrease in the effect sizes for subjective well-being, psychological well-being, and depression, and a slight decrease for anxiety, but a strong increase for stress. Moderator analyses only showed a significant effect for study quality, showing larger effect sizes for low quality studies compared to studies of moderate and high quality. In addition, a larger effect size for anxiety was found in studies from non-Western countries compared to studies from Western countries. In sum, this systematic review and meta-analysis found evidence for the efficacy of MPPIs in improving mental health. We conclude that MPPIs have a small effect on subjective well-being and depression, and a small to moderate effect on psychological well-being. In addition, they may have a small to moderate effect on anxiety and a moderate effect on stress, but definite conclusions of the effects of MPPIs on these outcomes cannot me made due to the limited number of studies. Further well-conducted research among diverse populations is necessary to strengthen claims on the efficacy of MPPIs.

Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery, and Community Participation following Stroke. Part One: Rehabilitation and Recovery Following Stroke; 6th Edition Update 2019

Abstract: The sixth update of the Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery, and Reintegration following Stroke. Part one: Rehabilitation and Recovery Following Stroke is a comprehensive set of evidence-based guidelines addressing issues surrounding impairments, activity limitations, and participation restrictions following stroke. Rehabilitation is a critical component of recovery, essential for helping patients to regain lost skills, relearn tasks, and regain independence. Following a stroke, many people typically require rehabilitation for persisting deficits related to hemiparesis, upper-limb dysfunction, pain, impaired balance, swallowing, and vision, neglect, and limitations with mobility, activities of daily living, and communication. This module addresses interventions related to these issues as well as the structure in which they are provided, since rehabilitation can be provided on an inpatient, outpatient, or community basis. These guidelines also recognize that rehabilitation needs of people with stroke may change over time and therefore intermittent reassessment is important. Recommendations are appropriate for use by all healthcare providers and system planners who organize and provide care to patients following stroke across a broad range of settings. Unlike the previous set of recommendations, in which pediatric stroke was included, this set of recommendations includes primarily adult rehabilitation, recognizing many of these therapies may be applicable in children. Recommendations related to community reintegration, which were previously included within this rehabilitation module, can now be found in the companion module, Rehabilitation, Recovery, and Community Participation following Stroke. Part Two: Transitions and Community Participation Following Stroke.