Background and Purpose—: Robust measures of functional outcome are required to determine treatment effects in stroke trials. Of the various measures available, the Barthel index (BI) is one of the more prevalent. We aimed to describe validity, reliability, and responsiveness (clinimetric properties) of the BI in stroke trials. Methods—: Narrative review of published articles describing clinimetric properties or use of the BI as a stroke trial end point. Results—: Definitive statements on properties of BI are limited by heterogeneity in methodology of assessment and in the content of “BI” scales. Accepting these caveats, evidence suggests that BI is a valid measure of activities of daily living; sensitivity to change is limited at extremes of disability (floor and ceiling effects), and reliability of standard BI assessment is acceptable. However, these data may not be applicable to contemporary multicenter stroke trials. Conclusions—: Substantial literature describing BI clinimetrics in stroke is available; however, questions remain regarding certain properties. The “BI” label is used for a number of instruments and we urge greater consistency in methods, content, and scoring. A 10-item scale, scoring 0 to 100 with 5-point increments, has been used in several multicenter stroke trials and it seems reasonable that this should become the uniform stroke trial BI.

Introduction: Delirium is associated with a wide range of adverse patient safety outcomes, yet it remains consistently under-diagnosed. We undertook a systematic review of studies describing delirium in adult medical patients in secondary care. We investigated if changes in healthcare complexity were associated with trends in reported delirium over the last four decades. Methods: We used identical criteria to a previous systematic review, only including studies using internationally accepted diagnostic criteria for delirium (the Diagnostic and Statistical Manual of Mental Disorders and the International Statistical Classification of Diseases). Estimates were pooled across studies using random effects meta-analysis, and we estimated temporal changes using meta-regression. We investigated publication bias with funnel plots. Results: We identified 15 further studies to add to 18 studies from the original review. Overall delirium occurrence was 23% (95% CI 19–26%) (33 studies) though this varied according to diagnostic criteria used (highest in DSM-IV, lowest in DSM-5). There was no change from 1980 to 2019, nor was case-mix (average age of sample, proportion with dementia) different. Overall, risk of bias was moderate or low, though there was evidence of increasing publication bias over time. Discussion: The incidence and prevalence of delirium in hospitals appears to be stable, though publication bias may have masked true changes. Nonetheless, delirium remains a challenging and urgent priority for clinical diagnosis and care pathways.

Recommended statistical methods for meta-analysis of diagnostic test accuracy studies require relatively complex bivariate statistical models which can be a barrier for non-statisticians. A further barrier exists in the software options available for fitting such models. Software accessible to non-statisticians, such as RevMan, does not support the fitting of bivariate models thus users must seek statistical support to use R, Stata or SAS. Recent advances in web technologies make analysis tool creation much simpler than previously. As well as accessibility, online tools can allow tailored interactivity not found in other packages allowing multiple perspectives of data to be displayed and information to be tailored to the user’s preference from a simple interface. We set out to: (i) Develop a freely available web-based “point and click” interactive tool which allows users to input their DTA study data and conduct meta-analyses for DTA reviews, including sensitivity analyses. (ii) Illustrate the features and benefits of the interactive application using an existing DTA meta-analysis for detecting dementia. To create our online freely available interactive application we used the existing R packages lme4 and Shiny to analyse the data and create an interactive user interface respectively. MetaDTA, an interactive online application was created for conducting meta-analysis of DTA studies. The user interface was designed to be easy to navigate having different tabs for different functions. Features include the ability for users to enter their own data, customise plots, incorporate quality assessment results and quickly conduct sensitivity analyses. All plots produced can be exported as either .png or .pdf files to be included in report documents. All tables can be exported as .csv files. MetaDTA, is a freely available interactive online application which meta-analyses DTA studies, plots the summary ROC curve, incorporates quality assessment results and allows for sensitivity analyses to be conducted in a timely manner. Due to the rich feature-set and user-friendliness of the software it should appeal to a wide audience including those without specialist statistical knowledge. We encourage others to create similar applications for specialist analysis methods to encourage broader uptake which in-turn could improve research quality.

Background and Purpose—: The Barthel Index (BI) is a 10-item measure of activities of daily living which is frequently used in clinical practice and as a trial outcome measure in stroke. We sought to describe the reliability (interobserver variability) of standard BI in stroke cohorts using systematic review and meta-analysis of published studies. Methods—: Two assessors independently searched various multidisciplinary electronic databases from inception to April 2012 inclusive. Inclusion criteria comprised: original research, human stroke participants, and inter-rater reliability data on equivalent methods of BI administration. Manuscripts were reviewed against prespecified inclusion criteria. Primary outcome for meta-analysis was reliability, measured by weighted κ (κw). Results—: From 20 210 titles, 306 abstracts were reviewed, 12 studies met inclusion criteria, and 10 were included in meta-analysis (n=543 participants; range of participants in studies, 7–21). There was substantial clinical heterogeneity with respect to method of BI application; population studied and assessors. Two papers were graded high quality. Overall interobserver reliability of standard administration of the BI was excellent (κw, 0.93; 95% confidence interval, 0.90–0.96 random effects modeling). Conclusions—: The BI has excellent inter-rater reliability for standard administration after stroke. However, included studies were modest in size, with clinical heterogeneity and variable methodological quality. Despite these limitations, standard BI seems an appropriate outcome measure for stroke trials and practice.

Growing evidence suggests a consistent association between atrial fibrillation (AF) and cognitive impairment and dementia that is independent of clinical stroke. This report from the AF-SCREEN International Collaboration summarizes the evidence linking AF to cognitive impairment and dementia. It provides guidance on the investigation and management of dementia in patients with AF on the basis of best available evidence. The document also addresses suspected pathophysiologic mechanisms and identifies knowledge gaps for future research. Whereas AF and dementia share numerous risk factors, the association appears to be independent of these variables. Nevertheless, the evidence remains inconclusive regarding a direct causal effect. Several pathophysiologic mechanisms have been proposed, some of which are potentially amenable to early intervention, including cerebral microinfarction, AF-related cerebral hypoperfusion, inflammation, microhemorrhage, brain atrophy, and systemic atherosclerotic vascular disease. The mitigating role of oral anticoagulation in specific subgroups (eg, low stroke risk, short duration or silent AF, after successful AF ablation, or atrial cardiopathy) and the effect of rhythm versus rate control strategies remain unknown. Likewise, screening for AF (in cognitively normal or cognitively impaired patients) and screening for cognitive impairment in patients with AF are debated. The pathophysiology of dementia and therapeutic strategies to reduce cognitive impairment warrant further investigation in individuals with AF. Cognition should be evaluated in future AF studies and integrated with patient-specific outcome priorities and patient preferences. Further large-scale prospective studies and randomized trials are needed to establish whether AF is a risk factor for cognitive impairment, to investigate strategies to prevent dementia, and to determine whether screening for unknown AF followed by targeted therapy might prevent or reduce cognitive impairment and dementia.

Peer reviewed article authored by (Harrison JK, McArthur KS, Quinn TJ). Read article or submit your manuscript for publishing.