Effect of mood symptoms on recovery one year after stroke

BACKGROUND

Depression and anxiety are the most common mood symptoms and psychological consequences of stroke. This study aimed to examine the influence of acute depression and anxiety symptoms on functional recovery and health-related quality of life (HRQoL) one year after stroke.

METHODS

At one month and one year after stroke, the prevalence and severity of depression and anxiety symptoms were examined in consecutively admitted patients, using the Hospital Anxiety and Depression Scale (HADS). Functional recovery was assessed using the Nottingham Extended Activities of Daily Living (NEADL) and HRQoL using the Stroke-Specific Quality of Life scale (SSQOL).

RESULTS

In 107 patients, the prevalence of depression and anxiety symptoms was 35% at one month and 36% and 34%, respectively, at one year. Depression symptoms were significantly associated with functional ability (r = -0.19, p < 0.05) and HRQoL (r = -0.41, p < 0.001) at one year. Anxiety symptoms were significantly associated with HRQoL (r = -0.33, p < 0.001) only. Multivariate analyses indicated that both depression (β = -0.33, p < 0.001) and anxiety (β = -0.26, p < 0.01) symptoms explained some variance in HRQoL at one month and did not predict functional recovery or HRQoL at one year, after controlling for other independent variables such as stroke severity and pre-morbid conditions.

DISCUSSION

Mood symptoms following acute stroke were associated with a poorer HRQoL one year later but only depression symptoms influenced functional recovery. Other clinical factors such as pre-morbid conditions may need to be taken into consideration when determining the effect of mood symptoms on stroke recovery.

What training do artists need to work in healthcare settings?

Given the increased attention paid to the development of arts in healthcare settings, the need for a formalised training framework to enable artists to work comfortably and safely in healthcare settings has become pressing. This paper sets out a review of literature and best practice regarding the training of professional artists wishing to work in healthcare settings. The authors' research confirms the gap in the arts sector with regard to such training. Very little formal training is currently available internationally for artists wishing to work in healthcare settings outside of the arts therapies professions. There is a need for the health sector to formalise a currently ad hoc approach to employing artists in healthcare settings. There are a number of best-practice models of arts and health practice from which we can learn but relatively scant literature on course development. The arts therapies are relatively expert in the domain of using the arts in healthcare and while there are different aims and intentions to this work, it is important that any establishment of arts and health training recognises the contribution and expertise of arts therapists in the healthcare arena. A culture of mutual learning between the arts therapies and the arts and health specialists is recommended.

Use of gene expression profile and mitotic index of metastatic melanoma lesions as an adjunct to TNM staging in predicting patient survival

9014

Background: Although remission rates for metastatic melanoma are generally very poor, some patients can survive for prolonged periods following metastasis. We used gene expression profiling of metastatic lesions to search for a molecular basis for this observation, and to develop improved methods for predicting patient survival. Methods: We analyzed gene expression profiles of 44 metastatic melanoma specimens collected from 38 patients (median follow-up of 20 months after surgery). We used the False Discovery Rate (FDR) approach to identify genes significantly associated with post-recurrence survival. We then evaluated matching H&E stained tissue samples for the presence of tumor-infiltrating leukocytes (TILs) and mitotic index, (MI). Support vector machines and multi-variable Cox regression analysis was used to examine the relative ability of the pre-validated gene expression predictor, TILs, MI and TNM staging to predict survival. Results: We identified a group of approximately 300 genes associated with survival. Genes associated with immune response (ICOS, CD3d, ZAP70, TRAT1, TARP, GZMK, LCK, CD2, CXCL13, CCL19, CCR7, VCAM1 etc.) or with cell proliferation (PDE4D, CDK2, GREF1, NUSAP1, SPC24 etc.) were highly represented .Prolonged survival was associated with the elevated expression of immune response genes and decreased expression of genes associated with proliferation. Furthermore, any of the three additional parameters (pre-validated gene expression signature, TILs or MI) improved the ability of TNM staging to predict post-recurrence survival; MI was the most significant contributor (HR = 2.65, p = 0.003) followed by the gene expression signature (HR = 2.71, p = 0.05). Conclusions: Gene expression profiling and MI of metastatic lesions can both be utilized to improve upon current staging of metastatic melanoma to predict patient survival. Gene expression signature and analysis of TILs indicate immune surveillance as a mechanism for prolonged survival in these patients.

No significant financial relationships to disclose.

A cure for the soul? The benefit of live music in the general hospital

From 2005 to 2006 a professional orchestra (the Irish Chamber Orchestra) performed in a university teaching hospital with the aims of bringing live music to patients who could not access traditional concert venues and of improving quality of life for patients and staff. This was the first time an orchestra was resident in a hospital in the Republic of Ireland. An independent contemporaneous evaluation was carried out to assess the benefit of live music for patients. Live music in hospital was found to enhance the quality of the aesthetic environment of the hospital, with both patients and staff stating that listening to live music helped them to relax, feel happier and more positive. Patients' perception of the hospital was affected positively by live music in waiting areas. Music was found to have strong emotional effect and the individual preferences and experiences of patients need to be carefully taken into account when programming music in hospital. Listening to live music while in hospital has positive benefits with few negative effects.

Imiquimod: A TLR-7 agonist as adjuvant for a recombinant protein cancer vaccine

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Purpose: This clinical trial evaluates the safety and adjuvant activity of imiquimod, a toll-like receptor (TLR)-7 agonist, when given with a NY-ESO-1 protein vaccine. Imiquimod, by locally activating and recruiting dendritic cells (DCs) into the skin, is expected to stimulate antigen uptake by DCs, induce maturation and migration to draining lymph nodes, and to induce antigen-specific T and B cell immunity. Methods: Pilot study; 9 patients with resected stage 2B-3C malignant melanoma. Four 21 day cycles consisted of topical imiquimod cream (250 mg) on days 1–5 and id. injected NY-ESO-1 protein (100 mcg) into the site on day 3. Blood was drawn at several time points for immune monitoring; skin punch biopsies were obtained from control, imiquimod and vaccination sites 48 hours after the last vaccination. Results: The regimen was tolerated well, all patients completed four vaccinations. AEs were mild and transient and included injection site reactions (8/9 patients), fatigue (4/9 patients) and fever (2/9 patients). Significant levels of antigen-specific CD4+ or CD8+ T cell responses were not detected in ex-vivo ELISPOT assays. However, intracellular cytokine staining assays after in vitro pre-stimulation indicated that 6 of 8 subjects developed NY-ESO-1 CD4+ T cell responses. Humoral immunity was manifest by the induction of anti-NY-ESO-1 antibodies in 7/9 patients post-vaccination. Histochemistry of skin sections showed significant dermal mononuclear cell infiltrates in Imiquimod treated skin, whereas none were seen in untreated skin (p<0.01). IHC revealed markedly increased numbers of CD3+ (T-cells), CD68+ (macrophages/monocytes), CD123+ (plasmacytoid DCs) and DC-LAMP+ (mature myeloid DCs) immune cells in Imiquimod treated skin when compared with control skin of the same patients (p<0.05). Conclusion: Imiquimod, a topical immune response modifier, generated clear inflammatory infiltrates in the dermis, with significant increases in antigen-presenting cells and T cells. Imiquimod was well tolerated when used as an adjuvant to an NY-ESO-1 protein vaccine. Systemic immunity of both humoral and cellular types was induced in the majority of patients; however, responses were weak and the vaccine combination needs to be optimized in future studies.

No significant financial relationships to disclose.

Defining and quantifying coping strategies after stroke: a review

The coping strategies that people use after a stroke may influence recovery. Coping measures are generally used to assess the mediating behaviour between a stressor (ie, disease or condition) and the physical or psychological outcome of an individual. This review evaluates measures that quantified coping strategies in studies on psychological adaptation to stroke. The main aspects of the coping measures reviewed were (a) conceptual basis; (b) coping domains assessed; (c) coping strategies used after a stroke; and (d) psychometric properties of coping measures used in studies assessing patients with stroke. Four databases (Medline, CINAHL, PsychINFO and Cochrane Systematic Reviews) were searched to identify studies that used a coping measure in stroke. 14 studies assessed coping strategies in patients after stroke. Ten different coping measures were used, and the studies reviewed had many limitations. Few studies provided definitions of "coping" and the psychometric properties of the coping measures were under-reported. The need for future studies to more clearly define the coping process and to present data on the reliability and validity of the measures used is emphasised.

Significant variation in mortality and functional outcome after acute ischaemic stroke between Western countries: data from the tinzaparin in acute ischaemic stroke trial (TAIST)

BACKGROUND

The medical care of patients with acute stroke varies considerably between countries. This could lead to measurable differences in mortality and functional outcome.

OBJECTIVE

To compare case mix, clinical management, and functional outcome in stroke between 11 countries.

METHODS

All 1484 patients from 11 countries who were enrolled into the tinzaparin in acute ischaemic stroke trial (TAIST) were included in this substudy. Information collected prospectively on demographics, risk factors, clinical features, measures of service quality (for example, admission to a stroke unit), and outcome were assessed. Outcomes were adjusted for treatment assignment, case mix, and service relative to the British Isles.

RESULTS

Differences in case mix (mostly minor) and clinical service (many of prognostic relevance) were present between the countries. Significant differences in outcome were present between the countries. When assessed by geographical region, death or dependency were lower in North America (odds ratio (OR) adjusted for treatment group only = 0.52 (95% confidence interval, 0.39 to 0.71) and north west Europe (OR = 0.54 (0.37 to 0.78)) relative to the British Isles; similar reductions were found when adjustments were made for 11 case mix variables and five service quality measures. Similarly, case fatality rates were lower in North America (OR = 0.44 (0.30 to 0.66)) and Scandinavia (OR = 0.50 (0.33 to 0.74)) relative to the British Isles, whether crude or adjusted for case mix and service quality.

CONCLUSIONS

Both functional outcome and case fatality vary considerably between countries, even when adjusted for prognostic case mix variables and measures of good stroke care. Differing health care systems and the management of patients with acute stroke may contribute to these findings.

Ethicists and clinicans: the case for collaboration in the teaching of medical ethics

It has become part of conventional wisdom that medical students experience a clear separation between the explicit ethics curriculum of the lecture room and the implicit curriculum of the clinic. This paper outlines and critiques some important assumptions made about the teaching of ethics in medical schools. It identifies the need for close collaboration between clinical and non-medical ethics teachers to advance the teaching of ethics in medical training.

Gait abnormalities in older people--comparison of inter-professional assessment

Gait abnormalities are common in older people but relatively under-diagnosed. We investigated the prevalence of gait abnormalities among patients presenting to a geriatric medicine day hospital, classified them according to whether they were lower, middle or higher level gait disorders and compared inter-professional (physician and physiotherapist) assessments for this classification. Prospective independent assessment by a physician and a senior physiotherapist of 50 consecutive patients presenting to a day hospital. Presence of a gait abnormality was determined and then classified. Levels of agreement were determined between the two professions. There was 98% agreement that a gait abnormality existed in 43 people. In classifying the gait abnormality there was complete agreement in over two-thirds of cases (67.4%). There was further agreement of higher level gait disorders (but disagreement in the sub-classification) in 11.6% of cases. Given the high prevalence of gait abnormality presenting to the day hospital, screening for gait and balance disorders should be of paramount importance. While levels of agreement between the two professions were high, disagreement existed in approximately one-third of cases. Agreement among professionals essential for appropriate tailoring of treatment and intervention.

Validating the Orpington Prognostic Score in an Irish in-patient stroke population

An accurate assessment of stroke severity and the ability to predict prognosis is important for determining rehabilitation needs and long term management of patients after stroke. The Orpington Prognostic Score (OPS) is a clinically derived stroke severity scale that can be used to stratify patients into different severity groups. The aim of this study was to validate the Orpington Prognostic Score (OPS) in an Irish in-patient stroke population. Fifty 'first stroke' patients (21 male, median age 72.5 [range 31-93] years) were assessed within two weeks following stroke onset. Subjects were stratified into mild, moderate and severe groups using previously established cut-offs for the OPS. Outcomes were determined prospectively and compared to initial severity groups. Patients in the severe group had a significantly increased chance of dying (Odds ratio [95%CI] 2.16 [1.72-2.72] and this persisted after adjustment for age and gender. Length of stay increased significantly with increasing stroke severity group (F ratio 7.0 p=0.0025) and this association remained after adjusting for age and gender. The odds of being discharged home or of being able to walk independently by time of discharge decreased significantly (all p<0.001) as stroke severity increased and adjusting for age and gender did not alter these associations. A higher OPS score within 2 weeks of stroke onset was significantly associated with longer length of stay, increased mortality, reduced mobility at discharge and a reduced likelihood of discharge home. The OPS is a valid measure of stroke severity in Irish stroke in-patients.

Immunogenicity and adverse reactions of influenza vaccination in elderly patients given acetaminophen or placebo

The objective was to examine the antibody responses to influenza immunization in an elderly population and the effect of prophylactic acetaminophen on adverse responses due to inactivated whole virus vaccine containing influenza A (H3N2 and H1N1) and B antigens. During the autumn of 1990, 100 patients 65 years or older were immunized and randomly allocated to receive placebo or 1,950 mg (2 x 975 mg) of acetaminophen. They recorded any local and systemic side effects over a 3-day period. Serology was performed on pre- and post (4-6 weeks) -vaccination sera. Age and gender distribution in the study were: 47% who were 75 years or older, and 61% of the patients were female. Most of the patients (97%) had pre-existing antibodies to Influenza A or B. Average peak preimmunization antibody titers were 40 to B Yamagata and A Taiwan (H1N1) and 80 for A Shanghai (H3N2). Half of each treatment group had a 4-fold or greater rise in antibody titer in response to the vaccine. Only 30% of patients immunized the previous year but 80% of those never vaccinated previously demonstrated a 4-fold or greater serological response to the vaccine. However, measurement of protection rates (HI >/= 40) before and after vaccination indicated 81.1-100% protection for the 3 viruses not influenced by treatment, gender or a history of previous vaccination. Both treatment groups had equally small numbers of patients who recorded systemic symptoms of drowsiness, myalgia, fever and chills and about 50% had arm soreness. Although about 80% of previously unimmunized adults mounted a 4-fold antibody rise to influenza vaccine antigens whereas booster effects were seen in only 30% of those immunized the previous year, protection rates were high (81-100%) after immunization and were not affected by acetaminophen treatment. Adverse effects (15% systemic and 50% local) were not ameliorated by 1950 mg of acetaminophen in these elderly patients.

Chronic kidney disease in the elderly; a silent epidemic

Chronic kidney disease has been shown to be associated with significant increases in mortality and morbidity even in early stages. Despite this it is rarely diagnosed, actively investigated or managed in the elderly. We set out to establish the prevalence of CKD and identify causative factors in a consecutive series of referrals to a geriatric medical clinic. We calculated glomerular filtration rates (GFR) for 101 patients attending a geriatric medical clinic using the Cockroft and Gault formula, and collected data on medications and relevant past medical history. Mild CKD (GFR <60ml/min) was present in 80% of the group. Only 10% of these patients had serum creatinine >130(mmol/L. hypertension was present in 50% and only 9% were diabetic. Almost one third were on inappropriate drugs or dosages; most commonly non-steroidal anti-inflammatory drugs (99%). Chronic kidney disease is extremely common in older people attending a geriatric medical clinic and carries significant risks. CKD will not be detected by serum creatinine alone in 90% of cases. Routine calculation of GFR should be used to provide a more accurate measure of renal impairment and allow earlier intervention, risk factor reduction and improve prescribing practices.

Acute medical take or subacute-on-chronic medical take?

INTRODUCTION

Older people are a significant source of emergency admissions to general hospitals relative to their proportion of the population. Little is known of the acuity of these admissions, aspects of which this study aims to determine.

METHODOLOGY

A prospective survey of 1 in 10 acute general takes in a university teaching hospital over 11 months. Age, sex, acuity of presentation, premorbid functional status and cognitive impairment were recorded.

RESULTS

Of 332 admissions, 127 (38%) patients were aged 65 years or over and 205 under 65. Of > or =65's, 53 (42 ) presented <2 days of symptoms compared to 117 (57%) <65's. Mean delay between onset of primary symptom and presentation was 8.76 days (> or =65's) and 6.77 days (<65's). Previous functional loss was present in 42% of > or =65's. On admission, 36% of > or =65's were deemed cognitively impaired.

CONCLUSION

Acute on chronic illness represents a significant proportion of 'acute general take'. Older patients admitted in this fashion also tend to present to hospital later after the onset of their symptoms and with more physical and cognitive impairment than younger counterparts. These findings are supportive of the development of better models for managing chronic disease, such as acute geriatric medicine, stroke units, admission avoidance strategies and focussed community supports.

Quantification of the role of temporal artery biopsy in diagnosing clinically suspected giant cell arteritis

PURPOSE

(1) To see the effectiveness of applying the criteria laid down by the American college of Rheumatology in the diagnosis of giant cell arteritis (GCA). (2) To quantify the role of temporal artery biopsy (TAB) in diagnosing GCA using the Greenwich grading system.

METHODS

A retrospective case notes review of consecutive patients undergoing TAB over 6 years, from 1995 to 2000, in a UK hospital eye unit was done. The American college of Rheumatology 1990 criteria for diagnosis of GCA were applied. A detailed analysis of age of onset, mode of presentation, laboratory findings and histology was done for all the patients. In an attempt to quantify the clinical value of TAB in patients with clinically suspected GCA, the Greenwich grading system was used. The role of TAB was graded as essential, important, helpful, unnecessary, and adverse effect.

RESULTS

Out of the 53 patients who underwent TAB, 13 were found to have positive TAB, while 40 had negative biopsies. On application of the American College of Rheumatology criteria, 36 patients fulfilled the criteria required to make a diagnosis of GCA. Temporal headache, ESR>50 mm/h and temporal artery tenderness were found to occur more often in patients with positive biopsy.

CONCLUSION

(1) The American College of Rheumatology criteria provide a framework in which the clinician can continually assess the need for TAB. (2) The Greenwich grading system, as applied in evaluating the role of TAB in the management of GCA, demonstrated the clinical usefulness of this invasive procedure in the majority of cases. It identified the patient groups that benefit the most from a TAB.

Community-based study of atrial fibrillation and stroke prevention

The benefits of anticoagulation and antiplatelet agents for stroke prevention in atrial fibrillation (AF) have been established. There is little data on the use of this form of stroke prevention in patients with AF in Ireland. To determine whether adequate stroke prevention measures are taken regarding anticoagulation and aspirin use for patients in the community with chronic AF. Audit of general medical services (GMS) patients with atrial fibrillation in two Dublin general practices. A total of 70 patients with AF were identified from 2684 GMS patients in the two practices: contraindications to anticoagulation were established in 26 of these. In those for whom warfarin was indicated, 21 of 44 (47%) were not anticoagulated. In those not anticoagulated and where aspirin was not contra-indicated, 20 of 42 were not on aspirin. Our study found that almost one third of patients with AF could be anticoagulated but were not, and the alternative of aspirin was only used in just over one half of patients. This represents a lost opportunity for stroke prevention. Various approaches should be explored to remedy this.

Causes of sensitisation in patients awaiting renal transplantation in Ireland

Sensitisation to HLA antigens, formed as a result of transfusion, previous allografts or pregnancy, remains a significant problem in transplantation. The aim of this study was to define the causes of sensitisation of potential renal allograft recipients in Ireland in the post-EPO era. A retrospective survey of all patients who were active on the renal transplant waiting list during 1996 was performed evaluating the panel reactive antibodies (PRA), history of sensitising events, and waiting time for transplantation. Of a total of 244 patients (151 males, 93 females), 163 (67%) were not sensitised (PRA < 10%), and 35 (14%) were sensitised (PRA 10-59%), 15 subjects (6%) were significantly sensitised (60-79%) and 31 (13%) were highly sensitised (PRA > 80%). Only 59 (24%) patients had no sensitising events recorded. Fifty-eight (24%) subjects had previous allografts. Transfusion was documented in 173 (71%) subjects. Pregnancy was noted in 55/93 (59%) female subjects. All highly sensitised patients had been transfused. Eighty per cent (12/15) significantly sensitised and 97 (60%) of the non-sensitised subjects had been transfused. The level of sensitisation clearly increased with the number of units transfused. Non-sensitised subjects received a mean of 5.65 units (SEM 1.38), sensitised subjects a mean of 9.8 units (SEM 3.17), significantly sensitised a men of 18.2 units (SEM 6.51), while highly sensitised subjects received a mean of 37.8 units, (SEM 8.4). There was a direct relationship between the waiting time for transplantation and the degree of sensitisation. The percentage of patients who had been transfused in the 1996 cohort (71%) was similar to the percentage of patients transfused on the waiting list in August 1999 (75%). These data demonstrate that transfusion remains an important cause of sensitisation, despite the use of EPO. Measures to further reduce the use of transfusion or the use of immunosuppression at the time of transfusion in potential allograft recipients may be of value in the future.

Community and social interventions at a geriatric medical OPD

Health and social services in Ireland tend to be relatively poorly coordinated. Surveys confirm the perceptions of older people with disability that access to and availability of both health and social services are limited. Multi-disciplinary geriatric medical clinics may provide a focus for better utilization and coordination of these services. The purpose of this study was to measure not only the existing service use but also the potential for community and social-care intervention with older people living in the community when using multi-disciplinary geriatric medical clinics. A sample of 60 consecutive patients aged over 65, attending our geriatric medical OPD for the first time, were interviewed using a semistructured questionnaire on the current and potential use of community and social care services. Our service arranged for 229 interventions or referral to services, an average of 3.8 interventions per patient. Ninety-six services were already in place (an average of 1.6 per patient) and 455 services were not applicable, an average of 7.6 per patient. A combined health and social care response is critical to a successful strategy to disease and disability in later life. Although this study describes a relative utilitarian approach to increase community and social care support, it shows there is significant scope to improve uptake of basic community and social care services by a focussed approach to the care needs of older people.

Dementia with oropharyngeal dysphagia and myopathy

A 72-year-old man was referred for geriatric evaluation with a view toward placement in institutional care. He presented originally to an internal medicine team with a six-month history of weight loss, constipation, generalized weakness, and apathy; investigations to rule out an underlying neoplasm were negative. Interdisciplinary assessment revealed coexisting dementia, myopathy, and oropharyngeal dysphagia. These findings prompted further diagnostic evaluation and a diagnosis of inflammatory myopathy with associated oropharyngeal dysphagia and dementia was made. The dementia, myopathy, and oropharyngeal dysphagia responded to steroids and rehabilitation and the patient regained his independence.

Tinzaparin in acute ischaemic stroke (TAIST): a randomised aspirin-controlled trial

BACKGROUND

Low-molecular-weight heparins and heparinoids are superior to unfractionated heparin in the prevention and treatment of venous thromboembolism, but their safety and efficacy in acute ischaemic stroke are inadequately defined.

METHODS

This randomised, double-blind, aspirin-controlled trial tested the safety and efficacy of treatment with high-dose tinzaparin (175 anti-Xa IU/kg daily; 487 patients), medium-dose tinzaparin (100 anti-Xa IU/kg daily; 508 patients), or aspirin (300 mg daily; 491 patients) started within 48 h of acute ischaemic stroke and given for up to 10 days. Primary intracerebral haemorrhage was excluded by computed tomography. Outcome was assessed, with treatment allocation concealed, by the modified Rankin scale at 6 months (independence [scores 0-2] vs dependence or death [scores 3-6]).

FINDINGS

Of 1486 randomised patients, two did not receive treatment and 46 were lost to follow-up. The proportions independent at 6 months were similar in the groups assigned high-dose tinzaparin (194/468 [41.5%]), medium-dose tinzaparin (206/486 [42.4%]), or aspirin (205/482 [42.5%]). There was no difference in effect in any predefined subgroup, including patients with presumed cardioembolic stroke. Other outcome measures were similar between the treatment groups (disability, case-fatality, and neurological deterioration rates). During the in-hospital treatment period no patient assigned high-dose tinzaparin developed a symptomatic deep-vein thrombosis compared with nine assigned aspirin. Conversely, seven patients assigned high-dose tinzaparin developed symptomatic intracerebral haemorrhage compared with one in the aspirin group.

INTERPRETATION

Treatment with tinzaparin, at high or medium dose, within 48 h of acute ischaemic stroke did not improve functional outcome compared with aspirin. Although high-dose tinzaparin was superior in preventing deep-vein thrombosis, it was associated with a higher rate of symptomatic intracranial haemorrhage.