Anthony Rudd

Sex Differences in the Clinical Presentation, Resource Use, and 3-Month Outcome of Acute Stroke in Europe: Data From a Multicenter Multinational Hospital-Based Registry

Background and Purpose— The information on the existence of sex differences in management of stroke patients is scarce. We evaluated whether sex differences may influence clinical presentation, resource use, and outcome of stroke in a European multicenter study. Methods— In a European Concerted Action involving 7 countries, 4499 patients hospitalized for first-in-a-lifetime stroke were evaluated for demographics, risk factors, clinical presentation, resource use, and 3-month survival, disability (Barthel Index), and handicap (Rankin Scale). Results— Overall, 2239 patients were males and 2260 females. Compared with males, female patients were significantly older (mean age 74.5±12.5 versus 69.2±12.1 years), more frequently institutionalized before stroke, and with a worse prestroke Rankin score (all values P <0.001). History of hypertension (P =0.007) and atrial fibrillation (P <0.001) were significantly more frequent in female stroke patients, as were coma (P <0.001), paralysis (P <0.001), aphasia (P =0.001), swallowing problems (P =0.005), and urinary incontinence (P <0.001) in the acute phase. Brain imaging, Doppler examination, echocardiogram, and angiography were significantly less frequently performed in female than male patients (all values P <0.001). The frequency of carotid surgery was also significantly lower in female patients (P <0.001). At the 3-month follow-up, after controlling for all baseline and clinical variables, female sex was a significant predictor of disability (odds ratio [OR], 1.41; 95% CI 1.10 to 1.81) and handicap (OR, 1.46; 95% CI 1.14 to 1.86). No significant gender effect was observed on 3-month survival. Conclusions— Sex-specific differences existed in a large European study of hospital admissions for acute stroke. Both medical and sociodemographic factors may significantly influence stroke outcome. Knowledge of these determinants may positively impact quality of care.

Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial.

Summary Background Deep vein thrombosis (DVT) and pulmonary embolism are common after stroke. In small trials of patients undergoing surgery, graduated compression stockings (GCS) reduce the risk of DVT. National stroke guidelines extrapolating from these trials recommend their use in patients with stroke despite insufficient evidence. We assessed the effectiveness of thigh-length GCS to reduce DVT after stroke. Methods In this outcome-blinded, randomised controlled trial, 2518 patients who were admitted to hospital within 1 week of an acute stroke and who were immobile were enrolled from 64 centres in the UK, Italy, and Australia. Patients were allocated via a central randomisation system to routine care plus thigh-length GCS (n=1256) or to routine care plus avoidance of GCS (n=1262). A technician who was blinded to treatment allocation undertook compression Doppler ultrasound of both legs at about 7–10 days and, when practical, again at 25–30 days after enrolment. The primary outcome was the occurrence of symptomatic or asymptomatic DVT in the popliteal or femoral veins. Analyses were by intention to treat. This study is registered, number ISRCTN28163533. Findings All patients were included in the analyses. The primary outcome occurred in 126 (10·0%) patients allocated to thigh-length GCS and in 133 (10·5%) allocated to avoid GCS, resulting in a non-significant absolute reduction in risk of 0·5% (95% CI −1·9% to 2·9%). Skin breaks, ulcers, blisters, and skin necrosis were significantly more common in patients allocated to GCS than in those allocated to avoid their use (64 [5%] vs 16 [1%]; odds ratio 4·18, 95% CI 2·40–7·27). Interpretation These data do not lend support to the use of thigh-length GCS in patients admitted to hospital with acute stroke. National guidelines for stroke might need to be revised on the basis of these results. Funding Medical Research Council (UK), Chief Scientist Office of Scottish Government, Chest Heart and Stroke Scotland, Tyco Healthcare (Covidien) USA, and UK Stroke Research Network.

Estimates of the Prevalence of Acute Stroke Impairments and Disability in a Multiethnic Population

Background and Purpose— The goals of the present study were to estimate the prevalence of acute impairments and disability in a multiethnic population of first-ever stroke and to identify differences in impairment and early disability between pathological and Bamford subtypes. Associations between impairments and death and disability at 3 months were identifed. Methods— Impairments that occur at the time of maximum neurological deficit were recorded, and disability according to the Barthel Index (BI) was assessed 1 week and 3 months after stroke in patients in the South London Stroke Register. Results— Of 1259 registered patients, 6% had 1 or 2, 31.1% had 3 to 5, 50.6% had 6 to 10, and 10.6% had >10 impairments. Common impairments were weakness (upper limb, 77.4%), urinary incontinence (48.2%), impaired consciousness (44.7%), dysphagia (44.7%), and impaired cognition (43.9%). Patients with total anterior circulation infarcts had the highest age-adjusted prevalence of weakness, dysphagia, urinary incontinence, cognitive impairment, and disability. Patients with subarachnoid hemorrhage had the highest rates of coma. Patients with lacunar stroke had the high prevalence of weakness but were least affected by disability, incontinence, and cognitive dysfunction. Blacks had higher age- and sex-adjusted rates of disability in ischemic stroke (BI <20, odds ratio 2.76, 95% CI 1.47 to 5.21, P =0.002; BI <15, odds ratio 1.8, 95% CI 1.45 to 2.81, P =0.01) but impairment rates similar to those of whites. On multivariable analysis, incontinence, coma, dysphagia, cognitive impairment, and gaze paresis were independently associated with severe disability (BI <10) and death at 3 months. Conclusions— The extent of these findings indicates that an acute assessment of impairments and disability is necessary to determine the appropriate nursing and rehabilitation needs of patients with stroke.

Qualitative analysis of stroke patients' motivation for rehabilitation

Abstract Objective: To explore the attitudes and beliefs of stroke patients identified by professionals as having either “high” or “low” motivation for rehabilitation. Design: Qualitative study with semistructured interviews. Setting: The stroke unit of an inner city teaching hospital. Participants: 22 patients with stroke who were undergoing rehabilitation; 14 with high motivation for rehabilitation and eight with low motivation. Results: All patients thought rehabilitation was important for recovery. High motivation patients were more likely to view rehabilitation as the most important means of recovery and to accord themselves an active role in rehabilitation. These patients were also more likely to understand rehabilitation and in particular to understand the specialist role of the nursing staff. Many patients reported independence at home as a personal goal, though few low motivation patients related this goal to success in rehabilitation. Information from professionals about rehabilitation, favourable comparisons with other stroke patients, and the desire to leave hospital had a positive effect on motivation. Conversely, overprotection from family members and professionals, lack of information or the receipt of “mixed messages” from professionals, and unfavourable comparisons with other patients had a negative effect. Conclusions: There are some differences in beliefs between stroke patients identified as having low or high motivation for rehabilitation. These beliefs seem to be influenced by the environment in which the patient is rehabilitated. Professionals and carers should be made aware of the ways in which their behaviour can positively and negatively affect motivation.

Ethnic differences in incidence of stroke: prospective study with stroke register

Abstract Objective: To identify ethnic differences in the incidence of first ever stroke. Design: A prospective community stroke register (1995-6) with multiple notification sources. Pathological classification of stroke in all cases was based on brain imaging or necropsy data. Rates were standardised to European and world populations and adjusted for age, sex, and social class in multivariate analysis. Setting: A multi-ethnic population of 234 533 in south London, of whom 21% are black. Results:612 strokes were registered. The crude annual incidence rate was 1.3 strokes per 1000 population per year (95% confidence interval 1.20 to 1.41) and 1.25 per 1000 population per year(1.15 to 1.35) age adjusted to the standard European population. Incidence rates adjusted for age and sex were significantly higher in black compared with white people (P<0.0001), with an incidence rate ratio of 2.21 (1.77 to 2.76). In multivariable analysis increasing age(P<0.0001), male sex (P<0.003), black ethnic group (P<0.0001), and lower social class (P<0.0001) in people aged 35-64 were independently associated with an increased incidence of stroke. Conclusions:Incidence rates of stroke are higher in the black population; this is not explained by confounders such as social class, age, and sex. Ethnic differences in genetic, physiological, and behavioural risk factors for stroke require further elucidation to aid development of effective strategies for stroke prevention in multi-ethnic communities.

A Long-term Follow-up of Stroke Patients

BACKGROUND AND PURPOSE Two hundred ninety-one residents of southeast London, younger than 75 years, suffered their first stroke in 1989/1990. The objectives of this study were to determine the long-term outcome of this cohort of stroke patients in terms of impairment, disability, handicap, and quality of life and their use of services and prevention measures subsequent to their stroke. METHODS The survivors and their identified caregivers were traced and completed a structured interview questionnaire that included the Barthel Index, modified Rankin Scale, Hospital Anxiety and Depression Scale (HAD), Mini-Mental State Examination, Frenchay Activities Index, and Caregiver Strain Index. RESULTS One hundred twenty-three people (42%) were alive, of whom 106 were interviewed. The mean interval between the stroke and the long-term follow-up was 4.9 years. Thirty-one of the survivors (29%) were severely or moderately disabled, 39 (37%) were mildly disabled, and 36 (34%) were functionally independent. Of the 96 people who completed the HAD, 35 (36%) had scores suggesting that they were depressed or had borderline depression. The most likely nontherapy services to have been provided were chiropody and district nursing. Five people had received respite care. Of the 104 subjects for whom information about their home was available, 53 (51%) had had an adaptation. Seventy-five people (71%) had an aid or appliance. Sixty-five people (61%) were on aspirin, and an additional 14 (13%) were on warfarin. Fifty subjects (47%) identified a main caregiver. No one with a moderate or more severe disability was living at home without an identified caregiver. CONCLUSIONS The levels of both health and social service provision are likely to be inadequate for this population. The use of prevention measures is encouraging. There is a clear need for a coordinated policy to guide assessment and management across sectors.

Socioeconomic status and stroke

This paper reviews the current evidence for the association between socioeconomic status and stroke incidence, survival, mortality, and other outcomes. The evidence is strongest for mortality and incidence of stroke, with high rates of stroke in low socioeconomic groups being a consistent finding. Low socioeconomic groups also have lower survival and greater stroke severity than high socioeconomic groups, although there is less evidence for this association. The mechanisms through which socioeconomic status affects stroke risk and outcomes are unclear but some studies report that differences in risk-factor prevalence could account for some of the variation. We discuss the implications of these findings and make recommendations for future research. Studies using prospective population-based methods with improved control for confounding factors are needed to confirm or refute these associations. Understanding the causal associations between socioeconomic status and stroke will allow interventions to be appropriately targeted and assessed.

Natural history, predictors and outcomes of depression after stroke: systematic review and meta-analysis.

BACKGROUND Depression after stroke is a distressing problem that may be associated with other negative health outcomes. AIMS To estimate the natural history, predictors and outcomes of depression after stroke. METHOD Studies published up to 31 August 2011 were searched and reviewed according to accepted criteria. RESULTS Out of 13 558 references initially found, 50 studies were included. Prevalence of depression was 29% (95% CI 25-32), and remains stable up to 10 years after stroke, with a cumulative incidence of 39-52% within 5 years of stroke. The rate of recovery from depression among patients depressed a few months after stroke ranged from 15 to 57% 1 year after stroke. Major predictors of depression are disability, depression pre-stroke, cognitive impairment, stroke severity and anxiety. Lower quality of life, mortality and disability are independent outcomes of depression after stroke. CONCLUSION Interventions for depression and its potential outcomes are required.

Cognitive impairment after stroke: clinical determinants and its associations with long-term stroke outcomes.

OBJECTIVES: To identify factors that were associated with cognitive impairment 3 months after stroke, and to examine the associations of cognitive impairment with stroke outcomes up to 4 years after stroke.

Early supported discharge services for stroke patients: a meta-analysis of individual patients' data

BACKGROUND Stroke patients conventionally undergo a substantial part of their rehabilitation in hospital. Services have been developed that offer patients early discharge from hospital with rehabilitation at home (early supported discharge [ESD]). We have assessed the effects and costs of such services. METHODS We did a meta-analysis of data from individual patients who took part in randomised trials that recruited patients with stroke in hospital to receive either conventional care or any ESD service intervention that provided rehabilitation and support in a community setting with the aim of shortening the duration of hospital care. The primary outcome was death or dependency at the end of scheduled follow-up. FINDINGS Outcome data were available for 11 trials (1597 patients). ESD services were mostly provided by specialist multidisciplinary teams to a selected group (median 41%) of stroke patients admitted to hospital. There was a reduced risk of death or dependency equivalent to six (95% CI one to ten) fewer adverse outcomes for every 100 patients receiving an ESD service (p=0.02). The hospital stay was 8 days shorter for patients assigned ESD services than for those assigned conventional care (p<0.0001). There were also significant improvements in scores on the extended activities of daily living scale and in the odds of living at home and reporting satisfaction with services. The greatest benefits were seen in the trials evaluating a coordinated multidisciplinary ESD team and in stroke patients with mild to moderate disability. INTERPRETATION Appropriately resourced ESD services provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as shortening hospital stays.