Neurometabolic timecourse of healthy aging

PURPOSE

The neurometabolic timecourse of healthy aging is not well-established, in part due to diversity of quantification methodology. In this study, a large structured cross-sectional cohort of male and female subjects throughout adulthood was recruited to investigate neurometabolic changes as a function of age, using consensus-recommended magnetic resonance spectroscopy quantification methods.

METHODS

102 healthy volunteers, with approximately equal numbers of male and female participants in each decade of age from the 20s, 30s, 40s, 50s, and 60s, were recruited with IRB approval. MR spectroscopic data were acquired on a 3T MRI scanner. Metabolite spectra were acquired using PRESS localization (TE=30 ms; 96 transients) in the centrum semiovale (CSO) and posterior cingulate cortex (PCC). Water-suppressed spectra were modeled using the Osprey algorithm, employing a basis set of 18 simulated metabolite basis functions and a cohort-mean measured macromolecular spectrum. Pearson correlations were conducted to assess relationships between metabolite concentrations and age for each voxel; Spearman correlations were conducted where metabolite distributions were non-normal. Paired t-tests were run to determine whether metabolite concentrations differed between the PCC and CSO. Finally, robust linear regressions were conducted to assess both age and sex as predictors of metabolite concentrations in the PCC and CSO and separately, to assess age, signal-noise ratio, and full width half maximum (FWHM) linewidth as predictors of metabolite concentrations.

RESULTS

Data from four voxels were excluded (2 ethanol; 2 unacceptably large lipid signal). Statistically-significant age*metabolite Pearson correlations were observed for tCho (r(98)=0.33, p<0.001), tCr (r(98)=0.60, p<0.001), and mI (r(98)=0.32, p=0.001) in the CSO and for NAAG (r(98)=0.26, p=0.008), tCho(r(98)=0.33, p<0.001), tCr (r(98)=0.39, p<0.001), and Gln (r(98)=0.21, p=0.034) in the PCC. Spearman correlations for non-normal variables revealed a statistically significant correlation between sI and age in the CSO (r(86)=0.26, p=0.013). No significant correlations were seen between age and tNAA, NAA, Glx, Glu, GSH, PE, Lac, or Asp in either region (all p>0.20). Age associations for tCho, tCr, mI and sI in the CSO and for NAAG, tCho, and tCr in the PCC remained when controlling for sex in robust regressions. CSO NAAG and Asp, as well as PCC tNAA, sI, and Lac were higher in women; PCC Gln was higher in men. When including an age*sex interaction term in robust regression models, a significant age*sex interaction was seen for tCho (F(1,96)=11.53, p=0.001) and GSH (F(1,96)=7.15, p=0.009) in the CSO and tCho (F(1,96)=9.17, p=0.003), tCr (F(1,96)=9.59, p=0.003), mI (F(1,96)=6.48, p=0.012), and Lac (F(1,78)=6.50, p=0.016) in the PCC. In all significant interactions, metabolite levels increased with age in females, but not males. There was a significant positive correlation between linewidth and age. Age relationships with tCho, tCr, and mI in the CSO and tCho, tCr, mI, and sI in the PCC were significant after controlling for linewidth and FWHM in robust regressions.

CONCLUSION

The primary (correlation) results indicated age relationships for tCho, tCr, mI, and sI in the CSO and for NAAG, tCho, tCr, and Gln in the PCC, while no age correlations were found for tNAA, NAA, Glx, Glu, GSH, PE, Lac, or Asp in either region. Our results provide a normative foundation for future work investigating the neurometabolic time course of healthy aging using MRS.

Salmeterol/Fluticasone combination inhaler: a new, effective and well tolerated treatment for asthma

OBJECTIVE

The efficacy and tolerability of a new combination inhaler containing both salmeterol 50mg and fluticasone 100mg in a single device was compared with the delivery of the two drugs via two separate inhalers in a multicentre, double-blind, double-dummy study.

PATIENTS

244 symptomatic asthma patients (age range 12 to 78 years) were randomised to a 12-week treatment period with either salmeterol/fluticasone (50/100mg twice daily) via a single inhaler (combination) and placebo twice daily via another, or salmeterol 50mg twice daily via one inhaler and fluticasone 100mg twice daily via another (concurrent).

RESULTS

Morning peak expiratory flow rate (PEFR), symptoms and tolerability were collected throughout the treatment period. Adjusted mean improvements in morning PEFR were 42 and 33 L/min for combination and concurrent therapies, respectively, over the 12-week treatment period. Adjusted mean improvements in forced expiratory volume in 1 second (FEV(1)) from baseline at week 12 were 0.20 and 0.17L for combination and concurrent therapies, respectively. 60% of patients receiving combination inhaler and 64% of those receiving concurrent therapy had a mean daytime symptom score of zero over the treatment period compared with 17 and 15%, respectively, at baseline. Both treatments were well tolerated. Geometric mean morning serum cortisol levels were similar and no differences in the frequency of abnormal results were noted between the two groups.

CONCLUSION

This was the first study reporting the control of asthma by administration of salmeterol and fluticasone in combination via a single inhaler. The new combination inhaler was as effective and well tolerated as the two drugs administered individually and has potential advantages in terms of convenience.

Assessing the need for diabetes self-management education in the Oklahoma city vietnamese community

INTRODUCTION

To assess the diabetes self-management educational (DSME) needs of the Vietnamese diabetic population in the Oklahoma City metropolitan area.

METHODS

Participants in this explorative study included 50 Vietnamese adults with type 1 or type 2 diabetes recruited from the offices of four primary care physicians in the Oklahoma City metropolitan area. Participants completed a culturally sensitive survey focused on their diabetes history, knowledge and need of DSME, and health beliefs. Responses were evaluated using means and frequency analysis.

RESULTS

The mean age of participants was 62.7±9.1 years. Over 80% of participants were most comfortable speaking and reading Vietnamese, and 62% had never received a high school diploma. Less than 50% of participants reported ever receiving education regarding diabetic complications, nutrition, desirable glycated hemoglobin values, diabetic medications, daily self-care, risk of smoking, or cardiovascular risk associated with diabetes. More than 80% of participants requested more education in all areas of DSME except smoking risk in diabetes, with all participants requesting delivery of this education in Vietnamese.

CONCLUSION

DSME is needed and desired in the Vietnamese community of the Oklahoma City metropolitan area. Education should be provided in the Vietnamese language with most targeted to lower literacy levels. Vietnamese diabetes educators should facilitate increased access to DSME knowledge and skills in efforts to improve glycemic control and overall health status for this community.

Circulatory manifestations and risk factors in patients with acute cerebrovascular disease and in matched controls

The occurrence of various circulatory manifestations and risk factors was evaluated in a consecutive series of 209 patients admitted for acute cerebrovascular disease (CVD) and 209 control patients admitted for acute surgical disorders. Old and recent myocardial infarction, atrial fibrillation, congestive heart failure and reduced arterial blood pressure in the big toe were all much more frequently noted in CVD patients than in their matched controls. Hypertension, diabetes mellitus, overweight, high haemoglobin values, were also overrepresented in the CVD patients. Male CVD patients had a higher alcohol consumption than their controls. These findings implicate that CVD in old age is strongly related to both hypertension and a generalized atherosclerosis. The heavy accumulation of primary risk factors, many of which are considered to be primarily associated with atherosclerosis among elderly stroke victims, may indicate their contribution to a progressive atherosclerotic process still in operation.

The diagnostic accuracy of CSF analyses in stroke

The ability of routine analyses of cerebrospinal fluid (CSF) to differentiate between haemorrhage and infarction was evaluated in 231 stroke patients, whose diagnoses were based on computed tomography or autopsy. In all diagnostic groups the mean protein level was above normal, the highest values being associated with haemorrhage. Taking a protein level greater than 1 g/l to be characteristic of bleeding, sensitivity was 89% and specificity 92%. Spectrophotometric CSF absorbance was measured at wave lengths of 410, 415, 455 and 630 nm. Validity was equal for the first three. Taking absorbance greater than or equal to 0.040 at 415 nm to be diagnostic for haemorrhage, sensitivity was 72% and specificity 94%. The human eye was almost as sensitive as spectrophotometry in this context. Thus, among 100 patients with stroke, 7-9 out of 10 plausible cases of haemorrhage would be identified by means of routine CSF analyses. At the same time, 5-9 patients with ischaemic lesions would be diagnosed incorrectly as bleedings.

Arrhythmias in patients with acute cerebrovascular disease

Cardiac disease is common in patients with cerebrovascular disease (CVD) and cerebral lesions as such may influence cardiac activity and rhythm. To study the indication for continuous ECG surveillance of patients with CVD, 100 consecutive patients admitted to a medical stroke unit were investigated with 24-hour Holter recordings. The patients' mean age was 73 years and 70% of them had a history of heart disease. Twenty-three patients had chronic atrial fibrillation and 55% of the remainder showed ventricular ectopic activity. Serious ventricular arrhythmias were comparatively rare and mainly seen in association with signs of congestive heart failure and acute myocardial infarction. A prolonged Q-T interval was registered in two-thirds of the patients but there was no significant association between this finding and ventricular ectopic activity. Close observation for cardiac complications is important in patients with CVD and continuous ECG surveillance is indicated in selected high-risk patients.

A study of stroke patients treated in a non-intensive stroke unit or in general medical wards

To study the representativity and outcome of patients admitted to a stroke unit (SU) (n = 269), a comparison was made with all stroke patients treated in general medical wards (GMW) (n = 225) in the same hospital during two years. There was no difference between the patient groups regarding sex, age, previous cardiovascular diseases or neurological deficit on admission. As expected, more diagnostic examinations were performed in the SU than in the GMW where a diagnosis of ill-defined stroke was very frequent. A higher frequency of lumbar puncture with CSF spectrophotometry would have increased considerably the number of specific diagnoses in the GMW. Acute and, particularly, secondary prophylactic treatment was more often given in the SU. There was no difference between the patient groups regarding mortality or length of hospital stay.

Hazards of therapy for excessive hypertension in acute stroke

Six cases with acute onset of neurological symptoms and extremely high blood pressure (BP) are reviewed. Hypertensive crisis or stroke were the main differential diagnoses. According to what is advocated for both situations, prompt antihypertensive therapy was instituted. Although recommended doses of hydralazine, reserpine or furosemide were given, the systolic BPs fell to less than 100 mmHg. Intracerebral hemorrhage or infarction was subsequently established in all patients and only one survived. Convincing evidence for a beneficial effect of BP reduction in acute stroke is lacking. Our data indicate excessive response to therapy in some patients. Also, moderate lowering of BP might reduce cerebral blood flow in these patients, often chronically hypertensive and with raised intracranial pressure. Extreme caution with antihypertensive therapy seems therefore warranted if the diagnosis of hypertensive crisis is not certain and a stroke is suspected.

A curriculum review and mapping process supported by an electronic database system

Curriculum mapping and review is now an expected continuous quality improvement initiative of pharmacy professional programs. Effectively implementing and sustaining this expectation can be a challenge to institutions of higher education and requires dedicated faculty members, a systematic approach, creativity, and--perhaps most importantly--demonstrated leadership at all levels of the institution. To address its specific situation and needs, the University of Oklahoma College of Pharmacy implemented a peer review process of ongoing curriculum mapping and evaluation. An electronic Pharmacy Curriculum Management System (PCMS) was developed to support faculty efforts to manage curricular data, monitor program outcomes, and improve communications to its stakeholders on 2 campuses and across the state.

Interventions to prevent obesity in children and adolescents: a systematic literature review

OBJECTIVE

Preventive measures to contain the epidemic of obesity have become a major focus of attention. This report reviews the scientific evidence for medical interventions aimed at preventing obesity during childhood and adolescence.

DESIGN

A systematic literature review involving selection of primary research and other systematic reviews. Articles published until 2004 were added to an earlier (2002) review by the Swedish Council on Technology Assessment in Health Care.

METHODS

Inclusion criteria required controlled studies with follow-up of at least 12 months and results measured as body mass index, skinfold thickness or the percentage of overweight/obesity. Children could be recruited from normal or high-risk populations.

RESULTS

Combining the new data with the previous review resulted in an evaluation of 24 studies involving 25 896 children. Of these, eight reported that prevention had a statistically significant positive effect on obesity, 16 reported neutral results and none reported a negative result (sign test; P=0.0078). Adding the studies included in five other systematic reviews yielded, in total, 15 studies with positive, 24 with neutral and none with negative results. Thus, 41% of the studies, including 40% of the 33 852 children studied, showed a positive effect from prevention. These results are unlikely to be a random chance phenomenon (P=0.000061).

CONCLUSION

Evidence shows that it is possible to prevent obesity in children and adolescents through limited, school-based programs that combine the promotion of healthy dietary habits and physical activity.

Mild head injury: observation or computed tomography? Economic aspects by literature review and decision analysis

OBJECTIVES

To compare the costs of two strategies for acute management of mild head injury: inhospital observation compared with acute computed tomography (CT) and home care.

METHODS

Studies comparing costs for the two strategies that seem to have similar outcomes for patients were systematically reviewed. A decision tree analysis to compare the costs was also constructed, based on Swedish national costs and the risks found in a recent review on mild head injury complications.

RESULTS

No studies were found that directly measured and compared risks, benefits, and costs of the two strategies. In the four studies retrieved, involving 4126 patients, the costs for hospital observation were factual, but a model was used to evaluate costs for the CT strategy. On average, costs were one third lower with CT. Also, the decision tree analysis demonstrated that the CT strategy was one third less expensive than inhospital observation. A sensitivity analysis showed this to be valid for nearly all cases. If these calculations hold true, a change of strategy could result in annual savings of pound 280,000/million inhabitants.

CONCLUSION

The CT strategy seems to cost one third less than hospital observation.

Diabetes enhances apoptosis induced by cerebral ischemia

The aim of this study is to explore the mechanism by which diabetes exaggerates cerebral stroke and its outcome. Since ischemia can be related to not only necrosis but apoptosis as well, we compared the development of apoptosis in STZ-diabetic rats and STZ-diabetic rats subjected to occlusion of the middle cerebral artery (MCA). 24-48 hr following MCA occlusion the animals were killed, the brain removed and prepared for evaluation by several indexes of apoptosis: nucleosomal DNA fragmentation, TUNEL staining, activation of caspase-3 and alteration in the expression of Bax and Bcl2. DNA fragmentation was not detected in the cortex of normal and diabetic animals, but was evident following MCA occlusion in diabetic rats. Bax expression was increased in the cortex of normal rats following MCA occlusion and this expression was further increased in the cortex of MCA occluded diabetic rats. Bcl2 expression was not changed in any of the groups. In the hippocampus, DNA fragmentation was not evident in control rats but was observed in diabetic rats. Ischemic injury did not enhance DNA laddering in diabetic animals. The expression of Bax was increased in diabetic rats but was not increased following MCA occlusion. Bcl2 expression was not changed by ischemia in any of the animal models. These data suggest that diabetes may enhance the development of stroke via increased cortical apoptotic activity but this was not additive in the hippocampus following ischemic injury.

Aspirin in the prevention of progressing stroke: a randomized controlled study

OBJECTIVES

In acute stroke, progression has a severe impact on patient outcome and no effective treatment is known. The main objective was to evaluate the efficacy of aspirin for prevention of stroke progression thereby improving outcome.

DESIGN

The trial was randomized, double-blind and placebo-controlled.

SETTING

The patients were treated in stroke units of four hospitals in Sweden.

SUBJECTS

Patients with ischaemic stroke but not complete paresis were included. No antiplatelet drugs were allowed within the last 72 h before onset. Delay until first trial dosage was maximized to 48 h. The trial was designed to detect a 20% reduction of the rate of stroke progression, which was estimated to take place in 20% of cases. Totally, 441 patients (220 aspirin, 221 placebo) completed the trial. Baseline comparisons between the groups showed no differences.

INTERVENTIONS

Aspirin (325 mg) or placebo was given once daily for five consecutive days.

MAIN OUTCOME MEASURES

Neurological assessments were carried out three times daily during the treatment period to detect progression of at least two points in the Scandinavian Stroke Supervision Scale. Patient outcome was followed up at discharge and at 3 months.

RESULTS

Aspirin treatment did not significantly reduce the frequency of stroke progression. Amongst aspirin-treated patients, stroke progression occurred in 15.9% as compared with 16.7% in the placebo group, which is less frequent than expected. The relative risk was 0.95 (95% CI 0.62-1.45) in the treatment group. As regards patient outcome at discharge and after 3 months, aspirin treatment did not show any difference.

CONCLUSION

No positive effect of aspirin, of the expected size, could be shown on the frequency of stroke progression or patient outcome.

Mild head injury - mortality and complication rate: meta-analysis of findings in a systematic literature review

BACKGROUND

Whether the strategy for care of mild head injury should be in-hospital observation or computed tomography (CT) investigation and home care has been discussed lately. A necessary requirement for guidelines and the design of clinical trials would be knowledge about the risks of the condition. These have not been reliably summarised. The study aims to estimate as accurately as possible the mortality, the complication rates, and the frequency of pathological findings on CT in patients with mild head injury.

METHODS

Mild head injury was defined as head trauma involving loss of consciousness or amnesia, but where neurological findings on arrival at hospital are normal (GCS 15). Large databases were searched to find relevant scientific literature, and the retrieved studies were critically appraised. Findings were used from all representative patient data sets that met predefined standards for minimum quality. Meta-analysis using the random-effects model was performed on the data collected.

FINDINGS

The search yielded 24 studies on 24249 patients fulfilling the requirements. The mean mortality of patients was low, 0.1% (CI 0.05-0.15). Complications, mostly requiring surgery, occurred in 0.9% (CI 0.6-1.2) of the cases. In approximately 8% (CI 6.1-9.5), pathological CT findings, dominated by haemorrhages, were identified in the acute phase.

CONCLUSIONS

Of 1000 patients arriving at hospital with mild head injury, 1 will die, 9 will require surgery or other intervention, and about 80 will show pathological findings on CT. At least these 8% of patients will probably need in-hospital care.

The burden of COPD in the U.K.: results from the Confronting COPD survey

Chronic obstructive pulmonary disease (COPD) is a condition characterized by progressive airflow limitation and decline in lung function. As seen in other developed countries throughout the world, COPD in the U.K is associated with considerable mortality, and morbidity from the disease places a significant burden on the healthcare system and society. Despite the obvious burden of COPD in this country, there is a lack of recognition of COPD among the general public. Healthcare professionals may also fail to recognize the burden of disease, as shown by underdiagnosis and inadequate managemen. A key step in increasing awareness of the burden of COPD is obtaining comprehensive information about the impact of the disease on patients, the health service and society. The large-scale international survey, Confronting COPD in North America and Europe, aimed to address this need for information, by interviewing patients and physicians in eight countries. An economic analysis of patient responses to the survey in the U.K showed that COPD places a high burden on the healthcare system and society with annual direct costs estimated at pounds 819.42 per patient, and indirect cost at pound 819.66 per patient resulting in total per patient costs of pound 1639.08. The cost impact of the disease was particularly marked in secondary care, as a result of inpatient hospitalizations, amounting to 54% of direct costs. These results suggest that reducing patient requirement for hospital care could alleviate the burden of COPD on the U.K. healthcare system. This will require considerable improvements to the way the disease is managed by healthcare professionals in primary care, with earlier diagnosis and the use of interventions aimed at preventing exacerbations and delaying the progression of disease.

The effects of middle cerebral artery occlusion on central nervous system apoptotic events in normal and diabetic rats

Apoptosis and neural degeneration are characteristics of cerebral ischemia and brain damage. Diabetes is associated with worsening of brain damage following ischemic events. In this study, the authors characterize the influence of focal cerebral ischemia, induced by middle cerebral artery occlusion, on 2 indexes of apoptosis, TUNEL (terminal deoxynucleotidyl transferase-mediated deoxyuridine 5-triphosphate nick end-labeling) staining and caspase-3 immunohistochemistry. Diabetes was induced in normal rats using streptozotocin and maintained for 5 to 6 weeks. The middle cerebral artery of both normal and diabetic rats was occluded and maintained from 24 or 48 hours. Sham-operated normal and diabetic animals served as controls. Following 24 to 48 hours of occlusion, the animals were sacrificed and the brains were removed, sectioned, and processed for TUNEL staining or caspase-3 immunohistochemistry. Middle cerebral artery occlusion in normal rats was associated with an increase in the number of both TUNEL-positive and caspase-3-positive cells in selected brain regions (hypothalamic preoptic area, piriform cortex, and parietal cortex) when compared to nonoccluded controls. Diabetic rats without occlusion showed significant increases in both TUNEL-positive and caspase-3-positive cells compared to normal controls. Middle cerebral artery occlusion in diabetic rats resulted in increases in TUNEL-positive as well as caspase-3-positive cells in selected regions, above those seen in nonoccluded diabetic rats. Both TUNEL staining and caspase-3 immunohistochemistry revealed that the number of apoptotic cells in diabetic animals tended to be greatest in the preoptic area and parietal cortex. The authors conclude that focal cerebral ischemia is associated with a significant increase in apoptosis in nondiabetic rats, and that diabetes alone or diabetes plus focal ischemia are associated with significant increases in apoptotic cells.

The epidemiology of mesothelioma

It has been more than 40 years since occupational crocidolite exposure in South African miners was found to be associated with development of malignant mesothelial tumors 30 to 40 years later. Similar cases were not seen in the amosite and chrysotile miners. Since then, epidemiological and toxicological knowledge have increased enormously, but mortality continues to rise steeply (5% to 10% per year) in most industrialized countries. Even with widespread asbestos abatement efforts, this increase is likely to continue in Western Europe and the United State well into the next century, at least until 2020. Unregulated use of asbestos in less industrialized countries may cause the epidemic to continue throughout the next century in those regions. Asbestos abatement seems to be successful as evidenced by a decline in the proportion of patients with peritoneal tumors, which are the most common malignancies in heavily exposed individuals. Whereas in the 1960s peritoneal tumors comprised up to 30% of the total, in recent years the proportion has fallen to about 10%, This changing ratio could also be due to the steady increase in pleural tumors. The difficulty in formulating the connection as to the etiology of mesothelioma resulted from an unforeseeable difference in the carcinogenicity of various asbestos and mineral fiber types and was compounded by the very long latency of the disease. Unfortunately, the use of a single term, "asbestos," to describe at least five fibrous silicate minerals, each with unique physical, chemical, and biological properties and not infrequently and naturally admixed, severely hampered scientific investigation into the occupational health risks. The field became confused and filled with debate. At the heart of the fiber type controversy lies a fundamentally differing view of the importance of biopersistence of various asbestos fibers in carcinogenesis. This review will deal with the epidemiology of mesothelioma with particular attention to the studies that elucidate the impact of various asbestos fiber types on the etiology of the disease.

A test of general relativity from the three-dimensional orbital geometry of a binary pulsar

Binary pulsars provide an excellent system for testing general relativity because of their intrinsic rotational stability and the precision with which radio observations can be used to determine their orbital dynamics. Measurements of the rate of orbital decay of two pulsars have been shown to be consistent with the emission of gravitational waves as predicted by general relativity, but independent verification was not possible. Such verification can in principle be obtained by determining the orbital inclination in a binary pulsar system using only classical geometrical constraints. This would permit a measurement of the expected retardation of the pulse signal arising from the general relativistic curvature of space-time in the vicinity of the companion object (the 'Shapiro delay'). Here we report high-precision radio observations of the binary millisecond pulsar PSR J0437-4715, which establish the three-dimensional structure of its orbit. We see the Shapiro delay predicted by general relativity, and we determine the mass of the neutron star and its white dwarf companion. The determination of such masses is necessary in order to understand the origin and evolution of neutron stars.

Acupuncture and transcutaneous nerve stimulation in stroke rehabilitation: a randomized, controlled trial

BACKGROUND AND PURPOSE

In small trials with control groups that receive no intervention, acupuncture has been reported to improve functional outcome after stroke. We studied effects of acupuncture and transcutaneous electrical nerve stimulation on functional outcome and quality of life after stroke versus a control group that received subliminal electrostimulation.

METHODS

In a multicenter randomized controlled trial involving 7 university and district hospitals in Sweden, 150 patients with moderate or severe functional impairment were included. At days 5 to 10 after acute stroke, patients were randomized to 1 of 3 intervention groups: (a) acupuncture, including electroacupuncture; (b) sensory stimulation with high-intensity, low-frequency transcutaneous electrical nerve stimulation that induces muscle contractions; and (c) low-intensity (subliminal) high-frequency electrostimulation (control group). A total of 20 treatment sessions were performed over a 10-week period. Outcome variables included motor function, activities of daily living function, walking ability, social activities, and life satisfaction at 3-month and 1-year follow-up.

RESULTS

At baseline, patients in each group were closely similar in all important prognostic variables. At 3-month and 1-year follow-ups, no clinically important or statistically significant differences were observed between groups for any of the outcome variables. The 3 treatment modalities were all conducted without major adverse effects.

CONCLUSIONS

When compared with a control group that received subliminal electrostimulation, treatment during the subacute phase of stroke with acupuncture or transcutaneous electrical nerve stimulation with muscle contractions had no beneficial effects on functional outcome or life satisfaction.

Home rehabilitation after stroke. Reviewing the scientific evidence on effects and costs

OBJECTIVES

The question addressed here is whether home rehabilitation after stroke is better and/or less expensive than the more conventional alternatives, i.e., rehabilitation during inpatient care, day care, and outpatient visits--alone or in combinations appropriate to disease stage and patient needs. Home rehabilitation is managed by teams of professionals who train patients at home.

METHODS

The scientific literature was systematically searched for controlled studies comparing outcomes and costs of home rehabilitation with the more conventional strategies.

RESULTS

The abstracts of 204 papers were evaluated, from which 89 were selected for greater scrutiny. From the 89 studies, we found 7 controlled studies involving 1,487 patients (6 of the 7 were randomized, 4 of the 6 assessed costs). No statistically significant differences, or tendencies toward differences, were revealed as regards the outcome of home rehabilitation versus hospital-based alternatives. Thus, home rehabilitation was neither better nor worse at improving patients' ability to manage on their own or resume social activities. Depression and reduced quality of life were common in all groups of patients and caregivers, irrespective of the rehabilitation strategy. In the four randomized studies that reported on costs, home rehabilitation was found to be less expensive than regular day care, but not less expensive than conventional strategies even though hospital stay was reduced.

CONCLUSION

The outcomes and costs of home rehabilitation after stroke seem to be comparable to alternative treatment strategies.

Effectiveness of heparin treatment for progressing ischaemic stroke: before and after study

OBJECTIVES

During the acute phase of stroke, symptoms progress in 25% of patients, resulting in a worse outcome. Could heparin treatment improve the situation?

DESIGN

Before and after study. During the first period, no treatment was given to patients with progress of symptoms, whereas heparin was used regularly in the second period. A comparison of outcome was performed.

SETTING

Patients with acute stroke cared for in stroke units of two big emergency hospitals in Stockholm. Besides heparin treatment, the groups were taken care of according to the same basic principles.

SUBJECTS

Consecutive patients admitted to a stroke unit during two periods of time. The first study comprised 314 patients with ischaemic stroke and the second 907.

INTERVENTION

In the treatment period, patients with ischaemic stroke and objectively recognized progression received heparin infusion for at least 5 days.

MAIN OUTCOME MEASURES

Continued progression, length of stay, unaided walking at discharge, discharge destination and mortality.

RESULTS

The progression rate was non-significantly higher in the first period: 28 vs. 21%. One-third continued to progress regardless of treatment given. Patients with progression, treated and untreated alike, had 40% longer stay in the stroke unit compared with stable patients, whereas mortality was unaffected. Treatment did not reduce the proportion of patients who needed aid for walking at discharge (77 vs. 74%) or those who needed further institutionalized care (65 vs. 66%).

CONCLUSION

Progression of focal stroke symptoms still constitutes a serious clinical problem for which heparin has insufficient effectiveness in clinical practice. New therapies, ideally preventive, are needed.

Management of minor head injuries in emergency departments in Sweden. Time for a new strategy?

OBJECTIVE

To study how patients with minor head injuries are currently managed.

DESIGN

Questionnaire to senior residents in emergency departments and data from registers covering all in-hospital care in Sweden.

SETTING

All 92 emergency departments in Sweden.

RESULTS

The response rate to the questionnaire was 100%. In Sweden, 75 emergency departments treat patients with minor head injuries. Four departments are paediatric. General surgeons are the main providers (87%) of care for patients with minor head injuries. All hospitals admit patients with a history of unconsciousness or amnesia. Skull radiography is not used routinely. The estimated use of computed tomography (CT) varies between 2% and 80%, the mean being 22%. The need for CT, or the result thereof, is not the deciding factor for admission. In 1996, 16877 patients were treated as inpatients for minor head injuries, (191/100000 inhabitants). The admission rates varied widely among departments, and the total figures have been constant since 1987. The mean hospital stay was 1.6 days, so a large number of hospital days are consumed. The resources more than cover routine CT investigations for those seeking care, and hospital care for those with abnormal findings or special needs.

CONCLUSION

In Sweden, patients with minor head injuries are routinely admitted to hospital for observation. The estimated use of CT varies considerably. No clinics report using CT to triage patients for admission, a strategy that would be consistent with effectiveness and economic arguments.

How do stroke patients fare when discharged straight to their homes? A controlled study on the significance of hospital follow-up after one month

In our experience, stroke patients discharged straight to their homes sometimes showed marked deterioration. We investigated whether this negative course of events could be prevented by means of follow-up visits entailing extensive testing and resultant measures one month after discharge. The patients in our study included a selection of mild cases with a short length of hospital stay. Forty-six patients returned to the stroke unit on a follow-up visit, and 49 patients made up the control group. The groups were compared after 3 months, by means of questionnaires. The results did not show any definite difference between the groups. However, after 3 months we detected depressions in 13 patients in the study group and in 11 patients in the control group, most of them untreated. The study points to a need for follow-up aimed specifically at detecting depression.

Meta-analysis of increased dose of inhaled steroid or addition of salmeterol in symptomatic asthma (MIASMA)

OBJECTIVE

To examine the benefits of adding salmeterol compared with increasing dose of inhaled corticosteroids.

DESIGN

Systematic review of randomised, double blind clinical trials. Independent data extraction and validation with summary data from study reports and manuscripts. Fixed and random effects analyses.

SETTING

EMBASE, Medline, and GlaxoWellcome internal clinical study registers.

MAIN OUTCOME MEASURES

Efficacy and exacerbations.

RESULTS

Among 2055 trials of treatment with salmeterol, there were nine parallel group trials of >/=12 weeks with 3685 symptomatic patients aged >/=12 years taking inhaled steroid in primary or secondary care. Compared with response to increased steroids, in patients receiving salmeterol morning peak expiratory flow was greater at three months (difference 22.4 (95% confidence interval 15.0 to 30.0) litre/min, P<0.001) and six months (27.7 (19.0 to 36.4) litre/min, P<0.001). Forced expiratory volume in one second (FEV(1)) was also increased at three months (0.10 (0.04 to 0.16) litres, P<0.001) and six months (0.08 (0.02 to 0.14) litres, P<0.01), as were mean percentage of days and nights without symptoms (three months: days-12% (9% to 15%), nights-5% (3% to 7%); six months: days-15% (12% to 18%), nights-5% (3% to 7%); all P<0.001) and mean percentage of days and nights without need for rescue treatment (three months: days-17% (14% to 20%), nights-9% (7% to 11%); six months: days-20% (17 to 23%), nights-8% (6% to 11%); all P<0.001). Fewer patients experienced any exacerbation with salmeterol (difference 2.73% (0.43% to 5.04%), P=0. 02), and the proportion of patients with moderate or severe exacerbations was also lower (2.42% (0.24% to 4.60%), P=0.03).

CONCLUSIONS

Addition of salmeterol in symptomatic patients aged 12 and over on low to moderate doses of inhaled steroid gives improved lung function and increased number of days and nights without symptoms or need for rescue treatment with no increase in exacerbations of any severity.

[Sensitive quality indicators stimulate improvement of care]

For the past four years, 52 of the approximately 80 departments of medicine in Sweden have collected data on key indicators of quality of care with regards to acute myocardial infarction, stroke, anticoagulant treatment, and diabetes. The results are analysed centrally, each department being supplied with feedback in the form of overall results, and comparison of its own values with the respective means. Gradual general improvement has been discernible over time, though there is still room for improvement at some departments. There have been isolated instances of manifest changes in indicator values associated with major departmental reorganisation, probably reflecting real deterioration in quality of care. Thus, indicator monitoring would appear a sensitive means of promoting qualitative improvement.

[Computed tomography as an alternative to observation in brain concussion]

In Sweden, patients with minor head injury (i.e., history of loss of consciousness or posttraumatic amnesia) are routinely admitted for neurological observation. The article reports the results of a small study of current clinical practices at St Göran's Hospital in Stockholm, and briefly reviews published reports of different management strategies. The findings suggest that computed tomography scanning might constitute better management than routine hospitalisation, both medically and economically. However, further investigation from a Swedish perspective is needed before any evidence-based recommendations can be made.

[Home rehabilitation after stroke. Review of the literature]

To find an answer to the question whether domiciliary rehabilitation after stroke is better or cheaper than alternative forms of rehabilitation, a systematic literature review of controlled trials was performed. Three large and two smaller, more preliminary studies of all together a thousand patients were found and regarded methodologically acceptable. Efficacy as regards functional, emotional and qualitative outcome of patients was equivalent for various modes of care. So was the degree of stress, social function and quality of life for the main carers. Home treatment costed less than regular day care but more than routine care including a mixture of outpatient and day care, as considered required. Domiciliary rehabilitation seems to be a good and cost effective alternative for stroke patients who need and cannot manage frequent out-patients visits without ambulance or other exhausting and expensive transports.

Development and evaluation of evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: case-control and cohort studies

OBJECTIVES

To identify clinical characteristics of elderly inpatients that predict their chance of falling (phase 1) and to use these characteristics to derive a risk assessment tool and to evaluate its power in predicting falls (phases 2 and 3).

DESIGN

Phase 1: a prospective case-control study. Phases 2 and 3: prospective evaluations of the derived risk assessment tool in predicting falls in two cohorts.

SETTING

Elderly care units of St Thomas's Hospital (phase 1 and 2) and Kent and Canterbury Hospital (phase 3).

SUBJECTS

Elderly hospital inpatients (aged > or = 65 years): 116 cases and 116 controls in phase 1,217 patients in phase 2, and 331 in phase 3.

MAIN OUTCOME MEASURES

21 separate clinical characteristics were assessed in phase 1, including the abbreviated mental test score, modified Barthel index, a transfer and mobility score obtained by combining the transfer and mobility sections of the Barthel index, and several nursing judgements.

RESULTS

In phase 1 five factors were independently associated with a higher risk of falls: fall as a presenting complaint (odds ratio 4.64 (95% confidence interval 2.59 to 8.33); a transfer and mobility score of 3 or 4 (2.10 (1.22 to 3.61)); and primary nurses' judgment that a patient was agitated (20.9 (9.62 to 45.62)), needed frequent toileting (2.48 (1.08 to 5.70)), and was visually impaired (3.56 (1.26 to 10.05)). A risk assessment score (range 0-5) was derived by scoring one point for each of these five factors. In phases 2 and 3 a risk assessment score > 2 was used to define high risk: the sensitivity and specificity of the score to predict falls during the following week was 93% and 88% respectively in phase 2 and 92% and 68% respectively in phase 3.

CONCLUSION

This simple risk assessment tool predicted with clinically useful sensitivity and specificity a high percentage of falls among elderly hospital inpatients.

Three new naphthyldihydroisoquinoline alkaloids from Ancistrocladus tectorius

Three new 5--1'-linked naphthyldihydroisoquinoline alkaloids (1-3) have been isolated from the organic extract of Ancistrocladus tectorius. The gross structures of the compounds have been established using 1D and 2D NMR spectroscopy and difference NOE experiments. The absolute stereochemistry of 1, 2, and 3 was determined from CD spectral comparison and chemical degradation. Evidence is presented to show that two of the compounds exist exclusively in the keto form at C-8 of the isoquinoline system (2b, 3b).

Validation of four scales for the acute stage of stroke

OBJECTIVES

To validate whether a simplified scale for the acute stage of stroke--the Scandinavian Stroke Supervision scale--is sufficient for monitoring symptom progression of prognostic importance.

DESIGN

The capacity of the scale was compared to that of the Mathew, Toronto and Fugl-Meyer stroke scales and the Barthel ADL index.

SETTING

The stroke unit of Danderyd Hospital, which cares for a defined population.

SUBJECTS

Fifty noncomatose patients with objectively recorded symptoms at entry were examined over a period of 5 days by one physician (250 ratings/scale). The last 10 patients were also investigated by another doctor in the same manner (50 ratings/scale) and by nurses (50 ratings) the Scandinavian scale only. The amount of time required by each scale was tested in another 10 patients by two nurses (100 ratings/scale).

INTERVENTIONS

Routine investigation and treatment.

MAIN OUTCOME MEASURES

The reliability, validity, time requirement and correlation of the scales were evaluated, as was their ability to reveal progress of symptoms.

RESULTS

All scales were highly significantly correlated. The interobserver agreement was excellent between the physicians but not as good between the physician and the nurses. The prediction of the outcome at discharge and after 3 months was very satisfactory for all of the scales with regard to the whole groups of patients, but none of them could predict the outcome for an individual with certainty. The Scandinavian Stroke Supervision scale was least time consuming, and had the fewest uncertainties expressed by the testers. This scale recorded the progression of slightly fewer symptoms, but did record those with a more serious impact on patient outcome.

CONCLUSION

The time-saving, simplified Scandinavian scale was as reliable and as valid as the other scales, and detected deterioration that was important for patient outcome as satisfactorily as the other scales.

The role of autopsies in medical audit: examples from a department of medicine

Autopsy findings from a representative sample of deaths in a clinic provide an opportunity for regular and systematic revision of medical diagnostics and treatment. A standardized analysis of the collected results can furnish useful figures for comparisons and follow-up. On this basis, new strategies for future improvement of medical care should be outlined. Autopsy results can also be used for medical audit concerning more limited items like the certification of death.