Efficacy and tolerability of lifarizine in acute ischemic stroke. A pilot study. Lifarizine Study Group.
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Adult↗
Biomedical subjects
J Bamford
Publications and source records attributed to J Bamford.
Atrial fibrillation and stroke: prevalence in different types of stroke and influence on early and long term prognosis (Oxfordshire community stroke project)
OBJECTIVE: To determine in patients with first ever stroke whether atrial fibrillation influences clinical features, the need to perform computed tomography, and prognosis. DESIGN: Observational cohort study with maximum follow up of 6.5 years. SETTING: Primary care, based on 10 general practices in urban and rural Oxfordshire. SUBJECTS: Consecutive series of 675 patients with first ever stroke registered in the Oxfordshire community stroke project. MAIN OUTCOME MEASURES: Prevalence of atrial fibrillation by type of stroke; effect of atrial fibrillation on case fatality rate and risk of recurrent stroke, vascular death, and death from all causes. RESULTS: Prevalence of atrial fibrillation was 17% (95% confidence interval 14% to 20%) for all stroke types (115/675), 18% (15% to 21%) for cerebral infarction (97/545), 11% (4% to 11%) for primary intercerebral haemorrhage (7/66), and 0% (0 to 11%) for subarachnoid haemorrhage (0/33). For patients with cerebral infarction the 30 day case fatality rate was significantly higher with atrial fibrillation (23%) than with sinus rhythm (8%); the risk of early recurrent stroke (within 30 days) was 1% with atrial fibrillation and 4% with sinus rhythm. In patients who survived at least 30 days the average annual risk of recurrent stroke was 8.2% (5.9% to 10.9%) with sinus rhythm and 11% (6.0% to 17.3%) with atrial fibrillation. CONCLUSIONS: After a first stroke atrial fibrillation was not associated with a definite excess risk of recurrent stroke, either within 30 days or within the first few years. Survivors with and without atrial fibrillation had a clinically important absolute risk of further serious vascular events.
Aged↗
Clinical examination in diagnosis and subclassification of stroke.
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Cerebrovascular Disorders↗
Diurnal variation in incidence of stroke: Oxfordshire community stroke project.
OBJECTIVE: To determine whether diurnal variation occurs in the onset of stroke. DESIGN: Community based study over four years. SETTING: Oxfordshire, United Kingdom. SUBJECTS: 105,000 people, of whom 675 had a first ever stroke. 545 had a cerebral infarction, 66 had primary intracerebral haemorrhage, 33 had subarachnoid haemorrhage, and in 31 the type of stroke was not known. MAIN OUTCOME MEASURES: Time of stroke and degree of activity at onset. RESULTS: In the 578 patients for whom it was known whether onset occurred while asleep or awake, the proportion with onset during sleep was 25% (135/545) for cerebral infarction, 17% (11/66) for primary intracerebral haemorrhage, and 0% (0/33) for subarachnoid haemorrhage. This difference persisted if patients in whom it was not known whether they were asleep or awake at onset were classed as asleep. For all stroke types together there was a significant (chi 2 = 218.7, p less than 0.001) diurnal variation with a morning peak between 0800 and 1000, which persisted even after allowing for strokes first noted on waking by redistributing the hour of onset through the preceding eight hours (chi 2 = 47, p less than 0.001). A significant diurnal variation was also found in the onset of cerebral infarction (peak 0800-1000, chi 2 = 208.4, p less than 0.001). Fewer patients had other forms of stroke and the diurnal variations for primary intracerebral haemorrhage (peak 1000-1200) and subarachnoid haemorrhage (peaks 0800-1000 and 1800-2000) were not significant. There seemed to be a second smaller peak for all types of stroke. CONCLUSIONS: All types of stroke are most likely to occur after waking in the morning. The cause of the circadian variation requires further study.
Cerebral Hemorrhage↗
Classification and natural history of clinically identifiable subtypes of cerebral infarction.
We describe the incidence and natural history of four clinically identifiable subgroups of cerebral infarction in a community-based study of 675 patients with first-ever stroke. Of 543 patients with a cerebral infarct, 92 (17%) had large anterior circulation infarcts with both cortical and subcortical involvement (total anterior circulation infarcts, TACI); 185 (34%) had more restricted and predominantly cortical infarcts (partial anterior circulation infarcts, PACI); 129 (24%) had infarcts clearly associated with the vertebrobasilar arterial territory (posterior circulation infarcts, POCI); and 137 (25%) had infarcts confined to the territory of the deep perforating arteries (lacunar infarcts, LACI). There were striking differences in natural history between the groups. The TACI group had a negligible chance of good functional outcome and mortality was high. More than twice as many deaths were due to the complications of immobility than to direct neurological sequelae of the infarct. Patients in the PACI group were much more likely to have an early recurrent stroke than were patients in other groups. Those in the POCI group were at greater risk of a recurrent stroke later in the first year after the index event but had the best chance of a good functional outcome. Despite the small anatomical size of the infarcts in the LACI group, many patients remained substantially handicapped. The findings have important implications for the planning of stroke treatment trials and suggest that various therapies could be directed specifically at the subgroups.
Age Factors↗
How often is non-valvular atrial fibrillation the cause of brain infarction?
To calculate how often non-valvular atrial fibrillation should be considered as the cause of ischaemic stroke rather than an incidental finding as in primary cerebral haemorrhage, the frequency of non-valvular atrial fibrillation in 75 consecutive patients with primary intracerebral haemorrhage was compared with that in 63 patients with cortical infarcts and 44 patients with lacunar infarcts who were taken at random from 1487 consecutive patients with cerebral infarcts admitted during the same period. The frequency of non-valvular atrial fibrillation in lacunar infarcts did not differ from that in primary intracerebral haemorrhage (odds ratio: 1.28; 95% confidence interval: 0.32-5.1) (P = 1.0), whereas it was significantly higher in cortical infarcts (odds ratio: 5.57; 95% confidence interval 2.00-15.4) (P = 0.0001). Our findings suggest that non-valvular atrial fibrillation in lacunar infarcts, as in primary intracerebral haemorrhage, is unlikely to be the cause of this type of stroke, whereas perhaps 30% of all cortical infarcts are not caused by non-valvular atrial fibrillation when present. These data are important for the planning and explanatory evaluation of trials on the preventive effect of anticoagulants in stroke patients with non-valvular atrial fibrillation.
Aged↗
Computed tomography in patients with transient ischaemic attacks: when is a transient ischaemic attack not a transient ischaemic attack but a stroke?
In a prospective community-based study, 184 patients with transient ischaemic attacks (TIAs) were identified from a study population of about 105,000 between 1981 and 1986. Computed tomography (CT) was attempted in all those with cerebral ischaemic attacks (n = 152, 83%); patients with amaurosis fugax only (n = 32, 27%) were not scanned routinely. Scans were obtained in 120 (79%) of those with cerebral attacks and 12 (38%) of those with amaurosis fugax. The scans were reported by a neuroradiologist who was blinded to the patients' clinical features. Of 120 (27%:95% confidence interval 19-35) scans in patients with cerebral attacks, 32 showed a focal area of hypodensity or cortical loss, but in only 14 (12%:95% confidence interval 6-18) was this in an area of the brain appropriate to the patients' symptoms. There were no significant differences in the clinical features, the duration of attacks or the prognosis (i.e., risk of death, stroke or myocardial infarction) of patients with and without ischaemic lesions on CT. It is concluded that patients with clinically definite TIAs who have a presumed ischaemic and appropriately sited lesion on CT should not be re-classified as having had a stroke.
Aged↗
Mood disorders in long-term survivors of stroke: associations with brain lesion location and volume.
Sixty surviving patients from a community-based stroke register who had CT scan evidence of a single brain lesion and neurological signs appropriate to it were interviewed three to five years following their first-ever stroke. Mood disorder (anxiety and depression), physical disability, and intellectual impairment were assessed using standardized measures. The position and volume of the brain lesion was determined from CT scans performed soon after the stroke. The prevalence of depressive disorder was lower in this sample than that reported in previous studies (DSM-IIIR major depression 8.3%; all DSM-IIIR depressive disorders 18.3%). Reports by other workers for an association of depressive disorder either with left-sided brain lesions, or with anteriorly placed lesions in the left cerebral hemisphere, were not supported. Neither was there evidence of a correlation between symptom score and proximity of the lesion to the anterior pole of the left cerebral hemisphere. Psychiatric symptom scores were however greater with larger volume brain lesions. Anxiety disorders, especially agoraphobia, were relatively common (20% if diagnosed in the presence of depressive disorder), but were not related to lesion location or volume.
Activities of Daily Living↗
A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project--1981-86. 2. Incidence, case fatality rates and overall outcome at one year of cerebral infarction, primary intracerebral and subarachnoid haemorrhage.
The age and sex specific incidence rates for cerebral infarction, primary intracerebral haemorrhage and subarachnoid haemorrhage in a population of approximately 105,000 are presented. Over four years 675 patients with a first-ever stroke were registered with the Oxfordshire Community Stroke Project. The pathological diagnosis was confirmed by computerised tomography (CT) scan, necropsy or lumbar puncture (cases of subarachnoid haemorrhage only) in 78% of cases and a further 17% were diagnosed according to the Guy's Hospital Stroke Diagnostic Score. The proportion of all first-ever strokes by pathological type was: cerebral infarction 81% (95% confidence interval 78-84), primary intracerebral haemorrhage 10% (8-12), subarachnoid haemorrhage 5% (3-7) and uncertain type 5% (3-7). These proportions are similar to other community-based studies. The overall 30 day case fatality rate was 19% (16-22), that for cerebral infarction being 10% (7-13), primary intracerebral haemorrhage 50% (38-62) and subarachnoid haemorrhage 46% (29-63). One year post stroke 23% (19-27) with cerebral infarction were dead and 65% (60-70) of survivors were functionally independent. The figures for primary intracerebral haemorrhage were 62% (43-81) dead and 68% (50-86) of survivors functionally independent and for subarachnoid haemorrhage were 48% (24-72) dead and 76% (56-96) of survivors functionally independent. There are important differences between these rates and those from other sources possibly due to more complete case ascertainment in our study. Nevertheless, the generally more optimistic early prognosis in our study, particularly for cases of cerebral infarction, has important implications for the planning of clinical trials and for the expected impact that any treatment might have on the general population.
Adolescent↗
The frequency, causes and timing of death within 30 days of a first stroke: the Oxfordshire Community Stroke Project.
In a prospective, community-based study of 675 consecutive patients with a first-ever stroke, of whom over 90% had computed tomography (CT) and/or necropsy examinations, 129 deaths occurred within 30 days of the onset of symptoms, a case fatality rate (CFR) of 19%. The 30 day CFR for patients with cerebral infarction was 10% (57 of 545, for primary intracerebral haemorrhage 52% (34 of 66), for subarachnoid haemorrhage 45% (15 of 33) and for those of uncertain pathological type 74% (23 of 31). The CFR for patients who had been functionally dependent pre-stroke was 33% compared with 17% for those who had been independent pre-stroke. The age-adjusted relative risk of death for patients who had been functionally dependent pre-stroke was not significantly greater (1.8, 95% confidence interval 0 to 4.3). There was a significant trend for CFR to increase with age (Chi square for trend = 4.0, p less than 0.05). This relationship was found in those patients who had been functionally independent prestroke (Chi square for trend = 7.9, p less than 0.005) but not in those who had been dependent pre-stroke (Chi square for trend = 0.5, NS). The pattern of increasing CFR with increasing age amongst those who had been independent prestroke was seen particularly in patients with cerebral infarction (Chi square for trend = 8.6, p less than 0.005). The age-adjusted relative risk of death for patients with cerebral infarction who had been functionally dependent pre-stroke was 2.2 (95% confidence interval 1.2 to 4.1). Fifty three percent of all deaths within 30 days of stroke were due to the direct neurological sequelae of the stroke. Patients with primary intracerebral or subarachnoid haemorrhages were significantly more likely to die in this way than those with cerebral infarction (relative risk 4.1; 95% confidence interval 3.4-4.9) and 56% of such deaths occurred within 72 hours of onset. In patients with cerebral infarction, 51% of deaths were due to complications of immobility (for example, pneumonia, pulmonary embolism) and these were more likely to occur after the first week. These findings have implications for clinical practice and the planning of clinical trials.
Aged↗
The lacunar hypothesis.
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Brain Ischemia↗
Prognosis of transient ischemic attacks in the Oxfordshire Community Stroke Project.
In a community-based study of approximately 105,000 people, 184 presented with a transient ischemic attack during the 5 years between 1981 and 1986; we believe these persons represent almost all new cases of transient ischemic attack going to a doctor during that period. During a mean follow-up of 3.7 years 49 patients died, 45 had a first-ever stroke, and 17 had a myocardial infarction. Cardiac disease accounted for 17 (35%) deaths, while stroke was the cause of death in 15 patients (31%). The average actuarial risk of death was approximately 6.3%/yr, slightly greater than that expected for similar people without transient ischemic attacks (risk ratio [observed divided by expected] = 1.4). The actuarial risk of stroke was 11.6% during the first year after a transient ischemic attack and approximately 5.9%/yr over the first 5 years. Patients who suffered a transient ischemic attack had a 13-fold excess risk of stroke during the first year and a sevenfold excess risk over the first 7 years compared with people without transient ischemic attacks. The actuarial risk of death, stroke, or myocardial infarction over the first 5 years after a transient ischemic attack was approximately 8.4%/yr. The prognosis in this community-based cohort was better than that in previous reports. The high early risk of stroke means that investigation and treatment of new cases should commence as soon as possible.
Cerebrovascular Disorders↗
Projecting the number of patients with first ever strokes and patients newly handicapped by stroke in England and Wales.
The common assumption that future increases in the number of elderly people will result in a parallel increase in the burden of care of long term disabled survivors of stroke was examined. The number of patients with first ever strokes and the net number of people handicapped after these strokes in England and Wales every five years until 2023 have been projected. Between the base year 1983 and the year 2023 an increase in population of about 5% will occur; first ever strokes are projected to increase by about 30% and deaths within six months of first ever strokes by about 40%. The net number of severely handicapped people six months after a first ever stroke is projected to increase by only about 8%, however, and the net number of people who are moderately or severely handicapped by only 4%. This paradox occurs because first ever stroke often kills people who have been handicapped by other causes, particularly if they are elderly. It is concluded that despite the limitations of these data they strongly suggest that the increased burden of health care of patients with first ever strokes in the next 40 years will be primarily that of caring for those in the acute stages of stroke and not with the management of chronic handicap after a stroke.
Age Factors↗
Hypertension and asthma: psychological aspects.
Essential hypertensive and asthmatic patients, plus normal non-clinical controls, were compared on a number of psychological measures in order to identify the relationship between psychological distress, coping strategies and compliance behaviour. The hypothesised relationship between chronic clinical ailments and psychological distress was confirmed. The association between the presence of physical symptoms in the symptomatic condition, asthma, and greater psychological distress was also confirmed. The coping strategies adopted by the patients did not discriminate between the two clinical groups. Compliance with medication was negatively correlated with measures of psychological distress. Compliance with an appropriate healthy lifestyle was not correlated with medication compliance, although it too was negatively correlated with other measures of psychological distress.
Adaptation, Psychological↗
Rust remover rash.
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Dermatitis, Contact↗
A comparative evaluation of four hearing aid selection procedures. I--Speech discrimination measures of benefit.
Speech discrimination measures of the benefit provided by four different hearing-aid selection procedures were determined on a group of experienced hearing-aid users. The results revealed that the advantages of prescriptive methods of selection (specifically the procedures of Berger et al., and of Byrne and Tonisson) over intuitive fitting (using an experience clinician) or 'fixed' selection (+ 6 dB/octave frequency response slope) are substantial in some circumstances. The effect of selection procedure on benefit was little influenced by degree of hearing loss but considerably influenced by configuration of loss (flat, sloping or irregular). For patients with gently to steeply sloping losses, the prescriptive methods of selection were shown to provide more benefit than the other methods studied.
Aged↗
A comparative evaluation of four hearing-aid selection procedures. II--Quality judgements as measures of benefit.
Quality judgements by hearing-aid wearers were used to compare hearing-aid frequency responses selected by four different aid selection procedures: the methods of Berger et al. and Byrne and Tonisson, 'intuitive' fitting by an experienced clinician, and a fixed frequency response of + 6 dB/octave. A previous study had demonstrated that the two 'prescription' methods (of Berger et al. and Byrne and Tonisson) showed greater benefit as measured by speech discrimination tests, particularly for patients with sloping audiograms. The results of this study indicated that quality judgements did not appear to be significantly influenced by the fitting procedure used. The only significant factor was the order in which the patients listened to the hearing aids. The second aid was always preferred. This finding was confirmed by a second study in which the only experimental variable was order. Again the second aid was preferred. The implications of this finding for clinical hearing-aid evaluation are discussed.
Aged↗
A new method for random mutagenesis of complete genes: enzymatic generation of mutant libraries in vitro.
A new efficient in vitro mutagenesis method for the generation of complete random mutant libraries, containing all possible single base substitution mutations in a cloned gene is described. The method is based on controlled use of polymerases. Four populations of DNA molecules are first generated by primer elongation so that they terminate randomly, but always just before a known type of base (before A, C, G or T respectively). Each of the four populations is then mutagenized in a separate misincorporation reaction, where the correct base can now be omitted. The regeneration of wild-type sequences can thus be efficiently avoided. Also, the misincorporating nucleotide concentrations can be optimized to give the three possible single mutations in close to equal ratio. The mutagenesis can be precisely localized within a predetermined target region of any size, and vector sequences remain intact. We have mutagenized the DNA coding for the alpha-fragment of Escherichia coli beta-galactosidase, and identified 176 different base substitution mutations by sequencing. The present method gives mutant yields of 40-60%, when the mutants contain about one amino acid change per protein molecule. All types of base substitution mutations can be generated and deletions are rare. The efficiency of this method permits the use of relatively elaborate screening systems to isolate mutants of either structural genes or regulatory regions.
Amino Acid Sequence↗