Javier Almazán

Randomized controlled trial of rehabilitation at home after stroke: one-year follow-up of patient outcome, resource use and cost.

Background and Purpose: This study sought to evaluate early supported discharge and continued rehabilitation at home after stroke, at a minimum of 6 months after the intervention, in terms of patient outcome, resource use and health care cost. Methods: Eighty-three patients, moderately impaired 5–7 days after acute stroke, were included in a randomized controlled trial, 42 being allocated to the intervention and 41 to routine rehabilitation. One-year follow-up of patient outcome included mortality, motor capacity, dysphasia, activities of daily living, social activities, perceived dysfunction, and self-reported falls. Resource use over 12 months included inpatient hospital care, outpatient health care, use of health-related services, informal care, and cost of health care. Results: On univariate analysis there was no difference in patient outcome. Multivariate regression analysis showed that intervention had a significant effect on independence in activities of daily living. A significant difference in inpatient hospital care, initial and recurrent, was observed, with a mean of 18 (intervention) versus 33 days (control) (p = 0.002). Further significant differences were that the control group registered more outpatient visits to hospital occupational therapists (p = 0.02), private physical therapists (p = 0.03) and day-hospital attendance (p = <0.001), while the intervention group registered more visits to nurses in primary care (p = 0.03) and home rehabilitation (p = <0.001). Other differences in outcomes or resource utilization were nonsignificant. Conclusion: In Sweden, early supported discharge with continued rehabilitation at home proved no less beneficial as a rehabilitation service, and provided care and rehabilitation for 5 moderately disabled stroke patients over 12 months after stroke onset for the cost of 4 in routine rehabilitation.

Parkinson's Disease Sleep Scale: validation study of a Spanish version.

The Parkinsons Disease Sleep Scale (PDSS) is the first published bedside clinical tool to specifically measure sleep disturbances in Parkinsons disease (PD). The objective of the present study was to carry out a metric analysis of a Spanish version (PDSS‐SV) using a cross‐sectional study of 100 PD patients who participated in the study. Usual measures for PD and mental status were applied by neurologists. Patients completed the Epworth Sleepiness Scale, Parkinsons Disease Questionnaire‐39 Items (PDQ‐39), and PDSS‐SV. PDSS internal consistency (Cronbachs α, 0.77; significant item‐total correlation for 11 items) was satisfactory. PDSS showed high test–retest reliability (intraclass correlation coefficient for items, 0.79–0.99; for total score, 0.94). Standard error of measurement was 9.80 (crossover) and 5.01 (longitudinal). Scores were distributed uniformly, with low floor and ceiling effect (1%). PDSS scores were correlated significantly with depression (Hamilton Depression Rating Scale, rS = −0.55; P < 0.0001) and quality of life (PDQ‐39 Summary Index, rS = −0.26; P = 0.007), but not with clinical variables. Self‐perception of mood disorder, pain, or hallucinations correlated individually with PDSS scores, and a factor explaining 65% of the variance was found. The assessment of PD sleep disorders with the PDSS met some basic standards required for health status measures.

Stroke Patients in South Madrid Function and Motor Recovery, Resource Utilization, and Family Support

BACKGROUND AND PURPOSE The purpose of the present study was to describe the epidemiology of stroke disability and the use of health resources in South Madrid. METHODS Among a population of 665 168 residents in South Madrid, patients with an acute stroke of clinical onset during March to July 1996 who were seen at a general hospital or at 1 of 3 primary care centers were evaluated at baseline (n=147) and at 3 months (n=110) and 6 months (n=112) after stroke. We assessed the frequencies of stroke and stroke-related residual disability per population unit, as well as the impairment, disability, secondary complications, use of health resources, and impact on quality of life. RESULTS In patients > or =60 years old, the incidence of stroke with severe residual disability after 6 months was 75 per 10 000, was higher in men, and increased with age; the proportion of survivors among those examined at baseline was 20%. The use of hospital days per population unit was similar to that of reported European data, but the use of other health care resources was less. Patients frequently used bladder and nasal catheters and presented with shoulder pain. Social activities were infrequent and decreased after stroke. Access to technical aids was limited, and home adaptations were exceptional. The impact of stroke on health-related quality of life among patients and main caregivers was modest. CONCLUSIONS The study shows that in South Madrid, (1) the use of health resources after stroke is low; (2) patients with stroke register low activities of daily living scores with a comparatively small impact on quality of life; and (3) relative to need, the use of rehabilitation, aids, and home adaptations and services was low.

Human transmissible spongiform encephalopathies in eleven countries: diagnostic pattern across time, 1993–2002

BackgroundThe objective of this study was to describe the diagnostic panorama of human transmissible spongiform encephalopathies across 11 countries.MethodsFrom data collected for surveillance purposes, we describe annual proportions of deaths due to different human transmissible spongiform encephalopathies in eleven EUROCJD-consortium countries over the period 1993–2002, as well as variations in the use of diagnostic tests. Using logistic models we quantified international differences and changes across time.ResultsIn general, pre-mortem use of diagnostic investigations increased with time. International differences in pathological confirmation of sporadic Creutzfeldt-Jakob disease, stable over time, were evident. Compared to their counterparts, some countries displayed remarkable patterns, such as: 1) the high proportion, increasing with time, of variant Creutzfeldt-Jakob disease in the United Kingdom, (OR 607.99 95%CI 84.72–4363.40), and France (OR 18.35, 95%CI 2.20–152.83); 2) high, decreasing proportions of iatrogenic Creutzfeldt-Jakob disease in France, (OR 5.81 95%CI 4.09–8.24), and the United Kingdom, (OR 1.54 95%CI 1.03–2.30); and, 3) high and stable ratios of genetic forms in Slovakia (OR 21.82 95%CI 12.42–38.33) and Italy (OR 2.12 95%CI 1.69–2.68).ConclusionConsiderable international variation in aetiological subtypes of human transmissible spongiform encephalopathies was evident over the observation period. With the exception of variant Creutzfeldt-Jakob disease and iatrogenic Creutzfeldt-Jakob disease in France and the United Kingdom, these differences persisted across time.

Time trends, cohort effect and spatial distribution of cerebrovascular disease mortality in Spain

Study objective: This study describes mortality due to cerebrovascular disease (CVD) in Spain, based on time-series analysis in the period 1951–1995 by age, sex, and cohort of birth; spatial distribution observed for the five-year period 1991–1995, and time-spatial analysis in the period 1992–1995 vs. 1988–1991. Special attention is paid to risk of medium aged population. Design: Longitudinal and cross-sectional observational study. Setting and participants: Spanish population. All mortality data used were taken from official statistics. Time trends and spatial distribution were analyzed using log-linear Poisson regression models. Main results: CVD mortality declined over the last two decades of the study period (1974–1995) by an annual average of 4.16% (95% CI: 3.95–4.36) and 4.00% (95% CI: 3.77–4.24) in men and women, respectively. The downward trends were accelerated in last decade. An excess of male mortality was in evidence. For all age groups mortality declined with more recent cohorts, but the decline was less marked among ages 35–64. Spatial distribution of CVD mortality revealed a north-south pattern, but this is being difuminated by increasing rates in the lower risk provinces. Internationally, Spain ranks midway to low in terms of its overall CVD mortality. Conclusions: Efforts to reduce CVD incidence and case fatality are the essential prerequisite for any long-term improvement in mortality. Accordingly, further research is called for into current disease morbidity and the risk factors to be targeted at a general population level, nationwide.

Effect of Age, Birth Cohort, and Period of Death on Cerebrovascular Mortality in Spain, 1952 Through 1991

BACKGROUND AND PURPOSE The continued decrease in cerebrovascular disease in Spain remains unexplained. Age-period-cohort analysis enables description of birth cohort and period-of-death components. This study sought to describe these effects on the decline of stroke mortality in Spain. METHODS Deaths due to cerebrovascular diseases in the period from 1952 through 1991 and the corresponding population figures were grouped into 11 age groups and 8 5-year periods, from which age-specific mortality rates for 18 birth cohorts were then computed. These were plotted for graphical presentation purposes and fitted to Poisson regression models to assess age, period, and cohort effects. RESULTS An exponential age effect was present for both sexes regardless of cohort or period. A definite downward period effect was observable from 1962 to 1991, except for a sharp fall and peak in the periods 1967 to 1971 and 1972 to 1976, respectively, which was possibly ascribable to changes in diagnostic and coding practices. Age- and period-adjusted stroke mortality increased for earlier cohorts and decreased for generations born between 1892 and 1940. For post-1940 generations, there was an increasing risk of stroke mortality. CONCLUSIONS The results suggest that a decrease in incidence coupled with an increase in survival may account for the observed decline in stroke mortality, but further studies on the Spanish population are needed to assess these findings. Although not yet definitive, there are signs of an increase in incidence among the more recent generations. If the decreasing period effect fails to offset this increase, future years may see a deceleration in the current decline in stroke mortality.

The association of dietary folate, B6, and B12 with cardiovascular mortality in Spain: an ecological analysis.

OBJECTIVES This study assessed the association of dietary folate, vitamin B6, and vitamin B12 with cardiovascular mortality. METHODS Poisson regression analyses assessed coronary/cerebrovascular mortality rates via nutrient data obtained from the National Nutrition Survey, which recorded 7-day food intakes from a national sample of 21,155 households. RESULTS In regard to coronary mortality, male and female rate ratios (highest vs lowest quintile) were 0.83 (95% confidence interval [CI] = 0.77, 0.91) and 0.95 (95% CI = 0.86, 1.05), respectively, for folate and 0.74 (95% CI = 0.65, 0.84) and 0.86 (95% CI = 0.73, 0.99), respectively, for B12. Intake of folate and B6 (but not B12) was significantly associated with cerebrovascular mortality. CONCLUSIONS B vitamins are associated with cardiovascular mortality in the general population.

The Diagnosis of Tourette's Syndrome: Communication and Impact

No study to date has investigated differences in perception regarding the manner in which a diagnosis of Tourettes Syndrome (TS) is communicated and the impact that this diagnosis can have on patients, as well as their relatives and physicians. The main objective was to explore the personal experiences regarding the communication and impact of a TS diagnosis on those who receive the diagnosis, their caregivers and physicians. A qualitative research methodology was used in this study, based on the use of focus groups (FGs). All health professionals, persons with TS and their relatives said that TS was difficult to diagnose. However, each group perceived different causes for the difficulty. Physicians cited the complexity of the symptoms, while the patients themselves noted the general lack of knowledge regarding the disease. In adittion, the physicians and the relatives both noted that the symptoms of TS were often hidden behind family guilt. The communication of the diagnosis to relatives of children with TS was not adequate because of poor understanding and interpretation of the clinical terminology. The most important conclusion was that the current method for communicating the diagnosis of TS to patients and relatives should be improved to facilitate better understanding and interpretation.

High levodopa use in periodically time-clustered, Icelandic birth cohorts. A vestige of parkinsonism etiology?

We evaluated levodopa use (LDU) by the Icelandic population focusing on: 1) annual gross levodopa (LD) sales from wholesalers to pharmacies for the period 1978–1990, using a reported method; 2) data from a prescription survey conducted from October 1st, 1990 to March 31st, 1991; and 3) raw and reported data on prevalences of Parkinsons disease (PD) in 1963 in this country. The standard for adjustments and reference population for LDU comparisons was the Swedish in 1984. Crude gross sales of LD in Iceland in 1990 and in Sweden in 1984 amounted to 1.67 and 1.35 DDD/1000 person days respectively. After respective adjustments for age, and for age and the infant mortality rates, taken as an indicator of health care quality, LDU in Iceland in 1990 was found to be 1.82 and 1.63 (95% CI 1.47–1.89) times that for Sweden. Prevalences of LD‐prescription recipients in 1990–1991 and of PD in 1963 increased with age: however, those of drug users were higher than those of PD among the elderly. Higher‐than‐expected prevalences of PD and LD‐prescription users (there being a partial overlap between these two categories) were found in periodically‐clustered, one‐year birth cohorts. These results support the notion that Iceland has a high LDU and suggest that this variation is due to a high prevalence of LD responsive disorders. Cohorts born after registered whooping cough outbreaks in Iceland may account for the magnitude and birth‐related pattern of PD prevalences and LDU levels.

Functional Outcome, Rehabilitation Use and Length of Hospital Stay for Stroke Patients in South Madrid

Background: Health status and use of resources by stroke patients in Spain are unknown. Methods: A total of 103 acute stroke patients resident in south Madrid, population 665,168, were seen in 1996 at a general hospital and three primary care centres and evaluated at 5–10 days, 3 and 6 months after stroke. Health outcomes and patterns of rehabilitation and hospital use by patient groups were studied using multivariate logistic regression. Results: The group receiving rehabilitation exhibited higher levels of impairment, disability and handicap at each time point, these differences decreasing with time, except in the distribution of walking ability which was unimodal in that group. Younger age, poor walking ability and motor capacity, pain on the paretic side and living with a spouse predicted use of rehabilitation; low level of education predicted a long hospital stay. Conclusion: Rehabilitation for stroke in south Madrid was sparse and used mainly by young, severely affected patients.