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Lindley RI, Anderson CS, Billot L, Forster A, Hackett ML, Harvey LA, Jan S, Li Q, Liu H, Langhorne P, Maulik PK, Murthy GVS, Walker MF, Pandian JD, Alim M, Felix C, Syrigapu A, Tugnawat DK, Verma SJ, Shamanna BR, Hankey G, Thrift A, Bernhardt J, Mehndiratta MM, Jeyaseelan L, Donnelly P, Byrne D, Steley S, Santhosh V, Chilappagari S, Mysore J, Roy J, Padma MV, John L, Aaron S, Borah NC, Vijaya P, Kaul S, Khurana D, Sylaja PN, Halprashanth DS, Madhusudhan BK, Nambiar V, Sureshbabu S, Khanna MC, Narang GS, Chakraborty D, Chakraborty SS, Biswas B, Kaura S, Koundal H, Singh P, Andrias A, Thambu DS, Ramya I, George J, Prabhakar AT, Kirubakaran P, Anbalagan P, Ghose M, Bordoloi K, Gohain P, Reddy NM, Reddy KV, Rao TNM, Alladi S, Jalapu VRR, Manchireddy K, Rajan A, Mehta S, Katoch C, Das B, Jangir A, Kaur T, Sreedharan S, Sivasambath S, Dinesh S, Shibi BS, Thangaraj A, Karunanithi A, Sulaiman SMS, Dehingia K, Das K, Nandini C, Thomas NJ, Dhanya TS, Thomas N, Krishna R, Aneesh V, Krishna R, Khullar S, Thouman S, Sebastian I. Family-led rehabilitation after stroke in India (ATTEND): a randomised controlled trial. Lancet 2017; 390:588-599. [PMID: 28666682 DOI: 10.1016/s0140-6736(17)31447-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 03/17/2017] [Accepted: 04/04/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Most people with stroke in India have no access to organised rehabilitation services. The effectiveness of training family members to provide stroke rehabilitation is uncertain. Our primary objective was to determine whether family-led stroke rehabilitation, initiated in hospital and continued at home, would be superior to usual care in a low-resource setting. METHODS The Family-led Rehabilitation after Stroke in India (ATTEND) trial was a prospectively randomised open trial with blinded endpoint done across 14 hospitals in India. Patients aged 18 years or older who had had a stroke within the past month, had residual disability and reasonable expectation of survival, and who had an informal family-nominated caregiver were randomly assigned to intervention or usual care by site coordinators using a secure web-based system with minimisation by site and stroke severity. The family members of participants in the intervention group received additional structured rehabilitation training-including information provision, joint goal setting, carer training, and task-specific training-that was started in hospital and continued at home for up to 2 months. The primary outcome was death or dependency at 6 months, defined by scores 3-6 on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) as assessed by masked observers. Analyses were by intention to treat. This trial is registered with Clinical Trials Registry-India (CTRI/2013/04/003557), Australian New Zealand Clinical Trials Registry (ACTRN12613000078752), and Universal Trial Number (U1111-1138-6707). FINDINGS Between Jan 13, 2014, and Feb 12, 2016, 1250 patients were randomly assigned to intervention (n=623) or control (n=627) groups. 33 patients were lost to follow-up (14 intervention, 19 control) and five patients withdrew (two intervention, three control). At 6 months, 285 (47%) of 607 patients in the intervention group and 287 (47%) of 605 controls were dead or dependent (odds ratio 0·98, 95% CI 0·78-1·23, p=0·87). 72 (12%) patients in the intervention group and 86 (14%) in the control group died (p=0·27), and we observed no difference in rehospitalisation (89 [14%]patients in the intervention group vs 82 [13%] in the control group; p=0·56). We also found no difference in total non-fatal events (112 events in 82 [13%] intervention patients vs 110 events in 79 [13%] control patients; p=0·80). INTERPRETATION Although task shifting is an attractive solution for health-care sustainability, our results do not support investment in new stroke rehabilitation services that shift tasks to family caregivers, unless new evidence emerges. A future avenue of research should be to investigate the effects of task shifting to health-care assistants or team-based community care. FUNDING The National Health and Medical Research Council of Australia.
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Tian M, Gong X, Rath S, Wei J, Yan LL, Lamb SE, Lindley RI, Sherrington C, Willett K, Norton R. Management of hip fractures in older people in Beijing: a retrospective audit and comparison with evidence-based guidelines and practice in the UK. Osteoporos Int 2016; 27:677-81. [PMID: 26267012 DOI: 10.1007/s00198-015-3261-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 07/24/2015] [Indexed: 10/23/2022]
Abstract
UNLABELLED Despite the high burden of hip fracture in China, there is limited information on its management. This study investigated the management of hip fractures in a Beijing tertiary hospital and compared practice with that in 180 hospitals in the UK. The findings show a significant gap exists between the countries. INTRODUCTION The purpose of this study was to determine if the management of older people with hip fractures in a Beijing tertiary hospital is comparable with the UK best practice guidelines for hip fracture management and the UK National Hip Fracture Database 2012, obtained from 180 hospitals. METHODS A retrospective audit was undertaken in a large tertiary care hospital in Beijing. Data were compared with the National Hip Fracture Database 2012 collected in 180 hospitals in the UK on the proportion of patients managed according to the UK Blue Book standards. RESULTS Sixty-six percent of patients were admitted to an orthopaedic ward within 24 h of fracture, while 100 % of patients in the UK were admitted to an orthopaedic ward within 24 h of arrival to an accident and emergency department. Only 8 % of patients received surgery within 48 h of admission compared with 83 % in the UK; 10 % received no surgery compared with 2.5 % in the UK; and 27 % received orthogeriatrician assessment compared with 70 % in the UK. New pressure ulcers developed in 2 % of patients compared with 3.7 % of those in the UK; whereas, 0.3 % of patients were assessed for osteoporosis treatment and 3.8 % received falls assessment, and comparable figures for the UK were 94 and 92 %, respectively. CONCLUSIONS Significant gaps exist in hip fracture management in the Beijing hospital compared with the best practice achieved in 180 UK hospitals, highlighting the need to implement and evaluate proactive strategies to increase the uptake of best practice hip fracture care in China.
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Affiliation(s)
- M Tian
- The George Institute for Global Health, Peking University Health Science Center, Beijing, China
| | - X Gong
- Jishuitan Hospital, Beijing, China
| | - S Rath
- The George Institute for Global Health, Nuffield Department of Population Health, University of Oxford, Oxford, England, UK.
- Oxford Martin School, University of Oxford, 34 Broad Street, Oxford, OX1 3BD, UK.
| | - J Wei
- Jishuitan Hospital, Beijing, China
| | - L L Yan
- The George Institute for Global Health, Peking University Health Science Center, Beijing, China
| | - S E Lamb
- Kadoorie Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, England, UK
| | - R I Lindley
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - C Sherrington
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - K Willett
- Kadoorie Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, England, UK
| | - R Norton
- The George Institute for Global Health, Nuffield Department of Population Health, University of Oxford, Oxford, England, UK
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, Australia
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De Silva DA, Woon FP, Manzano JJF, Liu EY, Chang HM, Chen C, Wang JJ, Mitchell P, Kingwell BA, Cameron JD, Lindley RI, Wong TY, Wong MC. The relationship between aortic stiffness and changes in retinal microvessels among Asian ischemic stroke patients. J Hum Hypertens 2011; 26:716-22. [PMID: 21975690 DOI: 10.1038/jhh.2011.88] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Large-artery stiffness is a risk factor for stroke, including cerebral small-vessel disease. Retinal microvascular changes are thought to mirror those in cerebral microvessels. We investigated the relationship between aortic stiffness and retinal microvascular changes in Asian ischemic stroke patients. We studied 145 acute ischemic stroke patients in Singapore who had aortic stiffness measurements using carotid-femoral pulse wave velocity (cPWV). Retinal photographs were assessed for retinal microvessel caliber and qualitative signs of focal arteriolar narrowing, arteriovenous nicking and enhanced arteriolar light reflex. Aortic stiffening was associated with retinal arteriolar changes. Retinal arteriolar caliber decreased with increasing cPWV (r=-0.207, P=0.014). After adjusting for age, gender, hypertension, diabetes, mean arterial pressure and small-vessel stroke subtype, patients within the highest cPWV quartile were more likely to have generalized retinal arteriolar narrowing defined as lowest caliber tertile (odds ratio (OR) 6.84, 95% confidence interval (CI) 1.45-32.30), focal arteriolar narrowing (OR 13.85, CI 1.82-105.67), arteriovenous nicking (OR 5.08, CI 1.12-23.00) and enhanced arteriolar light reflex (OR 3.83, CI 0.89-16.48), compared with those within the lowest quartile. In ischemic stroke patients, aortic stiffening is associated with retinal arteriolar luminal narrowing as well as features of retinal arteriolosclerosis.
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Affiliation(s)
- D A De Silva
- Singapore General Hospital Campus, National Neuroscience Institute, Singapore.
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De Silva DA, Manzano JJF, Liu EY, Woon FP, Wong WX, Chang HM, Chen C, Lindley RI, Wang JJ, Mitchell P, Wong TY, Wong MC. Retinal microvascular changes and subsequent vascular events after ischemic stroke. Neurology 2011; 77:896-903. [DOI: 10.1212/wnl.0b013e31822c623b] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Ridda I, MacIntyre CR, Lindley RI, Tan TC. Difficulties in recruiting older people in clinical trials: an examination of barriers and solutions. Vaccine 2009; 28:901-6. [PMID: 19944149 DOI: 10.1016/j.vaccine.2009.10.081] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Revised: 08/17/2009] [Accepted: 10/14/2009] [Indexed: 11/19/2022]
Abstract
Limited information exists regarding optimal methods for the recruitment and retention of older people in clinical trials. The aim of this review is to identify common barriers to the recruitment of older people in clinical trials and to propose solutions to overcome these barriers. A review of literature was performed to identify common difficulties in recruiting older people. This in combination with our experience during recruitment for a randomized control trial, have highlighted numerous barriers. Population-specific recruitment strategies, simple informed-consent processes, and effective communication between the researcher and subject are effective strategies to overcome these barriers.
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Affiliation(s)
- I Ridda
- National Centre for Immunisation Research and Surveillance Sydney, NSW, Australia.
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Stockler MR, March L, Lindley RI, Mellis C. Students' PEARLS: successfully incorporating evidence-based medicine in medical students' clinical attachments. ACTA ACUST UNITED AC 2009; 14:98-9. [DOI: 10.1136/ebm.14.4.98-a] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Ridda I, Macintyre CR, Lindley RI. A qualitative study to assess the perceived benefits and barriers to the pneumococcal vaccine in hospitalised older people. Vaccine 2009; 27:3775-9. [PMID: 19464561 DOI: 10.1016/j.vaccine.2009.03.075] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2009] [Revised: 03/18/2009] [Accepted: 03/24/2009] [Indexed: 01/15/2023]
Abstract
UNLABELLED Pneumococcal vaccine is now recommended for all people aged 65 years and over in Australia, yet many in this age group remain unvaccinated, especially those from Non-English Speaking Backgrounds (NESB). AIM Our aim was to assess some of the perceived beliefs, benefits and barriers to pneumococcal immunisation in older people. DESIGN AND SETTING We conducted qualitative open-ended interviews among elderly hospital inpatients aged receiving care in the geriatric, cardiology, and orthopaedic departments of a large, 800-bed tertiary referral hospital. METHODS 24 participants who had not received pneumococcal immunisation, and who were aged 60 years and over, were mentally competent and well enough to be interviewed were selected for our study. RESULTS Three topics were addressed: patient attitudes towards vaccination, knowledge of vaccines and their purpose, and accessibility of patient education materials about vaccines and their purpose. Patients who accepted pneumococcal immunisation (acceptors) generally were unaware of the vaccine or did not know it was recommended for them. Patients who refused the pneumococcal vaccine (refusers) either would not consider it without the recommendation of their general practitioner or they maintained the belief that the vaccination would cause illness or symptoms. Knowledge about the availability and purpose of the pneumococcal vaccine was poor amongst our group. CONCLUSION Poor knowledge of the availability and purpose of pneumococcal immunisation was prevalent in our subjects. Appropriate education campaigns and trusting and positive relationships with the general practitioners are likely to improve immunisation uptake.
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Affiliation(s)
- I Ridda
- National Centre for Immunisation Research and Surveillance Sydney, NSW, Australia.
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Affiliation(s)
- R I Lindley
- Department of Geriatric Medicine, Discipline of Medicine, Westmead Hospital (C24), The University of Sydney, NSW 2006, Australia.
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Abstract
BACKGROUND MR diffusion-weighted imaging (DWI) shows acute ischemic lesions early after stroke so it might improve outcome prediction and reduce sample sizes in stroke treatment trials. Previous studies of DWI and outcome produced conflicting results. OBJECTIVE To determine whether DWI lesion characteristics independently predict outcome in a broad range of patients with acute stroke. METHODS The authors recruited hospital-admitted patients with all severities of suspected stroke, assessed stroke severity on the NIH Stroke Scale (NIHSS), performed early brain DWI, and assessed outcome at 3 months (modified Rankin Scale). Clinical data and DWI lesion parameters were evaluated in a logistic regression model to identify independent predictors of outcome at 3 months and a previously described "Three-Item Scale" (including DWI) was tested for outcome prediction. RESULTS Among 82 patients (mean NIHSS 7.1 [+/-6.3 SD]), the only independent outcome predictors were age and stroke severity. Neither DWI lesion volume nor apparent diffusion coefficient nor the previously described Three-Item Scale predicted outcome independently. Comparison with previous studies suggested that DWI may predict outcome only in patients with more severe cortical ischemic strokes. CONCLUSIONS Across a broad range of stroke severities, diffusion-weighted imaging (DWI) did not predict outcome beyond that of key clinical variables. Thus, DWI is unlikely to reduce sample sizes in acute stroke trials assessing functional outcome, especially where estimated treatment effects are modest.
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Affiliation(s)
- P J Hand
- Division of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Edinburgh, EH4 2XU, UK
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Hand PJ, Wardlaw JM, Rowat AM, Haisma JA, Lindley RI, Dennis MS. Magnetic resonance brain imaging in patients with acute stroke: feasibility and patient related difficulties. J Neurol Neurosurg Psychiatry 2005; 76:1525-7. [PMID: 16227544 PMCID: PMC1739389 DOI: 10.1136/jnnp.2005.062539] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To assess organisational and patient specific limitations and safety of magnetic resonance imaging (MRI) as the first line investigation for hospital admitted stroke patients. METHODS Consecutive patients admitted with acute stroke were assessed and an attempt was made to perform MRI in all patients. Oxygen saturation and interventions required during scanning were recorded. RESULTS Among 136 patients recruited over 34 weeks, 85 (62%) underwent MRI. The patients' medical instability (15 of the 53 not scanned), contraindications to MRI (six of the 53 not scanned), and rapid symptom resolution (10 of the 53 not scanned) were the main reasons for not performing MRI. Of the 85 patients who underwent MRI, 26 required physical intervention, 17 did not complete scanning, and 11 of the 61 who had successful oxygen saturation monitoring were hypoxic during MRI. Organisational limitations accounted for only 13% of failures to scan. CONCLUSIONS Up to 85% of hospital admitted acute stroke patients could have MRI as first line imaging investigation, but medical instability is the major limitation. Hypoxia is frequent in MRI. Patients should be monitored carefully, possibly by an experienced clinician, during scanning.
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Affiliation(s)
- P J Hand
- Division of Clinical Neurosciences, Western General Hospital, Edinburgh EH4 2XU, UK
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Lindley RI. Medical management of ischaemic stroke. CRIT CARE RESUSC 2005; 7:189-94. [PMID: 16545044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2005] [Accepted: 06/30/2005] [Indexed: 05/07/2023]
Abstract
Stroke is a medical emergency as it is the third commonest cause of death and the most important cause of acquired severe disability in adults. Stroke services, funding and research have lagged behind cardiac medicine but evidence is now available to support a much more interventional approach to the assessment and management of patients with ischaemic stroke. Randomised controlled trials and meta-analyses of the most important interventions are the main sources of evidence for this review. This evidence supports the immediate assessment of patients with suspected stroke, including access to brain imaging, and consideration of urgent revascularisation strategies such as intravenous recombinant tissue plasminogen activator. Patients not eligible for thrombolysis should receive aspirin and specialised care in a stroke unit. Many other treatments have been evaluated for acute ischaemic stroke of which some have been shown to be ineffective such as haemodilution or anticoagulation, whilst other interventions have not been adequately investigated such as neuroprotection and blood pressure lowering strategies. There is now good evidence to support a much more active assessment and treatment of patients with stroke but it is recognised that stroke services still need substantial development to maximise the benefits from the current proven interventions.
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Affiliation(s)
- R I Lindley
- Geriatric Medicine, University of Sydney, Westmead Hospital, Sydney, NSW 2145, Australia
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Affiliation(s)
- R I Lindley
- Department of Clinical Neurosciences, University of Edinburgh, Western General Hospital, UK.
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Lindley RI. Further randomized controlled trials of tissue plasminogen activator within 3 hours are required. Stroke 2001; 32:2708-9. [PMID: 11692040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Affiliation(s)
- R I Lindley
- Department of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Edinburgh, UK
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Kaste M, Thomassen L, Grond M, Hacke W, Holtås S, Lindley RI, Roine R, Gunnar Wahlgren N, Wardlaw JM. Thrombolysis for acute ischemic stroke: a consensus statement of the 3rd Karolinska Stroke Update, October 30-31, 2000. Stroke 2001; 32:2717-8. [PMID: 11692044 DOI: 10.1161/hs1101.098639] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- M Kaste
- Department of Neurology, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland.
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Brett B, Peak EJ, Nair A, Lindley RI. Do not resuscitate decisions. More consumer education and involvement are needed. BMJ 2001; 322:103-4. [PMID: 11154635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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Wardlaw JM, Sandercock PA, Warlow CP, Lindley RI. Trials of thrombolysis in acute ischemic stroke: does the choice of primary outcome measure really matter? Stroke 2000; 31:1133-5. [PMID: 10797177 DOI: 10.1161/01.str.31.5.1133] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Controversy regarding the risks and benefits of thrombolysis has not been helped by the perception that some trials were "positive" and others "negative" on their primary outcome measure of either "good" or "poor" functional outcome. We wondered whether the definition of good or poor functional outcome might have contributed to this perception, and what effect altering the definition might have on the individual trials and on the systematic review of all the trials combined. METHODS We analyzed data on functional outcome, extracted from the randomized trials of thrombolysis in acute ischemic stroke, according to good (modified Rankin scale scores of 0 to 1 versus 2 to 6) and poor (modified Rankin 0 to 2 versus 3 to 6) functional outcome, to determine the effects of thrombolysis. RESULTS Twelve trials (4342 patients, treated up to 6 hours after stroke) contributed to this analysis. Overall, there was no difference in the estimate of treatment effect between the 2 definitions (modified Rankin 0 to 2 versus 3 to 6, and 0 to 1 versus 2 to 6 [ORs 0.83 and 0.79, respectively]). However, the apparent "success" of several individual trials did alter. CONCLUSIONS We should not place undue emphasis on the results of individual trials, when a change of a single point on the Rankin scale can make the difference between "success" and "failure." Overall, by either analysis, there was a significant benefit in patients treated with thrombolysis up to 6 hours after stroke.
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Affiliation(s)
- J M Wardlaw
- Department of Clinical Neurosciences, The University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, UK.
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Abstract
Assessment of acute stroke by hospital physicians will have to speed up if we are to expect referral to hospital and computed tomography (both previously targets of criticism) to improve.
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Lindley RI. Drug therapy for acute ischaemic stroke: risks versus benefits. Drug Saf 1998; 19:373-82. [PMID: 9825950 DOI: 10.2165/00002018-199819050-00004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Stroke is a very common medical emergency that, until recently, had no specific treatment. Following the results of several major trials (including 2 'mega-trials'), aspirin (acetylsalicylic acid) can be recommended for the majority of patients with acute ischaemic stroke. While the benefit of aspirin is only modest, i.e. an increase of 11 per 1000 long term independent survivors, the public health benefit in the world will be substantial as this treatment could be given to millions of patients with acute ischaemic stroke each year. Heparin is associated with a reduction in early recurrent ischaemic stroke, but there is no net benefit because of a similar sized excess of recurrent haemorrhagic stroke (even for those in atrial fibrillation). Thrombolytic therapy has not been so widely tested and the results of the small trials to date have yielded conflicting results. The only positive publication to date (comprised of 2 related trials) evaluated the recombinant tissue plasminogen activator alteplase, but such treatment is probably only indicated for highly selected patients. Further trials are almost certainly required and it would be unwise to change clinical practice based on the current evidence. No other stroke treatments have been shown to be beneficial, and much larger trials will be required to confirm or refute possible moderate benefits of treatment. A well organised stroke service and participation in clinical trials will improve the future care of patients with acute ischaemic stroke.
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Affiliation(s)
- R I Lindley
- Department of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Scotland.
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Anderson KE, Starr JM, Lindley RI. Acute psychosis in two elderly patients. Postgrad Med J 1998; 74:569-70. [PMID: 10211342 PMCID: PMC2361035 DOI: 10.1136/pgmj.74.875.569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- K E Anderson
- Department of Geriatric Medicine, University of Edinburgh, Royal Victoria Hospital, Scotland, UK
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Affiliation(s)
- R I Lindley
- Department of Clinical Neurosciences, Edinburgh University, Western General Hospital
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Abstract
The aim of the study reported here was to test the validity of a simple clinical classification of acute ischaemic stroke (Oxfordshire Community Stroke Project, OCSP) in predicting the site and size of cerebral infarction on computed tomography (CT). Consecutive patients admitted to hospital with acute ischaemic stroke were prospectively identified and classified into one of four clinical syndromes according to the OCSP classification, blind to the result of CT. The CT brain scans were classified blind to the clinical features into those demonstrating: small, medium or large cortical infarcts; small or large subcortical infarcts in the anterior circulation territory; and posterior cerebral circulation territory infarcts. A total of 108 patients were included. A recent infarct was seen on the CT scan in 91 patients (84%), and the clinical classification correctly predicted the site and size of the cerebral infarct in 80 of these (88%; 95% confidence interval 77-92%). The positive predictive value was best for large cortical infarcts (0.94) and worst for small subcortical infarcts (0.63). The OCSP clinical classification is a reasonably valid way of predicting the site and size of cerebral infarction on CT and can, therefore, be used very early after stroke onset before the infarct appears on the scan.
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Affiliation(s)
- J M Wardlaw
- Department of Clinical Neurosciences, Western General Hospital, Edingburgh, UK
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Lindley RI, Amayo EO, Marshall J, Sandercock PA, Dennis M, Warlow CP. Acute stroke treatment in UK hospitals: the Stroke Association survey of consultant opinion. J R Coll Physicians Lond 1995; 29:479-484. [PMID: 8748103 PMCID: PMC5401253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
The aim of the Stroke Association survey was to document United Kingdom consultant opinion of the immediate treatment for patients with acute stroke. A national postal survey of all UK hospital consultant general physicians, geriatricians and neurologist was carried out in 1992/3. We identified 1,953 consultants who routinely cared for patients with acute stroke; 39% of them regularly used aspirin for patients with acute stroke and 10% used low-dose subcutaneous heparin. Other treatments were rarely used. There was much uncertainty about the effectiveness of all currently available acute stroke treatments; 73% of physicians were prepared to start aspirin before a CT scan, but a much smaller proportion would start heparin therapy without one. Twenty-seven percent of consultants would actively treat hypertension in the initial 24 hours after stroke. Routine aspirin for secondary prevention after ischaemic stroke was widely accepted, but blood cholesterol lowering by drugs was not. In conclusion, aspirin and heparin alone are the only routinely used treatments for the immediate treatment of acute stroke; other treatments are used sparingly or not at all. The great uncertainty about the value of all available acute stroke treatments should encourage participation in randomised controlled trials.
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Lindley RI, Amayo EO, Marshall J, Sandercock PA, Dennis M, Warlow CP. Hospital services for patients with acute stroke in the United Kingdom: the Stroke Association Survey of consultant opinion. Age Ageing 1995; 24:525-32. [PMID: 8588545 DOI: 10.1093/ageing/24.6.525] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
A national postal survey of all UK hospital consultant geriatricians, general physicians and neurologists was performed in 1992/3 in order to describe the provision of hospital stroke services in the United Kingdom and to assess whether the recommendations of the King's Fund consensus conference on stroke had been widely implemented. Of 3478 survey forms, 2923 (84%) were returned and, of these 1953 (67%) consultants indicated that they routinely cared for patients with acute stroke. On their stated estimates, the survey respondents had admitted approximately 107,000 patients with acute stroke in the previous year, 40% of whom were cared for by geriatricians. Sixty-three per cent (1239/1953) worked in District General Hospitals. Few (5%) had access to an acute stroke unit, and a majority (51%) of consultants were uncertain of the benefits of such units. Less than half (44%) had access to a specialized stroke rehabilitation unit, but a majority (68%) were certain of the benefits of stroke rehabilitation units. Although a majority of consultants had on-site CT scanning, about a third of all UK stroke patients were admitted to a hospital without on-site CT facilities. Most (90%) consultants would want a CT scan themselves if they had a stroke. Only about a third of consultants were aware of a recent audit of stroke care in their hospital, or had a hospital policy for the implementation of minimum standards of stroke care, and less than half routinely provided written information for patients or carers. This survey illustrated that five years after the publication of the King's Fund consensus statement on the treatment of patients with acute stroke UK hospital stroke services are still poorly organized. Access to CT scanning for stroke patients is improving, but is still insufficient.
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Affiliation(s)
- R I Lindley
- Department of Clinical Neurosciences, University of Edinburgh, Western General Hospital
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Sandercock P, Lindley RI, Slattery J. MATTERS ARISING: Sandercock et al reply:. J Neurol Psychiatry 1994. [DOI: 10.1136/jnnp.57.2.254-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Lindley RI, Warlow CP, Wardlaw JM, Dennis MS, Slattery J, Sandercock PA. Interobserver reliability of a clinical classification of acute cerebral infarction. Stroke 1993; 24:1801-4. [PMID: 8248958 DOI: 10.1161/01.str.24.12.1801] [Citation(s) in RCA: 78] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND PURPOSE The Oxfordshire Community Stroke Project (OCSP) clinical classification of subtypes of cerebral infarction (total and partial anterior circulation infarction, lacunar infarction, and posterior circulation infarction) can be used to predict early mortality, functional outcome, and whether the infarct was likely due to large- or small-vessel occlusion. The OCSP classification was originally developed and tested by neurologists as part of a community-based study of first-ever stroke, in which some cases were seen after the acute phase. We examined the interobserver reliability of the classification when used in everyday clinical practice in patients seen during the acute phase of stroke shortly after admission to the hospital. METHODS Two clinicians independently assessed consecutive patients admitted to the hospital with an acute stroke and recorded both the neurological features and their opinion of the subtype of infarct. RESULTS Eighty-five patients were assessed. Interobserver agreement for the classification was moderate to good (kappa = 0.54; 95% confidence interval, 0.39 to 0.68). Differences in the assessment of the commonly elicited neurological signs explained many of the disagreements: interobserver agreement was good for some signs (hemiparesis [kappa = 0.77], dysphasia [kappa = 0.70]), moderate for some (hemianopia [kappa = 0.39]), and poor for others (sensory loss [kappa = 0.15]). CONCLUSIONS The classification was simple and practicable (and could be widely used in routine clinical practice, randomized controlled trials, and audit), and interobserver reliability was satisfactory.
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Affiliation(s)
- R I Lindley
- Department of Clinical Neurosciences, University of Edinburgh, Western General Hospital, UK
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Lindley RI, Sandercock PA. Uses of heparin. Withhold in acute ischaemic stroke. BMJ 1993; 306:1410. [PMID: 8518621 PMCID: PMC1677838 DOI: 10.1136/bmj.306.6889.1410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Sandercock PA, van den Belt AG, Lindley RI, Slattery J. Antithrombotic therapy in acute ischaemic stroke: an overview of the completed randomised trials. J Neurol Neurosurg Psychiatry 1993; 56:17-25. [PMID: 8429318 PMCID: PMC1014758 DOI: 10.1136/jnnp.56.1.17] [Citation(s) in RCA: 147] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
A formal statistical overview of all truly randomised trials was undertaken to determine whether antithrombotic therapy is effective and safe in the early treatment of patients with acute stroke. There were 15 completed randomised controlled trials of the value of early antithrombotic treatment in patients with acute stroke. The regimes tested in acute presumed or confirmed ischaemic stroke were: heparin, 10 trials with 1047 patients: oral anticoagulants, one trial with 51 patients: antiplatelet therapy, three trials with 103 patients. Heparin was tested in one trial with 46 patients with acute haemorrhagic stroke. Outcome measures were deep venous thrombosis (confirmed by I125 scanning or venography), pulmonary embolism, death from all causes, haemorrhagic transformation of cerebral infarction, level of disability in survivors. In patients with acute ischaemic stroke, allocation to heparin was associated with a highly significant 81% (SD 8, 2p < 0.00001) reduction in deep venous thrombosis detected by I125 fibrinogen scanning or venogram. Only three trials systematically identified pulmonary emboli, which occurred in 6/106 (5.7%) allocated control vs 3/132 (2.3%) allocated heparin, a non-significant 58% reduction (SD 45.7, 2p > 0.1). There were relatively few deaths in the trials in patients with presumed ischaemic stroke: 94/485 (19.4%) among patients allocated to the control group vs 79/497 (15.9%) among patients who were allocated heparin. The observed 18% (SD 16) reduction in the odds of death was not statistically significant. The least biased estimated of the effect of treatment on haemorrhagic transformation of the cerebral infarct (HTI) comes from trials where all patients were scanned at the end of treatment, irrespective of clinical deterioration; using this analysis, haemorrhagic transformation occurred in 7/102 (6.9%) control vs 8/106 (7.5%) treated, a non-significant 12% increase (SD 56, 2p > 0.1). These data cannot exclude the possibility that heparin substantially increases the risks of HTI. No data on disability in survivors could be obtained. Early heparin treatment might be associated with substantial reductions in deep venous thrombosis (and probably also pulmonary embolism) and possibly a one fifth reduction in mortality (equivalent to the avoidance of 20-40 early deaths per thousand patients treated.) However, the data were wholly inadequate on safety, particularly on the risk of haemorrhagic transformation of the infarct and on the hazards of heparin therapy in patients with known intracerebral haemorrhage. The trials of oral anticoagulants (15 deaths among 57 patients) and antiplatelet therapy (two deaths among 103 patients) were too small to be informative. Much larger randomized trials-comparing aspirin, heparin and the combination of both drugs against control-in patients with acute ischaemic stroke are justified (and several are now planned or underway).
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Affiliation(s)
- P A Sandercock
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
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Lindley RI, Warlow CP. Clinical trials in cerebrovascular disease. Curr Opin Neurol Neurosurg 1992; 5:58-62. [PMID: 1623239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Randomized clinical trials provide the most reliable evidence of the risks and benefits of a treatment or management plan. Often it is necessary to have information from many thousands of patients in a clinical trial to know how to manage the next patient in the clinic. Recent trials in stroke prevention will change clinical practice by the more appropriate use of carotid endarterectomy and the use of anticoagulation in non-rheumatic atrial fibrillation. Other studies have indicated that modification of risk factors, such as decreased salt consumption, is important. Despite many new trials there is still no proven treatment for acute ischaemic stroke. To provide reliable evidence on the risks and benefits of treatment of acute stroke we need much larger randomized controlled trials.
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Affiliation(s)
- R I Lindley
- Department of Clinical Neurosciences, University of Edinburgh, Western General Hospital, UK
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Lindley RI, Pattman RS, Snow MH. Yersinia pseudotuberculosis infection as a cause of reactive arthritis as seen in a genitourinary clinic: case report. Genitourin Med 1989; 65:255-6. [PMID: 2680895 PMCID: PMC1194363 DOI: 10.1136/sti.65.4.255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Patients are often referred to the genitourinary clinic for screening for urethral infections after a clinical diagnosis of Reiter's syndrome or reactive arthritis. We report a case of reactive polyarthritis in which serological evidence of Yersinia pseudotuberculosis infection was found in the absence of the other common precipitating organisms, such as Chlamydia spp, Klebsiella spp, Shigella spp, Campylobacter spp, or Yersinia enterocolitica.
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Affiliation(s)
- R I Lindley
- Department of Haematology, Royal Victoria Infirmary
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