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Biomedical subjects

A G Rudd

Publications and source records attributed to A G Rudd.

At least 19 recordsLinked to original sources
PubMed2006

Relationships between long-term stroke disability, handicap and health-related quality of life.

OBJECTIVES: To estimate levels of disability, handicap and health-related quality of life (HRQOL) up to 3 years after stroke and examine the relationships between these domains. DESIGN: A longitudinal, observational study SETTING: Population-based register of first-ever strokes METHODS: Subjects, registered between 1 January 1995 and 31 December 1997, were assessed at 1 year (n = 490) and 3 years (n = 342) post-stroke for disability [Barthel index (BI)], handicap [Frenchay activity index (FAI)] and HRQOL (SF-36). BI was categorised as severe, moderate, mild and independent (0-9, 10-14, 15-19 and 20); FAI was categorised as inactive, moderately active and very active (0-15, 16-30 and 31-45). SF-36 domains include: Physical Functioning (PF), Role Physical (RP), Bodily Pain (BP), General Health (GH), Vitality (VT), Social Functioning (SF), Role Emotional (RE) and Mental Health (MH). Physical (PHSS) and Mental Health (MHSS) Summary Scores were computed. RESULTS: at 1 and 3 years, 26.1 and 26.3%, respectively, were disabled (BI < 15); 55 and 51%, respectively, were handicapped (FAI = 0-15); and survivors had low mean PHSS (37.1 and 37.9), but satisfactory mean MHSS (46.6 and 47.7). There was a graded positive relationship between all SF-36 domains and the categories of BI and FAI. Spearman rank correlations were significant between BI and all SF-36 domains at both time points: strong (r > 0.70) with PF, moderate (r = 0.31-0.70) with RP, SF and PHSS, but weak (r < 0.30) with other domains. Correlations between FAI and SF-36 domains were strong with PF, weak with BP, RE and MHSS, and moderate with other domains. CONCLUSIONS: Disability and handicap remain highly prevalent up to 3 years after stroke. Patients' perception of physical health is persistently low, but mental health perception is satisfactory up to 3 years. Due to variable correlations between different HRQOL domains with disability and handicap, it is suggested that disability, handicap and HRQOL should all be assessed to acquire a broader measure of stroke outcome.

Disability Evaluation↗
PubMed2005

Improving clinical practice in stroke through audit: results of three rounds of National Stroke Audit.

BACKGROUND: The results of three rounds of National Stroke Audit in England, Wales and Northern Ireland are compared. METHODS: Audit of the organization of stroke services and retrospective case-note audit of up to 40 consecutive cases admitted per hospital over a 3-month period was conducted in each of 1998, 1999 and 2001/02. The changes in the organizational, case-mix and process results of the hospitals that had participated in all three rounds were analysed. RESULTS: 60% of all eligible trusts from England, Wales and Northern Ireland took part in all three audits in 1998, 1999 and 2001/02. Total numbers of cases were 4996, 4841 and 5152, respectively. Case-mix variables were similar over the three rounds. Mortality at 7 and 30 days fell by 3% and 5%, respectively. The proportion of hospitals with a stroke unit rose from 48% to 77%. The proportion of patients spending most of their stay in a stroke unit rose from 17% in 1998 to 26% in 1999 and 29% in 2001/02. Improvements achieved in process standards of care between 1998 and 1999 (median change was a gain of 9%) failed to improve further by 2001/02 (median change was 0%). In all three rounds process standards of care tended to be better in stroke units. CONCLUSIONS: Three rounds of national audit of stroke care have shown standards of care on stroke units were notably higher than on general wards. Slowing in the rise of the proportion managed on stroke units mirrors the slow down in improvement to overall national standards of care. To further improve outcomes and national standards of stroke care a much higher proportion of patients needs to be managed in stroke units.

Aged↗
PubMed2005

Stroke units: research and reality. Results from the National Sentinel Audit of Stroke.

OBJECTIVES: To use data from the 2001-2 National Stroke Audit to describe the organisation of stroke units in England, Wales and Northern Ireland, and to see if key characteristics deemed effective from the research literature were present. DESIGN: Data were collected as part of the National Sentinel Audit of Stroke in 2001, both on the organisation and structure of inpatient stroke care and the process of care to hospitals managing stroke patients. SETTING: 240 hospitals from England, Wales and Northern Ireland took part in the 2001-2 National Stroke Audit, a response rate of over 95%. These sites audited a total of 8200 patients. AUDIT TOOL: Royal College of Physicians Intercollegiate Working Party Stroke Audit Tool. RESULTS: 73% of hospitals participating in the audit had a stroke unit but only 36% of stroke admissions spent any time on one. Only 46% of all units describing themselves as stroke units had all five organisational characteristics that previous research literature had identified as being key features, while 26% had four and 28% had three or less. Better organisation was associated with better process of care for patients, with patients managed on stroke units receiving better care than those managed in other settings. CONCLUSION: The National Service Framework for Older People set a target for all hospitals treating stroke patients to have a stroke unit by April 2004. This study suggests that in many hospitals this is being achieved without adequate resource and expertise.

Health Services Research↗
PubMed2005

Institutionalization after stroke.

BACKGROUND AND PURPOSE: There are widespread regional variations in the institutionalization rate after stroke. This study sought to identify the factors that predict institutionalization after a primary diagnosis of stroke and determine whether institutionalization rate could be used to assess the quality of hospital care. METHODS: A retrospective case note audit of 2778 consecutive admissions with stroke, between 1 September and 31 October 2000 from a randomly selected sample of 79 hospitals in England, Wales and Northern Ireland. Data were collected on demographics, case-mix, clinical outcome, organization of discharge, and place of residence at discharge and at three and six months. The figures from this audit were validated using data from the 1998 National Sentinel Audit of Stroke. RESULTS: Overall 14% of patients previously living at home were discharged to nursing or residential homes. Using logistic regression, Barthel Index score at discharge accounted for 40% of variation. Two-thirds of patients with a discharge Barthel score of < 5 were institutionalized. Age alone explained 14% and when taken together with discharge Barthel and length of stay it accounted for 54% of variation. On admission 22% of the variation in institutionalization rate could be accounted for by total Glasgow Coma Score (15, < 15), age and ability to walk unaided. Regional variations in institutionalization rates are evident and may in part be explained by differences in ease of access to the institutions. CONCLUSIONS: Discharge disability and older age were the dominant factors determining admission to nursing and residential homes. It is not possible to predict sufficiently reliably for an individual patient the likelihood of institutionalization at admission or at 72 h after admission, to justify early resource allocation decisions.

Age Distribution↗
PubMed2004

Stroke unit care and outcome: results from the 2001 National Sentinel Audit of Stroke (England, Wales, and Northern Ireland).

BACKGROUND AND PURPOSE: Stroke unit care is one of the most powerful interventions available to help stroke patients. There are limited data available to assess the impact of stroke units in routine clinical practice outside randomized clinical trials. This article uses data from the 2001 to 2002 National Stroke Audit to assess the effectiveness of stroke unit care in England, Wales, and Northern Ireland in delivering effective processes of care and in reducing case fatality and disability. METHODS: An observational study of the organization, structure, process of care, and outcomes for stroke in 2001. Case fatality after stroke in England was compared using data from the audit and routinely collected data from the Department of Health. 240 hospitals (196 Trusts) from England, Wales, and Northern Ireland took part in the 2001 to 2002 National Stroke Audit, a response rate of >95%. These sites assessed a total of 8200 patients using the Royal College of Physicians Intercollegiate Working Party Stroke Audit Tool. RESULTS: The availability of stroke unit care varies hugely across the country. Case fatality after stroke was higher in Trusts with least availability of stroke unit care. These differences persisted after control for case mix. The process of care was better for patients managed on stroke units compared with other settings. Overall, the risk of death for patients who received stroke unit care was estimated to be approximately 75% that of the risk for those having no stroke unit care (95% CI, 60 to 90). CONCLUSIONS: Stroke unit care as provided in routine clinical practice in England, Wales, and Northern Ireland reduces case fatality by approximately 25%, which is in line with the figures obtained from systematic analysis of stroke unit trial data.

Aged↗
PubMed2004

Older stroke patients in Europe: stroke care and determinants of outcome.

BACKGROUND: in order to implement cost-effective stroke services for older patients, it is necessary to identify how stroke care is currently provided for these patients and how provision relates to outcome. OBJECTIVES: to estimate the structure and process of care, and identify independent factors associated with 3 month mortality and functional outcome in patients aged over 75 years compared with younger stroke patients across Europe. SETTING: 13 hospitals in 10 European countries. SUBJECTS AND METHODS: 1,847 subjects with first in a lifetime stroke admitted to hospital. Sociodemographic details, acute case severity, resource use and 3-month survival and dependency were collected. RESULTS: from a total of 1,847 patients, 1,112 patients (60%) were under 75 years. Older stroke patients were more likely to be incontinent, dysphasic, dysphagic and comatose (P < 0.001). Computed tomography scan rates were higher in younger (87%) than in older patients (79%) (P < 0.001). Access to organised stroke care was higher in older (58%) than in younger patients (51%) (P = 0.002). Median acute length of stay was longer in younger (14 days, range 7-21 days) than in older patients (11 days, range 8-22 days) (P = 0.04). Nursing time in hospital was higher in older patients (P = 0.01), whilst therapy time was higher in younger patients (P = 0.03). By 3 months, younger patients were more likely to receive outpatient care (P < 0.001), physiotherapy (P < 0.001) and occupational therapy (P < 0.001). For older stroke patients, not having a computed tomography scan (OR = 0.2, 95% confidence intervals (CI) = 0.01-0.6, P = 0.003) was significantly related to mortality at 3 months after adjusting for case mix. Access to organised stroke care was significantly associated with reduced 3-month mortality in younger patients only (OR = 0.29, 95% CI = 0.14-0.6, P < 0.001). CONCLUSION: stroke care varies considerably across European centres, with older people more likely to gain access to organised stroke care in many centres but less likely to receive diagnostic investigations, therapy input and outpatient review. Where there is evidence of age discrimination for access to stroke services, guidelines need to be adopted to ensure patients of all ages receive optimal evidence-based stroke care at all stages of their illness.

Adult↗
PubMed2003

Self ratings of health predict functional outcome and recurrence free survival after stroke.

STUDY OBJECTIVE: To measure stroke victims' self rated health (SRH) status and SRH transition, and to compare how the two are prospectively associated with disability and recurrence free survival. DESIGN: Prospective case registry study with face to face follow up interviews at three months, one, two, and three years. Ascertained were SRH status and SRH transition using single question assessments, Barthel Index (BI), Frenchay Activities Index (FAI), and Mini Mental State Examination (MMSE). SETTING: A multiethnic inner city population of 234 533. PARTICIPANTS: Patients surviving the initial three months after a first in a lifetime stroke in 1995 to 1998. RESULTS: Of 690 stroke survivors 561 (81.3%) could complete the self report items. Answers to the item on SRH status did not vary significantly between the four follow up interviews. However, responses to the item on SRH transition changed significantly during follow up with three months ratings being more negative than all subsequent ratings. SRH transition, but not SRH status, showed a prospective association with long term outcome in multivariate analyses controlling for the BI, FAI, and MMSE. Compared with all other patients, patients reporting "Much worse health" at three months were more likely to be disabled ( = BI<20) at one year (OR 6.29, 95% CI 2.26 to 17.52) and their combined risk of stroke recurrence and death was increased over five years (HR 1.72, 95% CI 1.25 to 2.38). CONCLUSIONS: Items on SRH should be used with caution in populations with high rates of disability and language problems, as many participants are unable to complete them. SRH transition may be a better predictor of disability and recurrence free survival after major medical events than SRH status.

Aged↗
PubMed2002

Incidence and case fatality rates of stroke subtypes in a multiethnic population: the South London Stroke Register.

OBJECTIVE: To identify sociodemographic differences in the incidence of the subtypes of first ever stroke in a multiethnic population. METHODS: A prospective community stroke register (1995-8) was developed using multiple notification sources and pathological and clinical classifications of stroke. Standardisation of rates was to European and World populations and adjusted for age, sex and socioeconomic status in multivariate analyses. A multiethnic population of 234 533 in south London, of whom 21% are black was studied. RESULTS: A total of 1254 cases were registered. The average age of stroke was 71.7 years with black patients being 11.3 years younger than white patients (p<0.0001). The incidence rate/1000 population was 1.33 (crude) (95% CI 1.26 to 1.41), 1.28 (European adjusted) (95% CI 1.2 to 1.35) with a 2.18 (95% CI 1.86 to 2.56) (p<0.0001) age and sex adjusted incidence rate ratio in the black population. Radiological diagnosis was confirmatory in 1107 (88.3%) with 862 (68.7%) infarction, 168 (13.4%) primary intracerebral haemorrhage, and 77 (6.2%) subarachnoid haemorrhage. Of the cerebral infarction cases 189 (21.9%) were total anterior circulatory, 250 (29%) partial anterior, 141 (16.4%) posterior (POCI) and 282 (32.7%) lacunar infarcts. The black group had a significantly higher incidence of all subtypes of stroke except for POCI and unclassified strokes. The incidence rate ratio (IRR) for men compared with women was 1.34 (95% confidence interval (95% CI) 1.19 to 1.50; p<0.001). The IRR for manual versus non-manual occupations in those aged 35-64 years was 1.64 (95%CI 1.22 to 2.23; p<0.0001). There was a borderline significant increase in adjusted survival at 6 months in the black group 95% (CI 0.61 to 1.03, p=0.078) with a hazard ratio of 0.79 after adjustment and stratification. CONCLUSIONS: Although the black population is at increased risk of stroke and most subtypes of stroke, this is not translated into significant differences in survival. Hence black/white differences in mortality are mainly driven by incidence of stroke. There are striking demographic inequalities in the risk of stroke in this multiethnic inner city population that need to be tackled through interagency working. Although the reasons for the increased risk in the black population are unclear, demographic factors such as socioeconomic status do seem to play a significant independent part.

Adolescent↗
PubMed2002

Stroke care: how do we measure quality?

The purpose of this paper is to review the methods used to measure quality of stroke care. Relevant articles were searched for on Medline using the following key words: stroke, quality, outcome of care, process of care, structure of care. Articles that examined how to measure the quality of stroke care and that examined difficulties in the measurement of care outcomes, processes, and structures were selected. Selected articles were reviewed to summarise methods used to measure quality of stroke care and the primary outcome measures of the studies were extracted. Conclusions were drawn about the best ways to measure the quality of stroke care. Practical problems in using outcome measures to monitor quality of care include the consequences of case mix and difficulties in risk adjustment. Clinicians may use process measures to understand differences in outcome. Once a process of care has been linked to an outcome measure, this care process should be measured. The national sentinel audit for stroke is an audit tool used to examine the quality of the processes of stroke care.

Humans↗
PubMed2001

A new method for predicting recovery after stroke.

BACKGROUND AND PURPOSE: Several prognostic factors have been identified for outcome after stroke. However, there is a need for empirically derived models that can predict outcome and assist in medical management during rehabilitation. To be useful, these models should take into account early changes in recovery and individual patient characteristics. We present such a model and demonstrate its clinical utility. METHODS: Data on functional recovery (Barthel Index) at 0, 2, 4, 6, and 12 months after stroke were collected prospectively for 299 stroke patients at 2 London hospitals. Multilevel models were used to model recovery trajectories, allowing for day-to-day and between-patient variation. The predictive performance of the model was validated with an independent cohort of 710 stroke patients. RESULTS: Urinary incontinence, sex, prestroke disability, and dysarthria affected the level of outcome after stroke; age, dysphasia, and limb deficit also affected the rate of recovery. Applying this to the validation cohort, the average difference between predicted and observed Barthel Index was -0.4, with 90% limits of agreement from -7 to 6. Predicted Barthel Index lay within 3 points of the observed Barthel Index on 49% of occasions and improved to 69% when patients' recovery histories were taken into account. CONCLUSIONS: The model predicts recovery at various stages of rehabilitation in ways that could improve clinical decision making. Predictions can be altered in light of observed recovery. This model is a potentially useful tool for comparing individual patients with average recovery trajectories. Patients at elevated risk could be identified and interventions initiated.

Activities of Daily Living↗
PubMed2001

The inter- and intraobserver reliabilities of a new classification system for ischaemic stroke: the South London Stroke Register.

OBJECTIVES: This study aims to determine the inter- and intraobserver reliabilities of an aetiological classification devised as part of a community-based stroke register. METHODS: Patients with first-ever acute ischaemic stroke were clinically assessed and received investigation according to a set protocol. Results of the clinical assessment and investigations were used to determine an aetiological stroke subtype for each patient by observer 1. Aetiological subtypes consisted of extracranial large artery atherosclerosis (LAAec), intracranial large artery atherosclerosis (LAAic), high-risk cardioembolism (CH), medium-risk cardioembolism (CM), small vessel occlusion (SVO), other aetiology (OTH), no aetiology identified (NA) and multiple probable or multiple possible aetiology (MPA). The same data were distributed to a further four observers along with the criteria for the classification system. Two of the observers were retested on the same patients after of period of 8 weeks. Inter- and intraobserver agreement was determined using the kappa statistic, which gives the chance-adjusted percentage agreement. RESULTS: Forty-five consecutive patients were included. The overall kappa statistic for ischaemic stroke was 0.91 indicating excellent agreement. Kappa statistics were highest for the more frequent subtypes of SVO (0.97) and CH (0.97). Substantially high kappa statistics were also obtained for the less-frequent categories of LAAec (0.91), CM (0.84), NA (0.89) and MPA (0.87). A low kappa statistic was obtained for the category OTH (0.16), which had a low frequency of reporting, indicating poor agreement. The kappa statistic for probable categories was higher than the kappa statistic for all stroke subtypes at 0.96. Intraobserver agreement between first and second assignments of subtype diagnoses for both observers reached excellent agreement with kappa statistics of 0.83 and 0.85. CONCLUSION: The aetiological classification system, designed for use in the investigation of the epidemiology, stroke subtype and their relation to the natural history of stroke in a multiethnic inner city population, allows high inter- and intrarater agreements of subtype diagnosis.

Acute Disease↗
PubMed2001

Reliability and validity of the Intercollegiate Stroke Audit Package.

The aim of this study was to assure the validity and reliability of the Intercollegiate Stroke Audit Package as used in the National Sentinel Audit of Stroke. The Intercollegiate Working Party for Stroke, which included most stakeholders, including patients, devised the audit standards. These were submitted to a formal consensus (modified Delphi) survey before the audit questions were developed and piloted for validity and reliability. Following the pilot, Help Booklets were developed to promote the involvement of all disciplines as auditors in the national sentinel audit of stroke and ensure inter-rater reliability. During the national audit each Trust was asked to double rate the first five cases with auditors of different disciplines working independently. A total of 886 case notes were double-rated in 184 separate sites (median 5, range 1-5 per site). Trusts used auditors from different disciplines in 77% of cases. After excluding the 'No answer' cases the kappa score for items ranged from 0.49 to 0.87 (median 0.70, IQR 0.63-0.78). Very good agreement was found for seven of the 45 items, good agreement for 30 items, and moderate agreement for eight items. This large study, across a range of hospital sites and involving many disciplines, demonstrates that careful piloting of audit tools, with use of clear instructions to auditors, promotes the reliability of data.

Delphi Technique↗
PubMed2001

The effect of 24 h blood pressure levels on early neurological recovery after stroke.

OBJECTIVES: To assess the influence of 24 h blood pressure (BP) levels on functional recovery 1 week after stroke and the effect of antihypertensive therapy on 24 h BP levels. DESIGN: Prospective study of patients admitted to hospital over 1 year with first in a lifetime stroke who underwent 24 h BP and casual measurements. Setting. Medical wards in a teaching hospital. Subjects. Of 160 patients, 72 patients admitted to hospital within 24 h of stroke onset were investigated. Patients with conditions and therapy that interfered with autonomic and sympathetic function were excluded. Interventions. All subjects underwent 24 h BP and casual recordings on admission to hospital and at day seven after stroke. The mean 24 h, day and night systolic BP (SBP) and diastolic BP (DBP) and their differences (nocturnal BP dip) were recorded. Patients were divided into three groups according to whether they were taking antihypertensive therapy during the first week: (i) no therapy, (ii) therapy continued after stroke, and (iii) new therapy introduced. Main outcome measures. Functional recovery (Rankin Scale 0-1) and neurological improvement [Scandinavian Stroke Scale (SSS) >/=3 points] by 1 week of stroke. Change in circadian 24 h BP over 1 week. RESULTS: For each 10 mmHg difference between day and night time DBP, the odds for making a complete recovery were 4.63 (95% CI: 1.57-13.7, P=0.01). For each 10 mmHg difference between day and night SBP, the odds for making an improvement in neurological status was 2.24 (95% CI: 1.16-4.32; P=0.016). Significant falls in 24 h DBP (P=0.01), daytime SBP (P=0.005) and mean arterial BP (MABP) (P=0.04) over 1 week were demonstrated in patients who had just commenced antihypertensive therapy (P=0.001). CONCLUSION: An increase in day to night time BP change is favourable in short-term outcome after acute stroke. Significant falls in BP are more likely in patients started on antihypertensive therapy for the first time. Further research is required to understand the effects of circadian BP rhythm on stroke outcome.

Aged↗
PubMed2001

Recovery from poststroke urinary incontinence: associated factors and impact on outcome.

OBJECTIVES: To determine factors associated with recovery from poststroke urinary incontinence and to estimate the impact of this recovery on stroke outcome at 3 months. DESIGN: Prospective, observational study. SETTING: Population-based stroke register. PARTICIPANTS: Three hundred twenty-four incident cases of stroke with incontinence 1 week poststroke were identified from the register between January 1, 1995, and December 31, 1998. MEASUREMENTS: At 3 months, 105 patients were dead and 12 were lost to follow-up. The remaining patients were classified by continence status; those who had regained continence (n = 127) were compared with those who remained incontinent (n = 80) in terms of demographic details, stroke risk factors, premorbid disability, neurological impairments, and Oxfordshire Community Stroke Project stroke subtypes. Data at 3 months included disability using the modified Barthel Index (BI) (without its urinary continence component) and the Frenchay Activity Index (FAI), and institutionalization. RESULTS: Multivariate analysis showed being age 75 and older (odds ratio (OR) = 0.38; 95% confidence interval (CI) = 0.17-0.83) was associated with poor recovery from incontinence. Compared with subjects with total anterior circulatory infarctions, those with lacunar infarctions were more likely to regain continence (OR = 3.66; 95% CI =1.10-12.2), and compared with subjects with a BI between 0 and 14, those with a BI between 15 and 18 were also more likely to regain continence (OR = 21.8; 95% CI = 5.95-79.7). At 3 months, the incontinent group had greater institutionalization rates (27 (34%) vs 9 (7%), P <.001) and worse disability, measured with BI and FAI (BI: P <.001, FAI: P =.002). CONCLUSIONS: Age 75 and older is independently associated with poor recovery from poststroke urinary incontinence. Further clinical trials are required to explore underlying mechanisms and efficacy of possible interventions for this group of stroke survivors. Recovery from poststroke urinary incontinence should be a major goal of stroke professionals because it is associated with lower institutionalization rates and less disability at 3 months.

Aged↗
PubMed2001

Giant cell arteritis presenting with arm claudication.

CASE REPORT: A 72-year-old woman presented after a series of falls with a history of malaise, lethargy, cold hands and arm weakness for several months. She had undergone extensive investigation for what remained an unexplained anaemia during this period. Examination revealed cold hands with absent radial pulses. Axillary Doppler studies confirmed grossly diminished systolic pressures. The erythrocyte sedimentation rate was markedly elevated. An arch aortogram showed obliterative changes selectively affecting the subclavian and axillary arteries. In spite of clinically normal temporal arteries, and the absence of headache, temporal artery biopsy revealed giant cell arteritis. DISCUSSION: Aortic arch syndrome is an important but under-appreciated complication of giant cell arteritis and may be the presenting feature. In this case, it resulted in falls consequent upon arm claudication when using a walking frame.

Aged↗
PubMed2001

Does admission to hospital improve the outcome for stroke patients?

OBJECTIVES: to identify the factors associated with hospital admission and the differences in management and outcome of stroke patients between hospital and home. DESIGN: a prospective community stroke register (1995-8) with multiple notification sources. SETTING: an inner city multi-ethnic population of 234 533 in South London, UK. PARTICIPANTS: 975 subjects with first in a lifetime strokes, whether or not they were admitted to hospital. Patients dying suddenly and those already hospitalized at the time of stroke were excluded. MAIN OUTCOME MEASURES: factors associated with hospital admission; differences in management in the acute phase of stroke; mortality and dependency assessed by the Barthel index 3 months post-stroke. RESULTS: 812 patients were admitted to hospital for stroke; 163 were managed in the community. Factors independently associated with hospital admission included stroke severity, pre-stroke independence, atrial fibrillation, having an intracranial haemorrhage and having a non-lacunar infarction. Computed tomography scan rates were higher in admitted (78%) than non-admitted patients (63%; P=0.001). By 3 months, 285 (35%) of the admitted patients had died compared with 13 (8%) of non-admitted patients (P<0.001). Of the admitted patients, 241 (47%) had a Barthel index > or =18 compared with 106 (72%) of those who were not admitted (P<0.001). After adjusting for case-mix variables, the odds ratios for death and dependency (Barthel index<18) in admitted and non-admitted patients were 2.21 (0.96-5.12) and 2.39 (1.35-4.22) respectively. CONCLUSION: patients with clinical indicators for a more severe stroke were more likely to be admitted to hospital. Hospitalized stroke patients may have poorer survival and disability rates than those who remain at home, even after adjustment for case mix. There may be some aspects of acute hospital care that may be detrimental to outcome in certain groups of stroke patients. This requires further investigation.

Aged↗
PubMed2001

Management of acute physiological parameters after stroke.

Considerable effort has been directed towards acute stroke research with numerous drug therapies being tried and tested. As yet there is still no routine treatment that is unequivocally effective in acute stroke. The development of stroke units has been a major breakthrough in reducing disability through co-ordinated rehabilitation, and new interest is being focussed towards limiting acute neurological deterioration through acute stroke units. Monitoring and attempting to stabilize acute physiological parameters within normal limits such as blood pressure, temperature, hydration status, glucose levels and oxygen saturations, has become standard practice for some acute stroke units. Strategies to correct hypertension, hypotension, dehydration, hyperglycaemia, pyrexia and hypoxia may potentially reduce neuronal damage in the acute phase of stroke and subsequently improve functional outcome and survival. Whether we require large prospective randomized controlled trials to test whether these specific interventions are to be used in mainstay practice is unclear.

Aged↗