Farzaneh Harraf

A multicentre observational study of presentation and early assessment of acute stroke

Abstract Objective:To investigate delays in the presentation to hospital and evaluation of patients with suspected stroke. Design: Multicentre prospective observational study. Setting: 22 hospitals in the United Kingdom and Dublin. Participants: 739 patients with suspected stroke presenting to hospital. Main outcome measures: Time from onset of stroke symptoms to arrival at hospital, and time from arrival to evaluation by a senior doctor. Results: The median age of patients was 75 years, and 400 were women. The median delay between onset of symptoms and arrival at hospital was 6 hours (interquartile range 1 hour 48minutes to 19 hours 12 minutes). 37% of patients arrived within 3 hours, 50% within 6 hours. The median delay for patients using the emergency service was 2 hours 3 minutes (47 minutes to 7 hours 12 minutes) compared with 7 hours 12 minutes (2 hours 5 minutes to 20 hours 37 minutes) for referrals from general practitioners (P<0.0001). Use of emergency services reduced delays to hospital (odds ratio 0.45, 95% confidence interval 0.23 to 0.61). The median time to evaluation by a senior doctor was 1 hour 9 minutes (interquartile range 33 minutes to 1 hour 50 minutes) but was undertaken in only 477 (65%) patients within 3 hours of arrival. This was not influenced by age, sex, time of presentation, mode of referral, hospital type, or the presence of a stroke unit. Computed tomography was requested within 3 hours of arrival in 166 (22%) patients but undertaken in only 60 (8%). Conclusion: Delays in patients arriving at hospital with suspected stroke can be reduced by the increased use of emergency services. Over a third of patients arrive at hospital within three hours of stroke; their management can be improved by expediting medical evaluation and performing computed tomography early.

Can differences in management processes explain different outcomes between stroke unit and stroke-team care?

BACKGROUND Stroke units reduce mortality and dependence, but the reasons are unclear. We have compared differences in management and complications of patients with acute stroke who were admitted to a stroke unit or to a general ward as part of a previously reported randomised trial. METHODS 304 patients had been randomly assigned to stroke units (n=152) or to general wards supported by a specialist stroke team (152). We used a structured format to gather prospective data on the frequency of prespecified interventions in each of the major aspects of stroke care. Observations were undertaken daily for the first week and every week for the next 3 months by independent observers. The effect of differences in management on outcome at 3 months was assessed with the modified Rankin score, dichotomised to good (0-3) and poor (4-6) outcome. FINDINGS Patients in the stroke unit were monitored more frequently (odds ratio 2.1 [1.3-3.4]) and more patients received oxygen (2.0 [1.3-3.2]), antipyretics (6.4 [1.5-27.5]), measures to reduce aspiration (6.0 [2.3-15.5]), and early nutrition (14.4 [5.1-40.9]) than those in general wards. Complications were less frequent in patients in the stroke unit than those in general wards (0.6 [0.2-0.7]), with fewer patients having progression of stroke, chest infection, or dehydration. Measures to prevent aspiration, early feeding, stroke unit management, and frequency of complications independently affected outcome. INTERPRETATION Differences in management and complications between the stroke unit and general wards differ substantially, even when specialist support is provided. Such differences could be responsible for the more favourable outcome seen in patients on stroke units than those on general wards.

The economic burden of stroke in the United Kingdom.

AbstractAim: To estimate the cost of treating stroke in the UK. Methods: A cost-of-illness model was constructed to estimate stroke-related costs over a 5-year period. The cost estimates were based on data from a large, randomised, prospective study comparing alternative strategies of stroke care. The study collected detailed data on resource use in hospital, primary care, healthcare contacts, and utilisation of social services over a period of 1 year following stroke. A Markov framework was used to extrapolate 1-year costs over 5 years. Results: The model estimated that, for every patient who experiences a stroke, the cost to the NHS in the UK is £15 306 over 5 years and, when informal care costs are included, the amount increases to £29 405 (2001/2002 prices). The robustness of the cost findings was explored with the use of sensitivity analysis. This focused on the key variables of rates of recurrent stroke, the estimated acute costs, and costs attached to institution and home care. Conclusion: As well as being a considerable cause of morbidity and mortality, stroke is also a huge cost burden to both the UK’s NHS and the carers of stroke victims.

Abdominal muscle and quadriceps strength in chronic obstructive pulmonary disease

Background: Quadriceps muscle weakness is common in chronic obstructive pulmonary disease (COPD) but is not observed in a small hand muscle (adductor pollicis). Although this could be explained by reduced activity in the quadriceps, the observation could also be explained by anatomical location of the muscle or fibre type composition. However, the abdominal muscles are of a similar anatomical and fibre type distribution to the quadriceps, although they remain active in COPD. Cough gastric pressure is a recently described technique that assesses abdominal muscle (and hence expiratory muscle) strength more accurately than traditional techniques. A study was undertaken to test the hypothesis that more severe weakness exists in the quadriceps than in the abdominal muscles of patients with COPD compared with healthy elderly controls. Methods: Maximum cough gastric pressure and quadriceps isometric strength were measured in 43 patients with stable COPD and 25 healthy elderly volunteers matched for anthropometric variables. Results: Despite a significant reduction in mean quadriceps strength (29.9 kg v 41.2 kg; 95% CI −17.9 to −4.6; p = 0.001), cough gastric pressure was preserved in patients with COPD (227.3 cm H2O v 204.8 cm H2O; 95% CI −5.4 to 50.6; p = 0.11). Conclusions: Abdominal muscle strength is preserved in stable COPD outpatients in the presence of quadriceps weakness. This suggests that anatomical location and fibre type cannot explain quadriceps weakness in COPD. By inference, we conclude that disuse and consequent deconditioning are important factors in the development of quadriceps muscle weakness in COPD patients, or that activity protects the abdominal muscles from possible systemic myopathic processes.