Disability, distress and unemployment in neurology outpatients with symptoms 'unexplained by organic disease'

OBJECTIVES

To determine the disability, distress and employment status of new neurology outpatients with physical symptoms unexplained by organic disease and to compare them with patients with symptoms explained by organic disease.

METHODS

As part of a cohort study (the Scottish Neurological Symptoms Study) neurologists rated the extent to which each new patient's symptoms were explained by organic disease. Patients whose symptoms were rated as 'not at all' or only 'somewhat' explained by disease were considered cases, and those whose symptoms were 'largely' or 'completely' explained by disease were considered controls. All patients completed self-ratings of disability, health status (Medical Outcomes Study Short Form 12-Item Scale (SF-12)) and emotional distress (Hospital Anxiety and Depression Scale) and also reported their employment and state financial benefit status.

RESULTS

3781 patients were recruited: 1144 (30%) cases and 2637 (70%) controls. Cases had worse physical health status (SF-12 score 42 vs 44; difference in means 1.7 (95% CI -2.5 to 0.9)) and worse mental health status (SF-12 score 43 vs 47; difference in means -3.5 (95% CI -4.3 to to 2.7)). Unemployment was similar in cases and controls (50% vs 50%) but cases were more likely not to be working for health reasons (54% vs 37% of the 50% not working; OR 2.0 (95% CI 1.6 to 2.4)) and also more likely to be receiving disability-related state financial benefits (27% vs 22%; (OR 1.3, 95% CI 1.1 to 1.6)).

CONCLUSIONS

New neurology patients with symptoms unexplained by organic disease have more disability-, distress- and disability-related state financial benefits than patients with symptoms explained by disease.

Neurology out-patients with symptoms unexplained by disease: illness beliefs and financial benefits predict 1-year outcome

BACKGROUND

Patients whose symptoms are 'unexplained by disease' often have a poor symptomatic outcome after specialist consultation, but we know little about which patient factors predict this. We therefore aimed to determine predictors of poor subjective outcome for new neurology out-patients with symptoms unexplained by disease 1 year after the initial consultation.

METHOD

The Scottish Neurological Symptom Study was a 1-year prospective cohort study of patients referred to secondary care National Health Service neurology clinics in Scotland (UK). Patients were included if the neurologist rated their symptoms as 'not at all' or only 'somewhat explained' by organic disease. Patient-rated change in health was rated on a five-point Clinical Global Improvement (CGI) scale ('much better' to 'much worse') 1 year later.

RESULTS

The 12-month outcome data were available on 716 of 1144 patients (63%). Poor outcome on the CGI ('unchanged', 'worse' or 'much worse') was reported by 482 (67%) out of 716 patients. The only strong independent baseline predictors were patients' beliefs [expectation of non-recovery (odds ratio [OR] 2.04, 95% confidence interval [CI] 1.40-2.96), non-attribution of symptoms to psychological factors (OR 2.22, 95% CI 1.51-3.26)] and the receipt of illness-related financial benefits (OR 2.30, 95% CI 1.37-3.86). Together, these factors predicted 13% of the variance in outcome.

CONCLUSIONS

Of the patients, two-thirds had a poor outcome at 1 year. Illness beliefs and financial benefits are more useful in predicting poor outcome than the number of symptoms, disability and distress.

Differences between intracranial vascular malformation types in the characteristics of their presenting haemorrhages: prospective, population-based study

OBJECTIVE

To determine the imaging and demographic characteristics of intracranial haemorrhages, which are subsequently found to be due to an underlying intracranial vascular malformation (IVM).

METHODS

We compared the demographic and brain imaging characteristics of adults presenting with intracranial haemorrhage, subsequently found to be due to a brain arteriovenous malformation (BAVM), dural arteriovenous fistula (DAVF) or cavernous malformation (CM) in a prospective, population-based cohort of adults diagnosed for the first time with an IVM (The Scottish IVM Study (SIVMS)).

RESULTS

Of the 141 adults in SIVMS who presented with intracranial haemorrhage, those with CMs presented at a younger age and were less handicapped. A total of 115 (82%) had intracerebral haemorrhage (ICH) with or without subarachnoid, intraventricular or subdural extension. ICH without extension into other compartments accounted for all CM bleeds, but only 50% of BAVM and DAVF bleeds. Median haematoma volumes differed (Kruskal-Wallis, p<0.0001): ICH due to BAVM (16.0 cm3, inter-quartile range (IQR) 4.7 to 42.0) and DAVF (14.1 cm3, IQR 4.9 to 21.5) were similar, but CM haematoma volumes were smaller (median 1.8 cm3, IQR 1.3 to 4.3). These findings were robust in sensitivity analyses. Small haematoma volumes occurred among all IVM types; the largest haematoma volume due to CM was 12 cm3, and volumes of >34 cm3 were only due to BAVM.

CONCLUSIONS

Intracranial haemorrhages found to be due to IVMs differ in adults' age of presentation and clinical severity, as well as the volume and distribution of the haematoma within the brain compartments.

Promoting awareness and practice of testicular self-examination

AIM

To evaluate the efficacy of a health promotion initiative on men's knowledge of testicular cancer and self-examination rates.

METHOD

A quasi-experimental, pre- and post-test questionnaire study of men at 14 workplace and leisure sites across two primary care trusts was undertaken: ten experimental sites received the intervention and four acted as a control. Men at all 14 sites were given a pre- and post-test questionnaire.

RESULTS

Of the 835 pre-test and 835 post-test questionnaires distributed, 518 (62.0 per cent) and 356 (42.6 per cent) were respectively returned for evaluation. In the intervention group, the median total knowledge score increased from three points (interquartile range: 2,4) at baseline to four points (interquartile range: 2,4) at post-test. However, no statistically significant change was observed in the control group. Post-intervention, the percentage of test participants examining their testicles regularly increased from 58.4 per cent to 68.3 per cent, while levels among control peers did not significantly alter.

CONCLUSION

This evaluation highlights the potential of using a low-cost initiative which targets innovative venues to improve men's knowledge of testicular cancer and rates of self-examination. Longer-term follow-up may be required to determine whether such increases are sustained.

Routine oral nutritional supplementation for stroke patients in hospital (FOOD): a multicentre randomised controlled trial

BACKGROUND

Undernutrition is common in hospital patients with stroke, can develop or worsen in hospital, and is associated with poor outcomes. We aimed to establish whether routine oral nutritional supplements improve outcome after stroke.

METHODS

The FOOD trials are a family of three pragmatic, multicentre, randomised controlled trials. We measured the outcomes of stroke patients who could swallow and who were randomly allocated normal hospital diet or normal hospital diet plus oral nutritional supplements until hospital discharge. The primary outcome was death or poor outcome (modified Rankin scale [MRS] grade 3-5), 6 months after enrollment, measured unaware of treatment allocation. Analysis was by intention to treat.

FINDINGS

Between Nov 1, 1996, and July 31, 2003, 4023 patients were enrolled by 125 hospitals in 15 countries. Only 314 (8%) patients were judged to be undernourished at baseline. Vital status and MRS at the end of the trial were known for 4012 and 4004 patients, respectively. Supplemented diet was associated with an absolute reduction in risk of death of 0.7% (95% CI -1.4 to 2.7) and an increased risk of death or poor outcome of 0.7% (-2.3 to 3.8).

INTERPRETATION

We could not confirm the anticipated 4% absolute benefit for death or poor outcome from routine oral nutritional supplements for mainly well nourished stroke patients in hospital. Our results would be compatible with a 1% or 2% absolute benefit or harm from oral supplements. These results do not support a policy of routine oral supplementation after stroke.

Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial

BACKGROUND

Undernutrition is common in patients admitted with stroke. We aimed to establish whether the timing and route of enteral tube feeding after stroke affected patients' outcomes at 6 months.

METHODS

The FOOD trials consist of three pragmatic multicentre randomised controlled trials, two of which included dysphagic stroke patients. In one trial, patients enrolled within 7 days of admission were randomly allocated to early enteral tube feeding or no tube feeding for more than 7 days (early versus avoid). In the other, patients were allocated percutaneous endoscopic gastrostomy (PEG) or nasogastric feeding. The primary outcome was death or poor outcome at 6 months. Analysis was by intention to treat.

FINDINGS

Between Nov 1, 1996, and July 31, 2003, 859 patients were enrolled by 83 hospitals in 15 countries into the early versus avoid trial. Early tube feeding was associated with an absolute reduction in risk of death of 5.8% (95% CI -0.8 to 12.5, p=0.09) and a reduction in death or poor outcome of 1.2% (-4.2 to 6.6, p=0.7). In the PEG versus nasogastric tube trial, 321 patients were enrolled by 47 hospitals in 11 countries. PEG feeding was associated with an absolute increase in risk of death of 1.0% (-10.0 to 11.9, p=0.9) and an increased risk of death or poor outcome of 7.8% (0.0 to 15.5, p=0.05).

INTERPRETATION

Early tube feeding might reduce case fatality, but at the expense of increasing the proportion surviving with poor outcome. Our data do not support a policy of early initiation of PEG feeding in dysphagic stroke patients.

Patients whom neurologists find difficult to help

BACKGROUND

All doctors recognise that some patients are more "difficult to help" than others, but the issue has received little systematic investigation in neurological practice.

OBJECTIVE

To test the hypothesis that patients whose symptoms were less explained by organic disease would be perceived as more difficult to help.

METHODS

In a consecutive series of 300 new neurology outpatients, neurologists indicated on four point Likert-type scales how "difficult to help" they found the patient and to what extent the patient's symptoms were explained by organic disease. The patients' demographics, health status, number of somatic symptoms, and mental state were also assessed.

RESULTS

The neurologists rated 143 patients (48%) as "not at all difficult" to help, 111 (37%) as "somewhat difficult", 27 (9%) as "very difficult", and 18 (6%) as "extremely difficult". A logistic regression model was constructed and the hypothesis that patients whose symptoms were less explained by organic disease would be perceived as more difficult to help was supported. The only other measured variable that contributed to perceived difficulty was physical disability, but it explained only a small amount of the variance.

CONCLUSIONS

Neurologists find patients whose symptoms are not explained by organic disease more difficult to help than their other patients.

Effects of a Perindopril-Based Blood Pressure–Lowering Regimen on the Risk of Recurrent Stroke According to Stroke Subtype and Medical History

BACKGROUND AND PURPOSE

The Perindopril Protection Against Recurrent Stroke Study (PROGRESS) showed that blood pressure lowering reduced stroke risk in patients with a history of cerebrovascular events. Here, we report the consistency of treatment effects across different stroke subtypes and among major clinical subgroups.

METHODS

PROGRESS was a randomized, double-blind trial among 6105 people with a prior history of cerebrovascular events. Participants were assigned to active treatment (perindopril for all participants and indapamide for those with neither an indication for nor a contraindication to a diuretic) or matching placebo(s).

RESULTS

During a mean of 3.9 years of follow-up, active treatment reduced the absolute rates of ischemic stroke from 10% to 8% (relative risk reduction [RRR], 24%; 95% confidence interval [CI], 10 to 35) and the absolute rates of intracerebral hemorrhage from 2% to 1% (RRR, 50%; 95% CI, 26 to 67). The relative risk of any stroke during follow-up was reduced by 26% (95% CI, 12 to 38) among patients whose baseline cerebrovascular event was an ischemic stroke and by 49% (95% CI, 18 to 68) among those whose baseline event was an intracerebral hemorrhage. There was no evidence that treatment effects were modified by other drug therapies (antiplatelet or other antihypertensive agents), residual neurological signs, atrial fibrillation, or the time since the last cerebrovascular event.

CONCLUSIONS

Beneficial effects of a perindopril-based treatment regimen were observed for all stroke types and all major clinical subgroups studied. These data suggest that effective blood pressure-lowering therapy should be routinely considered for all patients with a history of cerebrovascular events.

Stroke: killer clots and killer drugs

Therapeutic thrombolysis is an immense opportunity in acute stroke care. For the first time, there is a treatment that has a high probability of being effective if given early enough to patients with acute ischemic stroke. However, the risks of intracranial hemorrhage are substantial and as yet the exact indications and contraindications have not been worked out. And indeed how to deliver this treatment in routine clinical practice. As stroke units proliferate and become more organized, and physicians become more specialized in stroke care, it will become easier both to further assess in randomized trials and to deliver thrombolysis, certainly intravenously and maybe in some centers intra-arterially in suitable cases.

The outcome of neurology outpatients with medically unexplained symptoms: a prospective cohort study

BACKGROUND

In a previous cross sectional study of 300 consecutive new attenders at neurology outpatient clinics, 90 were detected with symptoms that were rated as "not at all" or only "somewhat" explained by organic disease.

OBJECTIVE

To report a follow up study of this cohort.

METHODS

Patients were reinterviewed by telephone eight months after their initial assessment. They were asked to rate their overall improvement on a clinical global improvement scale, and their health status on the medical outcome short form 36 item scale (SF-36). The PRIME MD interview was administered to determine psychiatric diagnoses. Neurological and primary care records were reviewed for any changes in diagnostic opinion during the follow up period.

RESULTS

Of the 90 eligible patients, 66 (73%) participated in follow up. Among these, five (8%) rated themselves as "much worse," four (6%) as "somewhat worse," 27 (40%) as "just the same," 15 (23%) as "somewhat better," and 15 (23%) as "much better." There were no cases in which an organic cause for the presenting complaint was uncovered during the follow up period. Poorer physical function at baseline was the only predictor of poorer outcome at follow up.

CONCLUSIONS

Over half the patients who presented to neurologists with symptoms that were rated as largely or completely medically unexplained had not improved eight months later. In no case was a disease explanation for the original presenting symptoms subsequently identified.

The outcome of depressive disorders in neurology patients: a prospective cohort study

BACKGROUND

In a previous prospective study of 300 consecutive new attenders at neurology outpatient clinics, depressive disorders were diagnosed in 119 patients (40%) and major depressive disorder in 77 (26%).

OBJECTIVE

To describe the eight month outcome of depression in this cohort.

METHODS

Patients were reinterviewed eight months after their baseline assessment. Mental state was examined using the primary care evaluation of mental disorders (PRIME-MD) interview and the hospital anxiety and depression (HAD) self rating scale. Health status was measured using the medical outcome study 36 item short form scale (SF-36).

RESULTS

Of the original cohort of 300, 226 (75%) participated in the follow up. Among them, 88 had a depressive disorder at baseline and 69 (78%) of those were still depressed at follow up; 54 had major depression at baseline and 46 (85%) of those still had a major depressive disorder at follow up. Among the 138 patients who had no depression at baseline, 20 new major depressive disorders had developed by the time of follow up. Resolution of major depressive disorders was associated with an improvement in health status.

CONCLUSIONS

Most depressive disorders detected in neurology outpatients persist at an eight month follow up, and a substantial number of new cases arise. Resolution of depressive disorders, particularly major depressive disorder, is associated with an improvement in health status.

Performance of a statistical model to predict stroke outcome in the context of a large, simple, randomized, controlled trial of feeding

BACKGROUND AND PURPOSE

Statistical models to predict the outcome of stroke patients have several uses. Their utility depends on their predictive accuracy in patients other than those on whom they were developed (ie, external validity). We sought to test the external validity of some recently described models in patients enrolled in the FOOD (Feed Or Ordinary Diet) trial: a large randomized trial evaluating feeding policies in patients with stroke.

METHODS

The predictive variables were collected during a telephone call to randomize the patient a median of 5 days after stroke onset. Patients were followed up 6 months later to establish their survival, functional status, and residence. Charts were plotted to demonstrate the discrimination and calibration of the models.

RESULTS

The models performed well in the first 2955 patients enrolled and followed up in the FOOD trial. The area under the receiver operating characteristic curves varied between 0.78 and 0.81 (with 0.5 indicating no discrimination and 1.0 indicating perfect discrimination). The discrimination was marginally better for patients enrolled within the first day of stroke than later. The models tended to provide rather pessimistic predictions in all groups except those predicted to have a high likelihood of surviving free of dependency.

CONCLUSIONS

As one might predict, the discriminatory power in the selected cohort of trial patients was marginally less good than in previously studied unselected cohorts used to test their external validity. These models provide a well-tested tool for stratification in trials, comparing outcomes in different cohorts and examining the additional predictive power of novel factors.