Pattern of neurological diseases in adult outpatient neurology clinics in tertiary care hospital

OBJECTIVES

The burden of neurological diseases in developing countries is rising although little is known about the epidemiology and clinical pattern of neurological disorders. The objective of this study was to understand the burden of disease faced by neurologists a in tertiary care setting.

RESULTS

A prospective observational study was conducted of all presentations to neurology clinics at Aga Khan University Hospital Karachi over a period of 2 years. A total of 16,371 out-patients with neurological diseases were seen during the study period. The mean age of the study participants were 46.2 ± 18.3 years and 8508 (52%) were male. Headache disorders were present in 3058 (18.6%) of patients followed by vascular diseases 2842 (17.4%), nerve and root lesions 2311 (14.1%) and epilepsies 2055 (12.5%). Parkinson's disease was more prevalent in male participants 564 (70.8%) as compared to female 257 (62.1%) (p = 0.002). Migraines and vertigo disease were more diagnosed in females as compared to males. Epilepsies were seen more in younger age groups. Parkinson's disease was seen in 50.9% of participants between the ages of 45 and 65 years, and the frequency increased with age.

A unique MRI presentation of fungal infection in the brain

Fungal infections of CNS are common in certain geographic locations. MRI with or without contrast is a useful prediagnostic tool. However, the findings may sometimes be misleading. In this case report, the authors present unusual imaging findings in the MRI of fungal infection in an immunocompetent host, whereby hyper-intense signals were seen on T2-weighted images and patchy post-contrast enhancement was observed with surrounding edema. These findings were suggestive of a neoplastic lesion but it was identified as aspergillosis on subsequent histopathology. This unusual MRI finding of CNS highlights the need to consider fungal infection as a differential diagnosis of all mass lesions on MRI, irrespective of their signal characteristics.

Mortality and neurodevelopmental outcomes of acute bacterial meningitis in children aged <5 years in Pakistan

OBJECTIVE

Significant neurodevelopmental sequelae are known to occur after acute bacterial meningitis (ABM). This study determined the burden of such sequelae in Pakistani children aged <5 years to guide policies for Haemophilus influenzae type b (Hib) and pneumococcal vaccination.

STUDY DESIGN

Cases of ABM were recruited from hospital-based surveillance and assigned to 1 of 3 etiologic groups (Hib, Streptococcus pneumoniae, or unknown etiology). Two age-matched controls were recruited for each case. Six months after enrollment, each case underwent neurologic history and examination, neurodevelopmental evaluation, and neurophysiological hearing test. Controls were assessed in parallel.

RESULTS

Of 188 cases, 64 (34%) died. Mortality among subgroups were 7 (27%), 14 (28%), and 43 (39%) for Hib, Streptococcus pneumoniae, and unknown etiology, respectively. Eighty cases and 160 controls completed the assessments. Sequelae among cases included developmental delay (37%), motor deficit (31%), hearing impairment (18.5%), epilepsy (14%), and vision impairment (14%). Sequelae were higher after pneumococcal meningitis (19, 73%) compared with Hib meningitis (8, 53%). Compared with controls, cases were at significantly higher risk for all sequelae (P < .0001).

CONCLUSIONS

ABM causes a substantial long-term burden of poor neurodevelopmental outcomes. Hib and pneumococcal vaccines are very effective interventions to prevent meningitis and its disabling sequelae.

Medical mortality in Pakistan: experience at a tertiary care hospital

AIM

To acquire systematic data on the causes of hospital mortality in Pakistan, a developing country with scant mortality records.

STUDY DESIGN

Retrospective review of death certificates and hospital charts of patients dying on general and specialty medical services at our hospital during one calendar year.

RESULTS

Of a total 10,590 admissions, 657 (6.2%) died in hospital. The deceased included 357 (54.4%) males and 299 (45.6%) females, with a collective median age of 63 years and mean length of stay 6.71 days (median 4 days, range 1-56 days). Primary cause of death was categorised as infectious (21.2%), pulmonary (17.2%), cancer related (15.7%), cardiovascular (12.6%), gastrointestinal and hepatic (10.8%), neurological (11.4%) and miscellaneous (11.1%). Within each category, the most common diagnoses were septicaemia (76.9% of infectious cases), pneumonia (55.7% of pulmonary cases), myocardial infarction (40.9% of cardiovascular), intracranial haemorrhage (37.3% of neurological), and cirrhosis (45.0% of gastrointestinal). There were multiple causes among malignant disorders with no single cause dominating. Patients with cardiovascular and pulmonary deaths tended to be older than the median age (p = 0.001), while patients with gastrointestinal and cancer related deaths tended to be younger than the median age (p = 0.001). Length of stay did not differ significantly among the various subgroups. About a quarter (26.4%) deaths occurred within 24 h of admission.

CONCLUSIONS

Infections, including septicaemia and pneumonia, are the leading causes of hospital mortality in our setting, followed by malignancy and cardiovascular causes. The overall mortality rate is comparable to published mortality data from other hospital settings.

Drug compliance after stroke and myocardial infarction: a comparative study

BACKGROUND

Stroke and myocardial infarction (MI) are both life-threatening diseases of vascular origin with a tendency to recur. In both conditions, risk of recurrence is reduced through similar drug regimens.

AIM

To determine if compliance with prescribed medication after stroke or MI was similar in the two populations.

SETTING AND DESIGN

Retrospective data collection and cross-sectional telephonic survey of patients discharged from a single academic medical center.

MATERIALS AND METHODS

Adult patients consecutively discharged over a two-year period with a diagnosis of first-ever stroke (ischemic or hemorrhagic) or first-ever MI (ST-elevation) were identified through ICD-9 codes. Clinical details were abstracted from hospital records. Medication compliance was assessed through a structured telephone interview.

STATISTICAL ANALYSIS

Bivariate analysis using Chi-square and Fisher exact tests, to determine the prevalence of noncompliance in stroke versus MI patients and differences in baseline characteristics and multivariate analysis with logistic regression to determine independent predictors of noncompliance.

RESULTS

Follow-up data was collected for 298 stroke and 275 MI patients. Compliance was lower in stroke patients (68% stroke patients compliant with at least half their discharge prescriptions versus 90% MI patients; P < 0.001). Literacy and post-discharge follow-up were associated with greater compliance (P < 0.05 for both). Compliance was highest with anti-hypertensive drugs (98% after MI, 78% after stroke), followed by anti-platelet agents (94% after MI, 75% after stroke) and anti-lipid agents (70% after MI, 59% after stroke). Patients reported simply not feeling the need, acquiring fresh medical advice or a perceived lack of benefit, as reasons for not complying with their discharge prescriptions.

CONCLUSIONS

Although similar drugs are involved, compliance with prescribed regimens is appreciably lower after stroke than after MI. Our findings underscore the need for better patient education regarding secondary prevention after stroke.

End of life in the intensive care unit: knowledge and practice of clinicians from Karachi, Pakistan

BACKGROUND

With improvements in the care of critically ill, physicians are faced with obligations to provide quality end-of-life care. Barriers to this include inadequate understanding of the dying patient and withdrawal or limitation of care. The objectives of this study were to document the comprehensions of physicians and nurses regarding the recognition and practice of end-of-life care for critically ill patients placed on life support in the intensive care unit.

METHODS

This was a cross-sectional study carried out at three hospitals in Karachi. Chi-squared analysis and one-way ANOVA were used to compare differences in response between the groups.

RESULTS

One hundred and thirty-seven physicians and critical care nurses completed the survey. 'Brain death' was defined as an 'irreversible cessation of brainstem function' by 85% respondents, with 50% relying on specialty consultation. Withdrawal of life support is practised by 83.2%; physicians are more likely (Chi square test P-value < 0.001) to withdraw mechanical ventilation, compared with nurses who would withdraw vasopressors (P-value 0.006). In a do not resuscitate patient, 72.3% use vasopressors, 83% initiate haemodialysis and 17.5% use non-invasive ventilation; 72.6% consult Hospital Ethics Committees; 16% respondents never withdraw life support; 28.3% considered it their responsibility to 'sustain life at all costs' and only 8% gave religious beliefs as a reason.

CONCLUSIONS

There are confusions in the definition of brain death, end-of-life recognition and indications and processes of withdrawal of life support. There are discrepancies between physicians' and nurses' perceptions and attitudes. Clearly, teaching programmes will need to incorporate cultural and religious differences in their ethics curricula.

Hypotension at presentation is an indicator of poor prognosis in acute intracerebral haemorrhage

OBJECTIVE

To identify frequency of hypotension in a large cohort of patients with intracerebral haemorrhage and its prognostic significance.

METHODS

We retrospectively reviewed medical records of 920 patients with spontaneous intracerebral haemorrhage (ICH). Patients were divided in three groups based on Diastolic blood pressure (DBP); hypotensive group (DBP < 70 mmHg), normotensive group (DBP; 71-90 mmHg) and hypertensive group (DBP > 90 mmHg).

RESULTS

Of the total patients with ICH, 7% (64) presented with hypotension, 13% (120) were normotensive and 80% (736) were hypertensive. In the hypotensive group, 37% (24) patients died as compared to 25%(30) in normotensive group and 25% (182) in hypertensive group (p = 0.03). Hypotension at presentation, thalamic and lobar haemorrhages were predictors of poor outcome. Patients with diastolic BP of less than 70 were significantly more likely to die than with DBP 71-90 (OR = 1.9, 95% CI; 1.1-2.9, p = 0.03). This relationship was still significant after adjusting for age, sex, history of presentation, coma at presentation and location of haemorrhage (OR = 1.45, 95% CI; 1.0-2.2, p = 0.045).

CONCLUSION

Our findings suggest that hypotension at presentation is a predictor of poor outcome in patients with ICH. Patients with diastolic blood pressure less than 70 are more likely to have a fatal outcome as compared to those with normal blood pressure.

Factors associated with helmet use among motorcycle users in Karachi, Pakistan

OBJECTIVES

Wearing a helmet is the single most effective measure for preventing head injuries in motorcycle users. The authors undertook this study to estimate compliance and determine reasons for noncompliance with helmet use among motorcyclists in their community.

METHODS

This was a cross-sectional survey of motorcyclists in three large randomly selected public-access parking spaces across Karachi, Pakistan's largest city. Questions covered personal demographics, frequency of helmet use, reasons for use or nonuse, and knowledge of local helmet laws. Analysis was based on frequencies and group comparisons using chi-square test or independent sample t-test.

RESULTS

Of the 300 (100% male) subjects, 169 (56%) reported using helmets regularly. Users listed injury prevention (78%) as the major reason for compliance, while nonusers listed physical discomfort (44%) and limited vision (25%) as the leading reasons for noncompliance. In univariate analysis, helmet users were significantly better educated than nonusers and were more likely to believe that helmets are protective (p = 0.002) and that passengers should also wear helmets (p < 0.001). The significance of these variables persisted in multivariate analysis. Several other variables (such as mean age, marital status, and knowledge of helmet laws) did not differ between users and nonusers.

CONCLUSIONS

Helmets are underused by motorcyclists in the authors' community. This study underscores the need for improved helmet design, public understanding, intense public education, and rigorous law enforcement in raising compliance with helmet use and minimizing the risk of preventable trauma.

Cryptogenic middle cerebral artery infarction in pure red cell aplasia

Pure red cell aplasia (PRCA) is a rare hematological disorder characterized by an isolated depletion of erythroid precursors with preservation of other cell lines. Neurological concomitants are not a recognized feature. We report a case of unexplained middle cerebral artery infarction in a 32-year-old woman with PRCA. This concurrence may reflect a predisposition to ischemic stroke in patients with PRCA.

Heparin in the treatment of cerebral venous thrombosis

Cerebral venous thrombosis (CVT) is a potentially life-threatening condition requiring rapid diagnosis and urgent treatment. Heparin anticoagulation is the time-honoured treatment, and is advocated in all cases of CVT, irrespective of etiology or presence of haemorrhage. The supportive evidence is largely observational; data from randomized placebo-controlled trials shows a nonsignificant trend favouring heparin. Current practice is to begin heparin (unfractionated or low-molecular weight) immediately on confirmation of the diagnosis. Newer antithrombotic agents such as ximelagatran may offer advantages over heparin and need to be investigated in the treatment of CVT.

Guillain-Barre syndrome in Pakistan: similarity of demyelinating and axonal variants

Guillain-Barré syndrome (GBS) comprises multiple subtypes whose nosological and pathophysiologic interrelationships are unclear. In an attempt to better understand the relationship between the disease's major subtypes, we reviewed the characteristics of GBS cases consecutively admitted to a tertiary care hospital in Karachi, Pakistan, over a 13-year period. Of 175 cases, 80 (46%) were demyelinating and 55 (31%) axonal, whilst 40 (23%) had ambiguous electrophysiological findings precluding classification. The three groups differed in severity of weakness at presentation (axonal approximately ambiguous > demyelinating; P = 0.002 for arm strength and P = 0.025 for leg strength); mean age (demyelinating > axonal > ambiguous; P = 0.05); and mean cerebrospinal fluid protein concentration (demyelinating > ambiguous > axonal; P = 0.05). However, they were similar in several other respects, including gender ratio, proportion of pediatric cases, history of antecedent infection, length of hospital stay, need and duration of mechanical ventilation, and functional outcome at discharge. Stool culture data was available for 146 (83%) cases in the study; none was positive for Campylobacter jejuni. GBS in Pakistan comprises a high proportion of axonal cases. Similarity of outcomes in axonal and demyelinating variants and lack of C. jejuni stool culture positivity are atypical features.

Stroke-associated pneumonia: microbiological data and outcome

INTRODUCTION

Pneumonia is a common complication after acute stroke. It affects the outcome adversely. However, data regarding microbiology of stroke-associated pneumonia and its effect on outcome is scarce.

METHODS

Stroke-associated pneumonia was identified through chart review of all ICD-9 identified adult stroke patients admitted to our hospital over a period of four years (1998-2001). The demographical, laboratory, radiological, microbiological data and outcome of patients with stroke-associated pneumonia were recorded and analysed.

RESULTS

443 patients with stroke were admitted over the four-year period and 102 (23 percent) had stroke-associated pneumonia. Their ages range from 28 to 100 (mean 64+/-14) years. 69 (68 percent) were men. Median length of stay was nine days compared to four days for all stroke patients. 68 (67 percent) patients manifested pneumonia within 48 hours and 34 (33 percent) after 48 hours of admission. Yield of tracheal aspirate cultures was 38 percent and that of chest radiographs was 25 percent. Pseudomonas aeruginosa and Staphylococcus aureus were the most common organisms (12 percent each) followed by Streptococcus pneumoniae and Klebsiella pneumoniae (4 percent each). Patients with infiltrates on chest radiographs were more likely to have positive tracheal aspirate cultures (p-value is 0.003). 35 patients (34 percent) expired during hospital stay. Positive chest radiographs and tracheal aspirates were independent predictors of prolonged hospital stay (p-value is less than 0.005).

CONCLUSION

Pneumonia is a common medical complication of stroke. It is associated with a high mortality and prolongs the hospital stay. The yield of chest radiographs and tracheal aspirates is low. However, these are independent predictors of prolonged hospital stay. Pseudomonas aeruginosa and Staphylococcus aureus are most common organisms in stroke-associated pneumonia.

Association of phosphodiesterase 4D gene with ischemic stroke in a Pakistani population

BACKGROUND AND OBJECTIVES

Identification of STRK1 locus by the deCODE group followed by the discovery of phosphodiesterase 4D (PDE4D) gene in strong association with ischemic stroke patients has provided useful insights toward understanding the genetic etiology of the disease. In this study, we aimed at investigating the association between 3 polymorphisms of the PDE4D gene and ischemic stroke in the Pakistani population.

METHODS

Three polymorphisms in PDE4D gene were analyzed in 200 patients of ischemic stroke and 250 controls of Pakistani origin using polymerase chain reaction-restriction fragment length polymorphism method. Data were coded and entered in SPSS Windows (version 12.0). Odds ratios and 95% CIs were calculated using multivariate logistic regression analysis.

RESULTS

Marker SNP83(rs966221) was found significantly associated with ischemic stroke on univariate and multivariate analysis (P<0.005; odds ratio, 1.64 [1.13 to 2.40]). Haplotype analysis for markers in linkage disequilibrium failed to show any association with the disease.

CONCLUSIONS

The association of PDE4D variation with ischemic stroke extends to the Pakistani population and supports a role for phosphodiesterases in stroke pathogenesis.

Holter monitoring in the diagnosis of stroke mechanism

BACKGROUND

Atrial fibrillation (AF), an important and treatable cause of ischaemic stroke, can occur as a sustained or a paroxysmal arrhythmia. Continuous cardiac rhythm monitoring (Holter monitoring) is often performed in stroke patients to identify paroxysmal AF, which is an indication for warfarin anti-coagulation in this patient population.

AIM

The aim of this study was to assess the clinical utility of Holter monitoring in detecting occult AF in patients with possible cardioembolic stroke.

METHODS

The medical records of ischaemic stroke patients consecutively hospitalized at a single academic centre during a one-year period were reviewed. Data regarding patient demographics, stroke characteristics, electrocardiography and echocardiography results and duration and findings of Holter monitoring were abstracted. The primary outcome was yield of newly diagnosed AF on Holter monitoring.

RESULTS

Of 465 consecutive patients admitted with a diagnosis of new ischaemic stroke, 210 underwent Holter monitoring. The mean duration of monitoring was 22.8 +/- 4.0 h. Previously undiscovered AF was -identified in five cases (2.4%), all of which represented non-rheumatic AF. In three cases, the Holter test was negative despite AF documented on an admission electro-cardiogram.

CONCLUSIONS

Holter monitoring can identify occult paroxysmal AF, assisting targeted secondary prevention in patients with new ischaemic stroke. However, the standard 24-h duration of monitoring probably under-estimates the prevalence of paroxysmal AF in this population. Prospective studies are indicated to evaluate the value of longer monitoring periods in stroke populations.

Brainstem encephalitis with Kikuchi-Fujimoto disease

A case of young woman is described who developed clinical and MRI features of brainstem encephalitis in the setting of fever and cervical lymphadenopathy. Lymph node biopsy revealed histiocytic necrotizing lymphadenitis (Kikuchi-Fujimoto disease), which may reflect host response to an unspecified immune insult.

Cost of acute stroke care at a tertiary care hospital in Karachi, Pakistan

OBJECTIVE

To evaluate cost of acute stroke care and its determinants at a tertiary care hospital in Karachi and to find out predictors of high cost care. Acute stroke is a leading cause of morbidity and mortality. Cost of care is the single most important determinant in availability of acute stroke care at a tertiary care hospital in Pakistan. It is also an important factor in development of public health policies and medical insurance plans. Average annual income in Pakistan is 4881 rupees (85 U dollars).

METHODS

Medical and billing records of 443 patients with acute stroke were retrospectively reviewed from 1998-2001 at The Aga Khan University Hospital (AKUH), Karachi. Acute stroke care at AKUH usually includes routine laboratory investigation including Lipid profile, Magnetic resonance imaging/angiography (MRI/MRA), Echocardiogram, Carotid Doppler's ultrasound and medical management in the Stroke care unit.

RESULTS

443 patients were included in study. Age range was 25-98 years (Mean 58 years). 269 (61%) were male. Length of hospital stay was 1 day; 67 patients, 2 days; 83 patients, 3 days; 70 patients, 4-5 days; 87 patients, 6-10 days; 75 patients, 11-30 days; 49 patients and more than 30 days; 12 patients. Average length of stay was five days and median length was three days. Average total cost was 70,714 rupees (1179 U dollars) which included average radiology cost; 12,507 rupees (208 U dollars), average laboratory cost; 8365 rupees (139 U dollars), average pharmacy cost; 13,320 rupees (222 U dollars) and average bed/room charges; 27,552 rupees (459 U dollars). Length of hospital stay is the most important determinant of cost. Average total cost for patients who stayed for 1 day was 19,597 rupees (326 U dollars), 2-3 days; 25,568 rupees (426 U dollars), 4-7 days; 49,705 rupees (828 U dollars), 8-30 days; 153,586 rupees (2559 U dollars), more than 30 days; 588,239 rupees (9804 U dollars). Average cost for general ward was 60,574 rupees (1010 U dollars), private ward was 74,880 rupees (1248 U dollars) and intensive care unit was 155,010 rupees (2583 U dollars).

CONCLUSION

Cost of acute stroke care is extremely high as compared to average national income at our hospital. Most important determinant of cost is length of hospital stay. Cost cutting measures and increased funding from state are necessary to increase the availability of acute stroke care.

Patient knowledge and expectations for functional recovery after stroke

OBJECTIVE

Understanding the causes and outcomes of stroke is important for stroke survivors and may affect their success in rehabilitation and their risk of recurrent stroke; therefore, this study was performed to assess the knowledge and expectation of functional recovery in stroke patients undergoing acute inpatient rehabilitation.

DESIGN

Survey study of 50 consecutive stroke patients undergoing inpatient rehabilitation at a single urban rehabilitation hospital.

RESULTS

Forty-six percent of participants were able to correctly identify whether they had sustained a cerebral infarct or hemorrhage. Rehabilitation length of stay was, on average, 1 wk longer than anticipated by patients. Patients overestimated their functional abilities on initial assessment and at discharge compared with staff assessments, with some improvement in accuracy for discharge predictions. Ninety-four percent of participants expected to be discharged home, and most achieved this goal. Although no participant anticipated discharge to a nursing home, 10% of patients were discharged to this location.

CONCLUSIONS

Knowledge of stroke and its treatment was limited, and expectations for recovery tended to exceed actual accomplishments. There are significant areas of opportunity for enhanced educational efforts for stroke patients undergoing inpatient rehabilitation.

Functional recovery following rehabilitation after hemorrhagic and ischemic stroke

OBJECTIVES

To quantify recovery after rehabilitation therapy and to identify factors that predicted functional outcome in survivors of intracerebral hemorrhage (ICH) compared with cerebral infarction.

DESIGN

Retrospective study of consecutive ICH and cerebral infarction admissions to a rehabilitation hospital over a 4-year period.

SETTING

Free-standing urban rehabilitation hospital.

PARTICIPANTS

A total of 1064 cases met the inclusion criteria (545 women, 519 men; 871 with cerebral infarction, 193 with ICH).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Functional status was measured using the FIM trade mark instrument, recorded at admission and discharge. Recovery was quantified by the change in FIM total score (DeltaFIM total score). Outcome measures were total discharge FIM score and DeltaFIM total score. Univariate and multivariate analyses were performed.

RESULTS

Total admission FIM score was higher in patients with cerebral infarction than in patients with ICH (59 vs 51, P=.0001). No difference in total discharge FIM score was present. Patients with ICH made a significantly greater recovery than those with cerebral infarction (DeltaFIM total score, 28 vs 23.3; P=.002). On multivariate analysis, younger age, longer length of stay, and admission FIM cognitive subscore independently predicted total discharge FIM and DeltaFIM total score. The severity of disability at admission, indicated by total admission FIM score, independently predicted total discharge FIM score, but not DeltaFIM total score. The ICH patients with the most severely disabling strokes had significantly greater recovery than cerebral infarction patients with stroke of similar severity.

CONCLUSIONS

The patients with ICH had greater functional impairment than the cerebral infarction patients at admission, but made greater gains. Patients with the most severely disabling ICH improved more than those with cerebral infarction of comparable severity. Initial severity of disability, age, and duration of therapy best predicted functional outcome after rehabilitation.

Moyamoya disease: an elusive diagnosis

OBJECTIVE AND BACKGROUND

Moyamoya disease is an idiopathic vasculopathy of circle of Willis. Stroke is a common presentation. We describe clinical and radiological features of moyamoya disease in four patients.

SETTING

Tertiary care center in a metropolitan city.

MATERIALS AND METHODS

Patients with moyamoya disease were identified by ICD-9 coding system of the hospital medical records. Demographic characteristics, clinical features/presentation, laboratory investigations and radiological investigations were recorded and analyzed.

RESULTS

Four patients (three children and one adult) presented with hemiparesis. One patient expired during hospital stay. Two patients underwent surgery (synangiosis). EEGs of three patients showed focal abnormalities. Neuroimaging showed ischemic infarctions in all patients. Findings on four vessel digital substraction angiography and/or magnetic resonance angiography were compatible with moyamoya disease.

CONCLUSION

Moyamoya disease should be considered in all young patients, especially children, presenting with stroke.

Family member knowledge and expectations for functional recovery after stroke

OBJECTIVE

To assess the stroke knowledge and expectations for recovery among the family members of stroke patients in an acute rehabilitation hospital.

DESIGN

Survey study of 50 family members of stroke patients undergoing inpatient rehabilitation at a single urban rehabilitation hospital.

RESULTS

Sixty percent of participants were able to identify whether their family member had sustained a cerebral hemorrhage or infarct; 48% were able to identify at least one treatment provided to their family member for his or her stroke. The average length of stay predicted by participants closely matched the average patient length of stay. Participants tended to overestimate the functional abilities of their family member with a stroke, both on initial assessment and discharge. This overestimation was more substantial for discharge functional ability than for initial assessment. Participants were able to predict discharge location with substantial accuracy (82% agreement, kappa = 0.41).

CONCLUSIONS

The knowledge of stroke etiology and functional outcome of family members of individuals undergoing rehabilitation after stroke shows significant limitations. Participants' ability to predict functional outcome on discharge was worse than their knowledge of current functional status. Participant predictions of length of stay and discharge disposition were areas of relative strength. Further efforts are needed to enhance the knowledge level of family members of patients undergoing rehabilitation after stroke.

Functional recovery after rehabilitation for cerebellar stroke

BACKGROUND AND PURPOSE

Relatively few data exist concerning functional recovery after ischemic and hemorrhagic cerebellar stroke. We studied patients admitted to a rehabilitation hospital after cerebellar stroke to quantify recovery after rehabilitation therapy and to identify variables that predicted functional outcome.

METHODS

This study was a retrospective review of consecutive cases admitted in a 4-year period with new cerebellar infarct or hemorrhage. Clinical features of stroke were recorded and comorbidities scored with the Charlson Index. Follow-up information was obtained by telephone interview. The Functional Independence Measure (FIM) was scored at admission (AFIM), discharge (DFIM), and follow-up (FFIM). Outcome measures were DFIM and FFIM. Univariate and multivariate analyses were performed.

RESULTS

Fifty-eight cases were identified (mean age 69.2 years; 49 infarcts, 9 hemorrhages). Mean AFIM was 65.5, and mean DFIM was 89.8. Mean AFIM was significantly higher in the infarct than in the hemorrhage subgroup (70 versus 43, P:=0.006). Mean DFIM was also higher in the infarct subgroup but did not reach statistical significance (93 versus 74, P:=0.1). Follow-up information was obtained for 45 cases (78%) (mean interval 19.5 months). Median FFIM was 123.5. Outcome was significantly positively correlated with AFIM and initial presenting syndrome of vertigo/vomiting/ataxia/headache. Outcome correlated negatively with preexisting comorbidity score, altered level of consciousness at initial presentation, and superior cerebellar artery infarction. On multivariate analysis, AFIM and comorbidity score were independent predictors of outcome.

CONCLUSIONS

Substantial improvement of mean FIM score frequently occurs after rehabilitation after cerebellar infarction. Functional outcome is best predicted by preexisting comorbidities and functional status at the time of discharge from acute hospitalization.

Role for telemedicine in acute stroke. Feasibility and reliability of remote administration of the NIH stroke scale

BACKGROUND AND PURPOSE

Immediate access to physicians experienced in acute stroke treatment may improve clinical outcomes in patients with acute stroke. Interactive telemedicine can make stroke specialists available to assist in the evaluation of patients at multiple urban or remote rural facilities. We tested whether interrater agreement for the NIH Stroke Scale (NIHSS), a critical component of acute stroke assessment, would persist if performed over a telemedicine link.

METHODS

One bedside and 1 remote NIHSS score were independently obtained on each of 20 patients with ischemic stroke. The bedside examination was performed by a stroke neurologist at the patient's bedside. The remote examination was performed by a second stroke neurologist through an interactive high-speed audio-video link, assisted by a nurse at the patient's bedside. Kappa coefficients were calculated for concordance between bedside and remote scores.

RESULTS

Remote assessments took slightly longer than bedside assessments (mean 9.70 versus 6.55 minutes, P<0. 001). NIHSS scores ranged from 1 through 24. Based on weighted kappa coefficients, 4 items (orientation, motor arm, motor leg, and neglect) displayed excellent agreement, 6 items (language, dysarthria, sensation, visual fields, facial palsy, and gaze) displayed good agreement, and 2 items (commands and ataxia) displayed poor agreement. Total NIHSS scores obtained by bedside and remote methods were strongly correlated (r=0.97, P<0.001).

CONCLUSIONS

The NIH Stroke Scale remains a swift and reliable clinical instrument when used over interactive video. Application of this technology can bring stroke expertise to the bedside, regardless of patient location.

Age-dependent rate of anaplastic transformation in low-grade astrocytoma

Age and histologic grade are interrelated characteristics of diffuse fibrillary astrocytomas, because the peak age incidence rises with increasing grade. The relationship between age and grade may be explained if age determines the rate of anaplastic progression in astrocytomas. The authors tested this hypothesis by determining the interval between diagnosis of low-grade astrocytoma and progression to high-grade astrocytoma in patients of various ages. A two-way scatterplot of age at initial diagnosis versus interval to anaplastic progression demonstrated a strong negative correlation (n = 24; Pearson correlation coefficient = -0.83; Spearman correlation coefficient = -0.79; p < 0.001 for both values). It was concluded that the rate of anaplastic progression in low-grade astrocytoma is directly correlated with patient age.

A novel nonopioid action of enkephalins: competitive inhibition of the mammalian brain high affinity L-proline transporter

The high affinity L-proline transporter (PROT) is a member of the family of Na+ (and Cl-)-dependent plasma membrane transport proteins that comprises transporters for several neurotransmitters, osmolytes, and metabolites. The brain-specific expression of PROT in a subset of putative glutamatergic pathways implies a specialized function for this novel transporter and its presumed natural substrate L-proline in excitatory synaptic transmission. However, definitive studies of the physiological role(s) of high affinity L-proline uptake have been precluded by the lack of specific uptake inhibitors. Here, we report that Leu- and Met-enkephalin and their des-tyrosyl derivatives potently and selectively inhibited high affinity L-proline uptake in rat hippocampal synaptosomes and in PROT-transfected HeLa cells. High concentrations of the opiate receptor antagonist naltrexone did not block the inhibitory actions of these peptides, arguing against an involvement of opioid receptors. Des-tyrosyl-Leu-enkephalin elevated the apparent K(m) of L-proline transport in transfected HeLa cells without altering the V(max). PROT-transfected HeLa cells did not accumulate [3H]Leu-enkephalin above background levels, demonstrating that enkephalins are not substrates for PROT. These findings indicate that enkephalins competitively inhibit mammalian brain PROT through a direct interaction with the transporter protein at or near the L-proline binding site. The high potency and specificity of des-tyrosyl-Leu-enkephalin make this compound a useful tool for elucidating the structure-function properties and physiological role(s) of PROT.

Human brain-specific L-proline transporter: molecular cloning, functional expression, and chromosomal localization of the gene in human and mouse genomes

L-Proline fulfills several of the classic criteria used to identify amino acid neurotransmitters, including the presence of a high affinity, Na(+)- (and Cl-)-dependent synaptosomal transport process and the Ca(2+)-dependent release of exogenously loaded radiolabeled L-proline from brain slices and synaptosomes after K(+)-induced depolarization. However, studies to define the role of L-proline in discrete pathways in the mammalian brain have been precluded by the inability to block its biosynthesis or high affinity transport in nervous tissue. We report the molecular cloning, functional expression, and chromosomal localization of a human brain-specific high affinity L-proline transporter (hPROT). The pharmacological specificity, kinetic properties, and ionic requirements of hPROT clearly distinguish this carrier from the other Na(+)-dependent plasma membrane carriers that transport L-proline. Multiple tissue Northern blot analysis revealed a prominent approximately 4-kb mRNA transcript in human brain tissue, whereas no specific hybridizing species were detected in peripheral tissue. An antipeptide antiserum directed against the carboxy-terminus of the predicted hPROT protein identified a single, broad immunoreactive protein of 68 kDa on immunoblots of synaptosomal membranes from various human brain regions. In contrast, no specific labeling was detected on immunoblots of membranes from human liver, kidney, or heart. A differential distribution of hPROT mRNA and protein was observed in the human corpus striatum, consistent with the hypothesis that the hPROT protein is synthesized in neuronal cell bodies in an extrastriatal location and axonally transported to the corpus striatum. These findings warrant the consideration of a synaptic regulatory role for this transporter and its presumed natural substrate, L-proline, in the mammalian central nervous system.

Cloning and expression of a novel Na(+)-dependent neutral amino acid transporter structurally related to mammalian Na+/glutamate cotransporters

A cDNA has been isolated from human hippocampus that appears to encode a novel Na(+)-dependent, Cl(-)-independent, neutral amino acid transporter. The putative protein, designated SATT, is 529 amino acids long and exhibits significant amino acid sequence identity (39-44%) with mammalian L-glutamate transporters. Expression of SATT cDNA in HeLa cells induced stereospecific uptake of L-serine, L-alanine, and L-threonine that was not inhibited by excess (3 mM) 2-(methylamino)-isobutyric acid, a specific substrate for the System A amino acid transporter. SATT expression in HeLa cells did not induce the transport of radiolabeled L-cysteine, L-glutamate, or related dicarboxylates. Northern blot hybridization revealed high levels of SATT mRNA in human skeletal muscle, pancreas, and brain, intermediate levels in heart, and low levels in liver, placenta, lung, and kidney. SATT transport characteristics are similar to the Na(+)-dependent neutral amino acid transport activity designated System ASC, but important differences are noted. These include: 1) SATT's apparent low expression in ASC-containing tissues such as liver or placenta; 2) the lack of mutual inhibition between serine and cysteine; and 3) the lack of trans-stimulation. SATT may represent one of multiple activities that exhibit System ASC-like transport characteristics in diverse tissues and cell lines.

Health, attitudes and beliefs of working women

A cross-sectional case-control study was conducted comparing working women employed by the Women's Work Centres of the Orangi Pilot Project with non-working matched controls. Differences in the knowledge, attitude and practice of several variables were elicited. Working women's families had significantly higher immunization rates, 73% vs 55%, and shorter duration of illness, 5.9 days vs 8.8 days, compared to controls. More working than non-working women supported contraception, 100% vs 74%, desired equal education for sons and daughters (P less than 0.005), and had a dominant role in family health decision-making, 48% vs 12%. We conclude that these working women in Orangi have a different set of beliefs and practices than non-working women and this may be one important factor responsible for the lower morbidity in their children.

HMFG1 antigen: a new marker for carcinomatous meningitis

Carcinomatous meningitis is a devastating metastatic complication of systemic carcinoma, which may occur insidiously, accompanied by a confusing spectrum of clinical symptoms and signs. In the absence of reliable diagnostic tumour markers, the diagnosis is established by the demonstration of malignant cells within the cerebrospinal fluid (CSF). Cytological techniques requiring skillful interpretation are occasionally negative in the presence of established disease, and when positive may indicate leptomeningeal malignancy of such advanced nature that effective palliation is difficult. Biochemical tumour marker technology offers the potential of reliable diagnosis in early disease states, prior to the appearance of exfoliated malignant cells. In a series of 100 patients, we assayed for an epithelial associated glycoprotein (HMFGI antigen) in CSF obtained at lumbar puncture. In 18 of 20 patients with carcinomatous meningitis, this high-molecular-weight glycoprotein was detectable in the CSF. The antigen was also present in 2 patients with neoplastic meningitis complicating lymphoma and medulloblastoma, but was not detected in the CSF of the remaining 78 patients.