Mona Britton

Blood pressure course in patients with acute stroke and matched controls.

The natural course of blood pressure (BP) was studied after emergency hospitalization in 209 consecutive stroke patients and as many age and sex matched controls. Histories of hypertension were more common among patients than controls (46% vs 26%). On admission 69% of the stroke group and 36% of the controls had BP greater than or equal to 170/100 mm Hg. In the first four days there was a spontaneous BP decline, which was greater the higher the initial values. During the whole hospitalization though, stroke patients with previous hypertension had the highest BP levels and previously normotensive controls the lowest. Even if WHO as well as the Joint Committee for Stroke have recommended cautious antihypertensive therapy in stroke patients with extreme hypertension, such therapy is not evaluated. If this is to be done, the present findings have to be taken into consideration. Stroke controls, matched according to the initial BP level, will thus be required.

Immediate computed tomography or admission for observation after mild head injury: cost comparison in randomised controlled trial

Abstract Objective To compare the costs of immediate computed tomography during triage for admission with those of observation in hospital in patients with mild head injury. Design Prospective cost effectiveness analysis within a multicentre, pragmatic randomised trial. Setting 39 acute hospitals in Sweden Participants 2602 patients (aged ≥ 6) with mild head injury. Interventions Immediate computed tomography or admission for observation. Main outcome measures Direct and indirect costs related to the mild head injury during the acute and three month follow-up period. Results Outcome after three months was similar for both strategies (non-significantly in favour of computed tomography). For the acute stage and complications, the cost was 461 euros (£314,

Prognosis in acute stroke with special reference to some cardiac factors

582) per patient in the computed tomography group and 677 euros (£462,

Diagnostic errors discovered by CT in patients with suspected stroke

854) in the observation group; an average of 32% less in the computed tomography group (216 euros, 95% confidence interval −272 to −164; P < 0.001). Sensitivity analysis showed that computed tomography was the most cost effective strategy under a broad range of assumptions. After three months, total costs were 718 euros and 914 euros per patient—that is, 196 euros less in the computed tomography group (- 281 to - 114; P < 0.001). The lower cost of the computed tomography strategy at the acute stage thus remained unchanged during follow-up. Conclusion Patients with mild head injury attending an emergency department can be managed more cost effectively with computed tomography rather than admission for observation in hospital. Trial registration ISRCTN81464462 [controlled-trials.com].

Quality of care in an outpatient department: The patient's view

Neurological assessments were done regularly during hospitalization in 283 consecutive patients (mean age 73 yr) with acute cerebrovascular disease treated at the Stroke Unit of Serafimerlasarettet. A preplanned investigation program and strict criteria for diagnosis and treatment were followed. Hospital mortality was 18%. Patients with a major cerebral infarction or haemorrhage often died very early during the hospital period and deaths due to complications increased significantly during the second week. Multivariate analysis regarding mortality showed that a low neurological score and heart failure were the most important factors for the short-term prognosis. In those patients with cerebral infarction, ambulatory capacity and ECG-diagnosed bundle branch block added significantly to the prognostic power of the neurological score. Among the 227 patients discharged alive, 1 and 2-yr mortality was 14 and 18% respectively. Here, the most important long-term prognostic factors were age and ST changes on the ECG. Again, considering only patients with cerebral infarction (N = 190), bundle branch block was found to be the single most useful predictive factor. Prognostication in acute ischemic stroke should thus be based not only on neurological findings but on careful evaluation of associated cardiac disease, especially in the long-term perspective.

Validation of admission criteria to a stroke unit

We assessed the frequency of stroke diagnostic errors revealed by CT in 197 patients. In five Patients, CT was an emergency procedure. In the other 192 patients, CT was used to check diagnosis based on routine investigations. All but eight diagnoses (4%) were thereby confirmed. Either hemorrhage was discovered where an ischemic lesion had been suspected (2 cases) or the reverse (3 cases). Disorders other than stroke were found in three Patients—subdural hematoma, hydrocephalus, and suspected tumor. Thus, few but important errors investigations.

Lack of effect of theophylline on the outcome of acute cerebral infarction

Abstract The quality of care offered in an outpatient department for Internal Medicine was studied by means of a questionnaire distributed to 55 patients after one year of treatment and by medical evaluation in the same 55 cases. Less than half of the 41 patients, who filled out the questionnaire, reported that they had had symptoms that were successfully treated. Nevertheless 85%, of the patients were satisfied with the care. Only in approximately one third of the cases was relief of symptoms the main reason for satisfaction. Equally important was the personal and thorough examination by the treating physician as well as the reassuring effect of repeated laboratory analysis. The review of medical forms gave a different picture. In only 25 of the 41 cases, both physicians and patients were satisfied with the outcome of the care. Ten patients, who themselves were satisfied, were judged by the treating physicians not to have benefitted medically from the care. In two further cases the care had the negative effect of delaying proper diagnosis. Four patients were dissatisfied, despite medical judgement that the care was beneficial. Thus, unanimous satisfaction was obtained in 61% of the cases.

Impact of health technology assessments. Some experiences of SBU.

Abstract Recent and sudden onset of focal neurological deficit as criteria for admission to a stroke unit was evaluated prospectively in 2252 consecutive admissions to a medical department. According to the criteria, 169 patients were initially suspected of having an acute cerebrovascular disorder. This was later confirmed in all but 17 of them. Another 24 patients, not correctly classified initially, also turned out to have suffered a stroke. In practice, sensitivity of the criteria was, therefore, 86% and specificity 99%. Had the criteria been more strictly adhered to in the emergency ward, sensitivity could have increased to 97%, and specificity to 100%. Thus, simple criteria of this kind seem appropriate for a standardized identification of stroke in the acute situation.

EDUCATION AND SUPPORT NETWORKS FOR ASSESSMENT OF HEALTH INTERVENTIONS

In patients with acute ischemic stroke, dramatic but often transient improvements have been noticed after theophylline injections. Whether better results could be obtained by continuous infusion of the drug was evaluated in a double‐blind study. Out of 46 patients with a mean age of 75 years, 22 got theophylline as aminophylline (bolus dose of 230 mg followed by 0.5 mg/kg/h) and 24 placebo during 3 days. The groups were comparable in all aspects at the outset of the trial. Serum theophylline concentrations were kept within the therapeutic range recommended for patients with asthma. No significant difference in outcome was noticed between the groups during the hospital period when repeated neurological assessments by two different scores and mortality were compared.

Should relatives be informed that autopsy is intended? Opinions of relatives with recent experience.

OBJECTIVE A recurring question is whether evidence from systematic reviews has any impact on medical practice. We have studied this question in relation to some conclusions in seven reports, where relatively simple means to monitor trends could be used. RESULTS As recommended, in the report preoperative routines, the number of preoperative examinations diminished at six hospitals, during around 3,000 operations studied, a savings of SEK 130 million. After the report on moderately elevated blood pressure, moderately elevated blood pressure sales of the preferred drugs, diuretics and beta-blockers, stopped falling while calcium blockers and ACE inhibitors stopped rising. As concluded in the report, general prostate cancer screening has not been introduced, but tests as a sign of opportunistic screening have increased. Bone density measurements were not recommended for screening, and sales of equipment have declined after the report. The use of neuroleptics as unspecific calming therapy for old persons was discouraged due to the serious side effects. The frequency of patients given this medication diminished from 34% to 28% at nursing homes after 1 year. For smoking cessation, the use of nicotine substitution medications has increased, which is in line with suggestions presented in the report. For stomach pain proton pump inhibitors given for functional dyspepsia have diminished in a region of the country after special efforts to disseminate the message. CONCLUSIONS It appears to be possible to monitor changes in practice corresponding to selected conclusions in systematic reviews. After rather extensive disseminating efforts, some results look encouraging.