Post-Stroke Depression: Prevalence, Associated Factors, and Relationship to Disability in a Tertiary Care Center in Sri Lanka

Background and Objectives The prevalence of stroke in urban Sri Lanka is estimated at 10.4 per 1000 and is expected to rise. Post-stroke depression (PSD) is an independent predictor of poor long-term outcomes. It leads to suboptimal rehabilitation, decreased quality of life, and increased mortality and is under-recognized. The main objectives of this study were to estimate the prevalence of depression in stroke, assess factors associated with PSD, and assess the relationship of PSD to disability. Materials and Methods A descriptive cross-sectional study was conducted at the Neurology and Medical Ward, National Hospital of Sri Lanka. Non-probability, consecutive sampling was used to collect data from patients with ischemic stroke admitted from January 2019 to January 2020. Patients with significant pre-existing depression, cognitive impairment, and language deficits were excluded. A structured, pre-tested interviewer-administered questionnaire was used to assess the prevalence and associated factors of PSD. Beck's Depression Inventory (BDI) was administered 3 months following the stroke to screen for depression. Modified Rankin Score (MRS) was used to assess disability on admission, discharge, and at 3 months. Results Eighty-one stroke patients were screened. The mean age was 66.6 years (±standard deviation [SD]: 12.5). Male:female ratio was 1.2:1. Depression at 3 months of follow-up was observed in 35.8% (95% confidence interval [CI]: 25.4–47.2%) of participants. Following bivariate analysis, large vessel stroke (p < 0.001), cortical stroke (p < 0.001), frontal lobe lesions (p < 0.001), history of past stroke (p = 0.014), and sexual dysfunction (p = 0.026) were associated with increased risk of PSD. The odds of a person with severe disability developing PSD was 7.9 times more than a person with a less severe disability at discharge from hospital and at 3 months of follow-up (odds ratio [OR] =7.9; 95% CI: 2.7–23.3, p = 0.000). Conclusions PSD occurs in one-third of strokes, keeping with previous studies. The risk of having PSD is higher among patients with severe disabilities. The difference in risk factors identified compared with previous studies can be attributable to differences in methodology. Identifying risk factors for post-stroke depression is essential to mitigate the poor outcome.

Family-Centered Telehealth Supporting Motor Skills and Activity in Individuals With Rett Syndrome

Rett syndrome is a rare genetically caused condition associated with severe disability and impaired motor functions. Local therapists typically see small numbers of affected individuals, and this limits their capacity to gain experience. Telehealth is being used increasingly to counter poor access to rehabilitation services. Moreover, there is a need to develop management plans that support individuals with Rett syndrome over their lifespan. Three projects in which telehealth support was provided by therapists experienced in Rett syndrome and supported by available local resources are presented in this chapter. The three projects responded to locally identified needs in a cost-efficient way and empowered those working with people with Rett syndrome to maintain and improve their clients' physical function and activity. This chapter will discuss the conceptual underpinnings of delivering a service using a telehealth approach and describe the results and the strategies implemented in the projects mentioned above.

Telomere Shortening linked to Disability and Mitochondrial DNA Copy Number in Patients with Relapsing-Remitting Multiple Sclerosis

Multiple sclerosis (MS) is a chronic autoimmune inflammatory disease that affects the nervous system. Peripheral blood leukocyte telomere length (LTL) and mitochondrial DNA copy number (mtDNA-CN) are potential biomarkers of disability and neurological damage. The present work evaluated LTL and mtDNA-CN in 75 relapsing-remittent MS (RRMS) patients 50 of whom had an Expanded Disability Status Scale (EDSS) 0 to 3 (mild-moderate disability), and 25 had an EDSS of 3.5 to 7 (severe disability). Absolute LTL and absolute mtDNA-CN were measured via real-time polymerase chain reaction (qPCR). The LTL and mtDNA-CN were significantly lower in RRMS severe disability than in RRMS mild-moderate disability (3.924 &plusmn; 0.124 vs 2.854 &plusmn; 0.092, p&lt;00001; 75.14 &plusmn; 1.77 vs 68.06 &plusmn; 1.608, p&lt;0.00001, respectively). The LTL and mtDNA-CN showed a linear correlation in RRMS with mild-moderate disability (r=0.2986, p=0.0351). In addition, in a binary logistic regression model the LTL can predict severe disability (AUC=0.697, p=0.0031, cutoff &le; 3.0875 Kb, sensitivity= 73.1%, specificity=62.5%), the prediction is improved by including age to the model (AUC=0.765, &lt;0.0001, sensitivity=78.26%, specificity=81.25%). Aging is closely linked to the development of disability in RRMS and can be evaluated through LTL and mtDNA-CN absolute quantification.

Telomere Shortening linked to Disability and Mitochondrial DNA Copy Number in Patients with Relapsing-Remitting Multiple Sclerosis

Multiple sclerosis (MS) is a chronic autoimmune inflammatory disease that affects the nervous system. Peripheral blood leukocyte telomere length (LTL) and mitochondrial DNA copy number (mtDNA-CN) are potential biomarkers of disability and neurological damage. The present work evaluated LTL and mtDNA-CN in 75 relapsing-remittent MS (RRMS) patients 50 of whom had an Expanded Disability Status Scale (EDSS) 0 to 3 (mild-moderate disability), and 25 had an EDSS of 3.5 to 7 (severe disability). Absolute LTL and absolute mtDNA-CN were measured via real-time polymerase chain reaction (qPCR). The LTL and mtDNA-CN were significantly lower in RRMS severe disability than in RRMS mild-moderate disability (3.924 &plusmn; 0.124 vs 2.854 &plusmn; 0.092, p&lt;00001; 75.14 &plusmn; 1.77 vs 68.06 &plusmn; 1.608, p&lt;0.00001, respectively). The LTL and mtDNA-CN showed a linear correlation in RRMS with mild-moderate disability (r=0.2986, p=0.0351). In addition, in a binary logistic regression model the LTL can predict severe disability (AUC=0.697, p=0.0031, cutoff &le; 3.0875 Kb, sensitivity= 73.1%, specificity=62.5%), the prediction is improved by including age to the model (AUC=0.765, &lt;0.0001, sensitivity=78.26%, specificity=81.25%). Aging is closely linked to the development of disability in RRMS and can be evaluated through LTL and mtDNA-CN absolute quantification.

Nominal group technique to establish the core components of home-based rehabilitation for survivors of stroke with severe disability

In the UK, over 20% of patients leaving hospital after a stroke will be severely disabled. Despite this, limited clinical guidance is available to teams tasked with providing support for this complex population at home. Additionally, many areas across the UK are not commissioned to treat this patient cohort, leaving them with no specialist support on discharge.ObjectivesTo establish core components of home-based rehabilitation for survivors of stroke with severe disability, based on expert panel consensus.SettingVirtual nominal group technique (vNGT) across the UK.ParticipantsExperts in the field of stroke rehabilitation (n=14) including researchers, clinicians and those with lived experience.MethodsTwo vNGT were completed using a freely available online platform, Microsoft Teams. The technique’s five stages were completed virtually; introduction, silent idea generation, round robin, clarifications and scoring. Statements were analysed for consensus, those achieving consensus underwent content analysis to form rich overarching consensus statements.ResultsA combined total of 421 statements achieved positive consensus (>75% in agreement), which formed 11 overarching consensus statements. These outline key components of home-based rehabilitation for survivors of stroke with severe disability including the structure and members of the team, as well as the skills and knowledge required.ConclusionThe consensus statements highlight the complexity of managing patients with severe stroke disability following discharge from hospital. This study has the potential to support the provision of services for this patient group, providing a benchmark for commissioners and clinicians as well as setting expectations for stroke survivors and their carers. What remains unknown is how many services currently offer this service to patients with severe disability.

The Othering of Older People in Disability Policies

Disability policies in Sweden rest on the idea that all humans have equal value and a goal of policies has been to enable persons with disabilities to be able to live like other members of society, but older people do not seem to be included as part of this goal. The presentation concerns the Swedish support system’s legal discourse, and investigates the rationale for excluding people over the age of 65 from services that younger people with disabilities may obtain. Data consists of government texts and court decisions under the Severe Disability Act about services for people over the age of 65. It was found that little in the legal discourse concerns the needs and rights of older people, and the general belief is that the Severe Disability Act is primarily intended for children, young people, and adults of working age. The legal discourse contained a type of “residual ageism” that was justified through the indirect construction of older people as different. Othering of older people was present in assumptions about differences in categorizations (people with disabilities vs older people with support needs), needs (active age vs not active age), and comparisons (with people without disabilities of the same age vs with others receiving eldercare). The presentation outlines potential changes of these policies.

Two-staged tactics of treatment of postoperative sternomediastinitis using technique of negative pressure followed by two-flap omentoplasty according to K. Yoshida

This article presents an observation of a clinical case in a patient with the postoperative sternomediastinitis. In cardio-thoracic surgery this complication ranges from 1 to 10 % [2, 3, 14, 16, 19] depending on who the work is done by and the ratio of deaths can reach up to 40 % [13]. Due to untimely diagnosis of the pyoinflammatory process in the tracheostomy orifice, the patient developed progressive instability of the sternum followed by sternomediastinitis. A two-staged tactics of treatment of the postoperative sternomediastinitis using the technique of negative pressure followed by two-flap omentoplasty according to K. Yoshida in this case is the technique of choice for surgical treatment, which allows to restore the integrity of the chest wall frame in the shortest possible time and ensure tightness for the mediastinum. This technique is the most effective in the treatment of destructive forms of purulent complications of the sternum after a median sternotomy. The relevance and expediency of the use of omentoplasty is also justified from a financial and medico-social position, since the procedure reduces mortality among patients of this category, as well as the risk of severe disability at the able-bodied age.

Functional Status and Therapy for Nursing Home Residents with Diffuse Large B-Cell Lymphoma: A Population-Based Study

Background: Diffuse large B-cell lymphoma (DLBCL) is a potentially curable cancer, predominantly affecting older patients. Functional limitations and comorbidities make its management challenging among those with advanced age. Approximately 23% of Medicare beneficiaries do not receive curative chemoimmunotherapy (Hamlin et al, Oncologist, 2014), and the treatment rates decrease with increasing age (Williams et al, Cancer, 2015). Treatment may be particularly difficult for older nursing home (NH) residents who are physiologically frail and have significant functional limitations. The goal of this study is to describe patterns of cancer-directed therapies and outcomes among NH residents with DLBCL in the United States and dissect the association between functional impairment and receipt of treatment. Methods: We used the SEER-Medicare registry to identify Medicare beneficiaries diagnosed with DLBCL in 2011-2015, who had Minimum Data Set (MDS) assessments within 120 days prior to diagnosis or treatment. The MDS is routinely performed in NHs and includes multiple geriatric domains, including physical and cognitive function. We used the Morris activities of daily living (ADL) scale to quantify functional limitations in 7 activities (bed mobility, dressing, eating, locomotion on unit, personal hygiene, toileting, and transfers). We characterized limitations based on dependency in ADLs: no disability (0 ADLs), moderate disability (1-4 ADLs), or severe disability (5-7 ADLs). We used the Cognitive Function Scale (CFS) to characterize cognition as intact, mild, or moderate to severe impairment. We used multivariable logistic regression to compare the receipt of chemoimmunotherapy (including receipt of curative multiagent, anthracycline-containing regimen), 30-day mortality, and 30-day hospitalization, respectively, between the NH and non-NH population, reporting the odds ratio (OR) and 95% confidence interval (CI). We used multivariable Cox regression to compare overall survival (OS) between these two populations, reporting hazard ratio (HR) with 95% CI. Within the NH population, we examine the association of receipt of chemotherapy with functional and cognitive impairment, respectively. All models were adjusted for age, sex, race, stage, comorbidities, Medicaid dual coverage, and type of NH stay (long vs. short stay). Results: Among 11,128 patients with DLBCL, 718 received care in NHs (median age 82 years, 59% women, 90% White, 50% stage III/IV disease). Compared with non-NH patients, NH residents were less likely to receive any chemoimmunotherapy (41% vs. 69%, OR: 0.34, 95% CI: 0.29-0.41) or, when treated, curative regimens (47% vs. 71%, OR: 0.51, 95% CI: 0.37-0.72) (Fig. 1A-1B). NH residents had high rates of 30-day mortality after therapy (18% vs. 7%, OR: 1.99, 95% CI: 1.43-2.77) and 30-day hospitalization (58% vs. 43%, OR: 1.51, 95% CI: 1.18-1.93), and had short median OS of 3.7 months (versus 31.7 months for non-NH residents; HR: 1.36, 95% CI: 1.11-1.65) (Fig. 1C). Rates of disability and cognitive impairment were high, 20% had moderate disability, 60% had severe disability and 17-26% had mild or moderate to severe cognitive impairment. Compared with patients with no ADL disability, those with severe disability were less likely to receive any chemoimmunotherapy (38% vs. 50%, OR: 0.58, 95% CI: 0.38-0.89) (Fig. 2A-2B). Compared with those with intact cognitive function, patients with mild (39% vs. 47%, OR: 0.66, 95% CI: 0.45-0.97) and moderate to severe (24% vs. 47%, OR: 0.31, 95% CI: 0.19-0.51) impairment, respectively, were less likely to receive chemoimmunotherapy (Fig. 2C). Conclusions: In this population-based study, over half of NH residents with DLBCL did not receive chemoimmunotherapy, and 47% of chemotherapy recipients received curative regimens. Despite treatment, NH residents had higher rates of early mortality and hospitalization, and short median survival (only 3.7 months). These findings indicate a need for alternative treatment strategies for patients in NHs, particularly those with high levels of disability. Routinely collected NH assessment data revealed strong associations between receipt of chemotherapy, functional limitations, and cognitive impairment among NH residents with DLBCL. These findings suggest that structured assessment of function and cognition may improve patient selection for curative therapy. Figure 1 Figure 1. Disclosures Olszewski: TG Therapeutics: Research Funding; PrecisionBio: Research Funding; Celldex Therapeutics: Research Funding; Genentech, Inc.: Research Funding; Acrotech Pharma: Research Funding; Genmab: Research Funding. Panagiotou: International Consulting Associates, Inc: Other: Personal fees.

Development and Internal Validation of a Disability Algorithm for Multiple Sclerosis in Administrative Data

Objective: We developed and internally validated an algorithm for disability status in multiple sclerosis (MS) using administrative data.Methods: We linked administrative data from Manitoba, Canada to a clinical dataset with Expanded Disability Status Scale (EDSS) scores for people with MS. Clinical EDSS scores constituted the reference standard. We created candidate indicators using the administrative data. These included indicators based on use of particular health care services (home care, long-term care, rehabilitation admission), use of specific diagnostic codes (such as spasticity, quadriplegia), and codes based on use of Employment and Income Insurance. We developed algorithms to predict severe disability (EDSS ≥6.0), and to predict disability as a continuous measure. We manually developed algorithms, and also employed regression approaches. After we selected our preferred algorithms for disability, we tested their association with health care use due to any cause and infection after potential confounders.Results: We linked clinical and administrative data for 1,767 persons with MS, most of whom were women living in urban areas. All individual indicators tested had specificities &gt;90% for severe disability, and all but a diagnosis of visual disturbance had positive predictive values (PPV) &gt;70%. The combination of home care or long-term care use or rehabilitation admission had a sensitivity of 61.9%, specificity of 90.76%, PPV of 70.06% and negative predictive of 87.21%. Based on regression modeling, the best-performing algorithm for predicting the EDSS as a continuous variable included age, home care use, long-term care admission, admission for rehabilitation, visual disturbance, other paralytic syndromes and spasticity. The mean difference between observed and predicted values of the EDSS was −0.0644 (95%CI −0.1632, 0.0304). Greater disability, whether measured using the clinical EDSS or either of the administrative data algorithms was similarly associated with increased hospitalization rates due to any cause and infection.Conclusion: We developed and internally validated an algorithm for disability in MS using administrative data that may support population-based studies that wish to account for disability status but do not have access to clinical data sources with this information. We also found that more severe disability is associated with increased health care use, including due to infection.