Helen Rodgers

The incidence of thyroid disorders in the community: a twenty-year follow-up of the Whickham Survey

BACKGROUND AND OBJECTIVE The original Whlckham Survey documented the prevalence of thyroid disorders in a randomly selected sample of 2779 adults which matched the population of Great Britain in age, sex and social class. The aim of the twenty‐year follow‐up survey was to determine the Incidence and natural history of thyroid disease in this cohort.

A review of the properties and limitations of the Ashworth and modified Ashworth Scales as measures of spasticity

Background: The Ashworth Scale and the modified Ashworth Scale are the primary clinical measures of spasticity. A prerequisite for using any scale is a knowledge of its characteristics and limitations, as these will play a part in analysing and interpreting the data. Despite the current emphasis on treating spasticity, clinicians rarely measure it. Objectives: To determine the validity and the reliability of the Ashworth and modified Ashworth Scales. Study design: A theoretical analysis following a structured literature review (key words: Ashworth; Spasticity; Measurement) of 40 papers selected from the BIDS-EMBASE, First Search and Medline databases. Conclusions: The application of both scales would suggest that confusion exists on their characteristics and limitations as measures of spasticity. Resistance to passive movement is a complex measure that will be influenced by many factors, only one of which could be spasticity. The Ashworth Scale (AS) can be used as an ordinal level measure of resistance to passive movement, but not spasticity. The modified Ashworth Scale (MAS) will need to be treated as a nominal level measure of resistance to passive movement until the ambiguity between the ‘1’ and ‘1+’ grades is resolved. The reliability of the scales is better in the upper limb. The AS may be more reliable than the MAS. There is a need to standardize methods to apply these scales in clinical practice and research.

Prevalence of atrial fibrillation and eligibility for anticoagulants in the community

BACKGROUND Anticoagulants are effective in the prevention of stroke in atrial fibrillation and flutter (AF). We aimed to find out the prevalence of AF in the UK and to estimate the proportion of patients with AF who might benefit from anticoagulation. METHODS We screened with electrocardiography a random sample of 4843 people from the community aged 65 years and older for AF. Participants with AF had further investigations to identify risk factors for stroke and contraindications to anticoagulants. We used three sets of criteria to assess risk and eligibility for anticoagulation. FINDINGS 228 (4.7%) participants had AF. According to analyses derived from risk stratifications based on the Stroke Prevention in Atrial Fibrillation (SPAF) study 61% of these patients would have benefited from anticoagulation, 49% according to pooled analysis of trial results, and 41% according to the inclusion criteria for the SPAF 3 study. Anticoagulants were used by 1114 (23%) of all patients and were least used among elderly women, who may be the most likely to benefit. Echocardiography would be useful to assess the need for anticoagulation only in patients younger than 75 years with no contraindications to treatment and no clinical risk factors for stroke. INTERPRETATION Anticoagulants seem to be underused and misdirected in treatment of AF, according to various criteria. Efforts to promote and support wider and more appropriate use of anticoagulants would seem to be justified, and should decrease the incidence of stroke amongst elderly patients.

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.

Randomized Controlled Trial of a Comprehensive Stroke Education Program for Patients and Caregivers

BACKGROUND AND PURPOSE We report the findings of a randomized controlled trial to determine the effectiveness of a multidisciplinary Stroke Education Program (SEP) for patients and their informal carers. METHODS Two hundred four patients admitted with acute stroke and their 176 informal carers were randomized to receive an invitation to the SEP or to receive conventional stroke unit care. The SEP consisted of one 1-hour small group educational session for inpatients followed by six 1-hour sessions after discharge. The primary outcome measure was patient- and carer-perceived health status (SF-36) at 6 months after stroke. Knowledge of stroke, satisfaction with services, emotional outcome, disability, and handicap and were secondary outcome measures. RESULTS Only 51 of 108 (47%) surviving patients randomized to the SEP completed the program, as did 20 of 93 (22%) informal carers of surviving patients. Perceived health status (Short Form 36 [SF-36] health survey) scores were similar for SEP patients and controls. Informal carers in the control group scored better on the social functioning component of the SF-36 than the SEP group (P=0.04). Patients and informal carers in the SEP group scored higher on the stroke knowledge scale than controls (patients, P=0.02; carers, P=0. 01). Patients in the SEP group were more satisfied with the information that they had received about stroke (P=0.004). There were no differences in emotional or functional outcomes between groups. CONCLUSIONS Although the SEP improved patient and informal carer knowledge about stroke and patient satisfaction with some components of stroke services, this was not associated with an improvement in their perceived health status. Indeed, the social functioning of informal carers randomized to the SEP was less than in the control group.

Can Stroke Patients Use Visual Analogue Scales

BACKGROUND AND PURPOSE Visual analogue scales (VAS) have been used for the subjective measurement of mood, pain, and health status after stroke. In this study we investigated how stroke-related impairments could alter the ability of subjects to answer accurately. METHODS Consent was obtained from 96 subjects with a clinical stroke (mean age, 72.5 years; 50 men) and 48 control subjects without cerebrovascular disease (mean age, 71.5 years; 29 men). Patients with reduced conscious level or severe dysphasia were excluded. Subjects were asked to rate the tightness that they could feel on the (unaffected) upper arm after 3 low-pressure inflations with a standard sphygmomanometer cuff, which followed a predetermined sequence (20 mm Hg, 40 mm Hg, 0 mm Hg). Immediately after each change, they rated the perceived tightness on 5 scales presented in a random order: 4-point rating scale (none, mild, moderate, severe), 0 to 10 numerical rating scale, mechanical VAS, horizontal VAS, and vertical VAS. Standard tests recorded deficits in language, cognition, and visuospatial awareness. RESULTS Inability to complete scales with the correct pattern was associated with any stroke (P<0.001). There was a significant association between success using scales and milder clinical stroke subtype (P<0.01). Within the stroke group, logistic regression analysis identified significant associations (P<0.05) between impairments (cognitive and visuospatial) and inability to complete individual scales correctly. CONCLUSIONS Many patients after a stroke are unable to successfully complete self-report measurement scales, including VAS.

Early supported hospital discharge following acute stroke: pilot study results

Objective: To establish the feasibility and method of evaluation of an early supported hospital discharge policy for patients with acute stroke. Design: A randomized controlled trial comparing an early supported discharge service to conventional care. Setting: Three acute hospitals in Newcastle upon Tyne. Subjects: Ninety-two eligible patients with acute stroke admitted between 1 February 1995 and 31 January 1996. Main outcome measures: Placement, length of stay, readmission rates, mortality, functional ability (Nottingham Extended Activities of Daily Living (ADL) Scale), handicap (Oxford Handicap Scale), global health status (Dartmouth Coop Function Charts) and carer stress (General Health Questionnaire 30 item). Results: The median length of stay for patients randomized to early supported discharge was 13 days compared to 22 days in the conventional care group (p = 0.02). The median Barthel ADL Index at seven days post stroke of patients randomized to early supported discharge was 15, and 13 for those randomized to conventional care (NS). At three months post stroke the median Nottingham EADL score of patients randomized to early supported discharge was 10 compared to 7 for those who received conventional care (NS). There were no statistically significant differences in the global health status of patients or carer stress. Conclusion: An early supported discharge service following acute stroke with individualized rehabilitation in the community is feasible and can be evaluated by a randomized controlled trial but a larger multicentre trial is needed before such a service is widely adopted.

Population based study of use of anticoagulants among patients with atrial fibrillation in the community

Several randomised controlled trials have shown that warfarin treatment for patients with atrial fibrillation substantially reduces their risk of stroke.1 Studies have found low treatment rates among patients with atrial fibrillation in hospital2 and in primary care,3 but these have been limited by their reliance on identifying patients with atrial fibrillation from coding of records and prescription of antiarrhythmic drugs. We report the use of warfarin among patients with atrial fibrillation in a community survey. Concern has been expressed about the high rates of exclusion of subjects from randomised trials of warfarin treatment. It has been suggested that the use of similar exclusions in clinical practice would greatly reduce the number of patients eligible for treatment,4 which might explain the low treatment rates. We therefore applied exclusion criteria similar to one of these trials …

Systematic review of mass media interventions designed to improve public recognition of stroke symptoms, emergency response and early treatment

BackgroundMass media interventions have been implemented to improve emergency response to stroke given the emergence of effective acute treatments, but their impact is unclear.MethodsSystematic review of mass media interventions aimed at improving emergency response to stroke, with narrative synthesis and review of intervention development.ResultsTen studies were included (six targeted the public, four both public and professionals) published between 1992 and 2010. Only three were controlled before and after studies, and only one had reported how the intervention was developed. Campaigns aimed only at the public reported significant increase in awareness of symptoms/signs, but little impact on awareness of need for emergency response. Of the two controlled before and after studies, one reported no impact on those over 65 years, the age group at increased risk of stroke and most likely to witness a stroke, and the other found a significant increase in awareness of two or more warning signs of stroke in the same group post-intervention. One campaign targeted at public and professionals did not reduce time to presentation at hospital to within two hours, but increased and sustained thrombolysis rates. This suggests the campaign had a primary impact on professionals and improved the way that services for stroke were organised.ConclusionsCampaigns aimed at the public may raise awareness of symptoms/signs of stroke, but have limited impact on behaviour. Campaigns aimed at both public and professionals may have more impact on professionals than the public. New campaigns should follow the principles of good design and be robustly evaluated.

Botulinum Toxin for the Upper Limb After Stroke (BoTULS) Trial Effect on Impairment, Activity Limitation, and Pain

Background and Purpose— Botulinum toxin is increasingly used to treat upper limb spasticity due to stroke, but its impact on arm function is unclear. We evaluated botulinum toxin for upper limb spasticity and function poststroke. Methods— Three hundred thirty-three patients with stroke with upper limb spasticity and reduced arm function participated in a multicenter randomized controlled trial. The intervention group received botulinum toxin type A injection(s) plus a 4-week therapy program. The control group received the therapy program alone. Repeat injection(s) and therapy were available at 3, 6, and 9 months. The primary outcome was upper limb function at 1 month (Action Research Arm Test). Secondary outcomes included measures of impairment, activity limitation, and pain at 1, 3, and 12 months. Outcome assessments were blinded and analysis was by intention to treat. Results— There was no significant difference in achievement of improved arm function (Action Research Arm Test) at 1 month (intervention group: 42 of 167 [25.1%], control group 30 of 154 [19.5%]; P=0.232). Significant differences in favor of the intervention group were seen in muscle tone at 1 month; upper limb strength at 3 months; basic arm functional tasks (hand hygiene, facilitation of dressing) at 1, 3, and 12 months; and pain at 12 months. Conclusions— Botulinum toxin type A is unlikely to be useful for improving active upper limb function (eg, reaching and grasping) in the majority of patients with spasticity after stroke, but it may improve basic upper limb tasks (hand hygiene, facilitation of dressing) and pain.