Heather Rigby

A systematic review of caregiver burden following stroke

Caregiver burden following stroke is increasingly recognised as a significant health care concern. A growing number of studies have evaluated the patient, caregiver, and social support factors that contribute to increased caregiver burden. We conducted a systematic review of this literature to guide future research. A search of the MEDLINE, PsyclNFO, CINAHL, and EMBASE databases (up to July 2008) and reference sections of published studies using a structured search strategy yielded 24 relevant articles. Studies were included if they evaluated predictors and/or correlates of caregiver burden in the setting of stroke. The prevalence of caregiver burden was 25–54% and remained elevated for an indefinite period following stroke. In studies that evaluated independent baseline predictors of subsequent caregiver burden, none of the factors reported were consistent across studies. In studies that assessed concurrent factors independently contributing to caregiver burden in the poststroke period, patient characteristics and social support factors were inconsistently reported. Several studies identified caregiver mental health and the amount of time and effort required of the caregiver as significant determinants of caregiver burden. Our findings highlight the need for more research to identify caregivers in need of support and guide the development and implementation of appropriate interventions to offset caregiver burden.

Caring for Stroke Survivors: Baseline and 1-Year Determinants of Caregiver Burden

Background Caregiver burden following stroke can have significant adverse health consequences for caregivers and threatens the recovery and successful rehabilitation of patients. Our objective was to identify patient factors that contribute to higher levels of caregiver burden. Methods We prospectively studied patients admitted to our stroke unit over a 2-year period (2001-2002). Data were collected at baseline and at 1 year. Caregiver burden was measured at 1 year using the Relatives Stress Scale (completed by 155 caregivers) and the Bakas Caregiver Outcomes Scale (143 caregivers). Explanatory patient factors at baseline included sociodemographic status, stroke severity, stroke sub-type, functional disability (Barthel Index), functional handicap (Oxford Handicap Scale and Modified Rankin Scale), and cognitive status (orientation, clock drawing). At 1 year, mental health and health-related quality of life were assessed using the Fatigue Impact Scale, Geriatric Depression Scale, Global Deterioration Scale, and 36-item Short Form Health Survey. Results The baseline patient factors predictive of caregiver burden by multiple regression analysis were older patient age (P<0·01), male gender (P<0·05), ischemic stroke (P<0·05), urinary incontinence (P<0·0001), and impaired clock drawing (P<0·05). At 1 year, significant correlates of caregiver burden were older patient age (P<0·05), male gender (P<0·01), poor mental health (P<0·05), functional handicap (P<0·05), and functional disability (P<0·001). Conclusions The functional status of patients can be used to identify caregivers at risk of caregiver burden. Patient demographic variables, cognitive function, and mental health status may further expose vulnerable caregivers. These factors should be considered in the development of strategies to offset caregiver burden.

Lack of response of a metastatic renal perivascular epithelial cell tumor (PEComa) to successive courses of DTIC based‐therapy and imatinib mesylate

An 11 year‐old girl presented with two large abdominal masses in the left flank and epigastrium and left supraclavicular lymphadenopathy. Subsequent investigations led to the diagnosis of metastatic perivascular epithelioid cell tumor (PEComa) arising from the left kidney. Effective treatment for this rare tumor is not yet known. The tumor did not respond to an initial treatment of two cycles of a dacarbazine (DTIC) based regimen. She was placed on a trial of imatinib mesylate based on tumor expression of c‐KIT, a tyrosine kinase targeted by this drug. This report highlights the first documented case of the use of imatinib for PEComa. Lack of response and adverse effects of the drug required discontinuation of therapy.

Amyloid β-related Angiitis of the Central Nervous System: Report of 3 Cases

OBJECTIVE Amyloid-β (Aβ) related angiitis (ABRA) is a recently described clinicopathological entity characterized by cerebrovascular Aβ deposition and arteritis. Cerebral Aβ deposition is commonly present in cerebal amyloid angiopathy (CAA) and Alzheimers disease (AD) but is rarely associated with inflammatory infiltration of vessel walls. Our objective is to help clarify the clinical spectrum, radiographic findings, response to treatment, and outcomes of ABRA. The neuropathological relationship between ABRA, cerebral amyloid angiopathy, and Alzheimers disease is discussed. METHODS We present three cases of ABRA managed at a tertiary care centre. RESULTS All three patients presented with seizures and cognitive dysfunction; one had multifocal neurologic findings. Brain biopsies revealed inflammatory arteritis with Aβ deposits in the vessel walls. All were treated with steroids and cyclophosphamide. Two had favorable outcomes and one stabilized but with severe residual neurologic disability. CONCLUSIONS ABRA is an unusual but likely under-recognized and potentially treatable disorder. As in other reported cases, our findings suggest that many patients respond favorably to immunosuppressive therapy. We believe that all biopsy specimens consistent with primary angiitis of the central nervous system (CNS) should be further examined for vascular Aβ deposition.

Abnormal visual contrast acuity in Parkinson's disease.

BACKGROUND Low-contrast vision is thought to be reduced in Parkinsons disease (PD). This may have a direct impact on quality of life such as driving, using tools, finding objects, and mobility in low-light condition. Low-contrast letter acuity testing has been successful in assessing low-contrast vision in multiple sclerosis. We report the use of a new iPad application to measure low-contrast acuity in patients with PD. OBJECTIVE To evaluate low- and high-contrast letter acuity in PD patients and controls using a variable contrast acuity eye chart developed for the Apple iPad. METHODS Thirty-two PD and 71 control subjects were studied. Subjects viewed the Variable Contrast Acuity Chart on an iPad with both eyes open at two distances (40 cm and 2 m) and at high contrast (black and white visual acuity) and 2.5% low contrast. Acuity scores for the two groups were compared. RESULTS PD patients had significantly lower scores (indicating worse vision) for 2.5% low contrast at both distances and for high contrast at 2 m (p < 0.003) compared to controls. No significant difference was found between the two groups for high contrast at 40 cm (p = 0.12). CONCLUSIONS Parkinsons disease patients have reduced low and high contrast acuity compared to controls. An iPad app, as used in this study, could serve as a quick screening tool to complement more formal testing of patients with PD and other neurologic disorders.

Routine Surveillance for Bloodstream Infections in a Pediatric Hematopoietic Stem Cell Transplant Cohort: Do Patients Benefit?

BACKGROUND Hematopoietic stem cell transplant (HSCT) recipients are at a high risk for late bloodstream infection (BSI). Controversy exists regarding the benefit of surveillance blood cultures in this immunosuppressed population. Despite the common use of this practice, the practical value is not well established in non-neutropenic children following HSCT. METHODS At the IWK Health Centre (Halifax, Nova Scotia), weekly surveillance blood cultures from central lines are drawn from children following HSCT until the line is removed. A retrospective chart review was performed to determine the utility and cost of this practice. Eligible participants were non-neutropenic HSCT recipients with central venous access lines. The cost of laboratory investigations, nursing time, hospital stay and interventions for positive surveillance cultures was calculated. RESULTS Forty-three HSCTs were performed in 41 children. Donors were allogenic in 33 cases (77%) and autologous in 10 cases (23%). There were 316 patient contacts for surveillance cultures (mean seven per patient) and 577 central line lumens sampled. Three of 43 patients (7%) had clinically significant positive surveillance blood cultures. Bacteria isolated were Klebsiella pneumoniae (n=2) and Corynebacterium jeikeium (n=1). All follow-up cultures before initiation of antimicrobial therapy were sterile. All three patients were admitted for antimicrobial therapy if they were not already hospitalized and/or had an uncomplicated course. The estimated total cost of BSI surveillance and management of asymptomatic infection over six years was

Longitudinal neuropsychological findings in amyloid beta-related angiitis (AβRA): A case report

27,989. CONCLUSION The present study suggests that BSI surveillance in children following HSCT engraftment has a very low yield and significant cost. It is unclear whether it contributes to improved patient outcomes.

Orthostatic Tremor: A Spectrum of Fast and Slow Frequencies or Distinct Entities?

Amyloid β-related angiitis (AβRA) is a clinicopathological diagnosis of primary central nervous system angiitis theoretically triggered by vascular deposition of amyloid β peptide. Deposits of Aβ are associated with degeneration of the vasculature, thereby increasing risks of a stroke and/or cognitive impairment. Despite this, no prior studies have presented a detailed neuropsychological profile associated with AβRA. We present longitudinal neuropsychological findings for the case of a 58-year-old man with biopsy-diagnosed AβRA. Neuropsychological test results and clinical presentation demonstrated a mild to moderate dysexecutive syndrome implicating dorsolateral frontal and orbitofrontal-subcortical systems involvement. Despite prior reports of cognitive decline following a diagnosis of AβRA, cognitive functioning remained relatively stable over a 15-month period after immunosuppressive treatment. For the most part, objective measures did not demonstrate a measurable change in cognitive functioning, except for a mild decline in memory. There were subjective reports of improvement in cognitive and adaptive functioning from the patient and his spouse over this time period. The clinical significance of these results is discussed in the context of theories of executive dysfunction, and with reference to previously-published cases of AβRA.

Dysmetropsia and Cotard's syndrome due to migrainous infarction – or not?

Background Orthostatic tremor (OT) is defined by the presence of a high-frequency (13–18 Hz) tremor of the legs upon standing associated with a feeling of unsteadiness. However, some patients have discharge frequencies of <13 Hz, so-called “slow OT”. The aim of this study was to characterize patients with unsteadiness upon standing found to have <13 Hz tremor discharges on neurophysiologic testing. Methods A retrospective review was performed on all subjects with a diagnosis of OT who were referred to the Mayo Clinic, Scottsdale, AZ, between 1999 and 2013 for confirmation using neurophysiology. Results Fourteen of 28 subjects (50%) had OT discharges of <13 Hz, of whom eight had frequencies of <10 Hz and six had frequencies of 10–13 Hz. Lower frequency discharges tended to have a broader spectral peak, greater variability in discharge duration, and lower inter-muscular coherence. Subjects with <13 Hz OT had shorter mean disease duration at time of neurophysiology testing (2.00 years in <10 Hz group, 7.96 years 10–13 Hz group, and 11.43 years >13 Hz; p = 0.002). The proportion of subjects who experienced gait unsteadiness (85.7% vs. 66.6% vs. 21.4%; p = 0.016), falls (37.5% vs. 50% vs. 0%; p = 0.010), and had abnormal gait on examination (71.4% vs. 66.0% vs. 14.3%; p = 0.017) was greater in those with low and intermediate frequencies. Discussion Slow tremor electromyography frequencies (<13 Hz) may characterize a substantial proportion of patients labeled as OT. These subjects may have greater gait involvement and higher likelihood of falls leading to earlier presentation to subspecialty care.

Antipsychotic Prescribing Practices in Those with Parkinsonism: Adherence to Guidelines

Introduction Migrainous infarction accounts for 12.8% of ischemic strokes of unusual etiology. Case report A 59-year-old woman with longstanding migraine with aura experienced what appeared to be migrainous infarction characterized by dysmetropsia and transient Cotard’s syndrome. Imaging demonstrated right temporal-parietal-occipital changes with apparent cortical laminar necrosis. Conclusion The spectrum of the pathophysiology of migrainous infarction has not been established; however, cortical spreading depression may explain the appearance of imaging findings that do not obey a vascular territory.