Richard Sainsbury

What do patients and their carers want to know about stroke? A two-year follow-up study

Objective: To clarify what issues are important to stroke patients and their carers. To determine whether these issues change over time. Design: Prospective study of consecutive patients admitted to hospital with a diagnosis of an acute stroke. Each participant had interviews at six and 24 months. In addition, a subgroup of these patients (consecutive discharges over a two-month period) were also seen at two weeks post discharge. Setting and subjects: Hospital-based cohort of stroke survivors. Interviewed in their own homes. Main outcome measures: Documentation of the questions asked. Results: At two weeks, six and 24 months, a median of three, two and three questions were asked by each patient respectively. Enquiries about basic aspects of stroke were common but diminished over time. Fear of recurrence was apparent at all three interview periods. Enquiries about the psychological sequelae of stroke became more prevalent at six and 24 months. At two years, 32% of respondents asked about concentration/memory difficulties with smaller numbers commenting on tiredness, depression and frustration. At two years, 18% of the sample were still uncertain of their chances of further recovery. Conclusions: Patients with stroke continue to have unanswered questions even two years after their stroke. The types of questions asked changed over time.

A community study of vitamin B12 and folate levels in the Elderly

Objective: To measure the prevalence of low serum vitamin B12, folate, and red cell folate levels and their relationship with other nutritional indices.

The Effect of Compliance on Clinical Outcomes for Patients with Dysphagia on Videofluoroscopy

This study investigates clinical outcomes and the degree of compliance in patients who received advice on dysphagia management and the effect of the level of compliance on the incidence of chest infections and aspiration pneumonia, cause of death, and hospital readmission. We performed a retrospective cohort study of 140 patients who had videofluoroscopic studies at Princess Margaret Hospital, Christchurch, New Zealand, from 1 January 1996 to 30 June 1997. The degree to which recommendations on dysphagia management were followed was correlated with the incidence of chest infections, aspiration pneumonia, and readmissions to the hospital. Cause of death, including the contribution of aspiration pneumonia, was assessed by review of medical records and death certificates. Information was available for 89% of the cohort. Twenty-one percent of the survivors never complied with the advice given. Noncompliant subjects were younger (p<0.05) and more likely to be living at home rather than receiving institutional care (p=0.05). Noncompliers had more hospital admissions because of chest infections or aspiration pneumonia (22% vs. 1.5%; p<0.001). Home-dwelling noncompliant subjects received more courses of antibiotics (p<0.02), but there was no difference in the number of chest infections. Fifty-four people died during the study period. Aspiration pneumonia was recorded as a definite or probable cause of death in 26 (52%) of the 50 subjects for whom reliable information was available and in 6 of 7 subjects who made a deliberate and documented decision not to comply. We conclude that noncompliance with recommendations about dysphagia management is associated with adverse outcomes. There was a high mortality rate and aspiration pneumonia was a common cause of death.

The risk of recurrent stroke after intracerebral haemorrhage

Background and aim: The risks of recurrent intracerebral haemorrhage (ICH) vary widely (0–24%). Patients with ICH also have risk factors for ischaemic stroke (IS) and a proportion of ICH survivors re-present with an IS. This dilemma has implications for prophylactic treatment. This study aims to determine the risk of recurrent stroke events (both ICH and IS) following an index bleed and whether ICH recurrence risk varies according to location of index bleed. Patients and methods: All patients diagnosed with an acute ICH presenting over an 8.5 year period were identified. Each ICH was confirmed by reviewing all of the radiology results and, where necessary, the clinical case notes or post-mortem data. Recurrent stroke events (ICH and IS) were identified by reappearance of these patients in our stroke database. Coronial post-mortem results for the same period were also reviewed. Each recurrent event was reviewed to confirm the diagnosis and location of the stroke. Results: Of the 7686 stroke events recorded, 768 (10%) were ICH. In the follow-up period, there were 19 recurrent ICH and 17 new IS in the 464 patients who survived beyond the index hospital stay. Recurrence rate for ICH was 2.1/100 in the first year but 1.2/100/year overall. This compares with 1.3/100/year overall for IS. Most recurrences were “lobar–lobar” type. Conclusion: The cumulative risk of recurrent ICH in this population is similar to that of IS after the first year.

The earlier, the better: the effect of early community contact on the attitudes of medical students to older people

Background  Early clinical contact for medical students is an important curricular innovation. We wished to determine if early contact with older people in the second year of a more vertically integrated medical undergraduate programme influenced attitudes to older people and if any effect was synergistic with the effect of an existing fourth year course.

Assessment of Creatinine Clearance in Healthy Subjects over 65 Years of Age

Eighteen healthy people over 65 years of age were studied to compare the 99mTC-diethylenetriamine pentaacetic acid (DTPA) clearance, the measured 24-hour creatinine clearance and the assessed creatinine clearance using the Cockcroft and Gault (C-G) formula to measure their glomerular filtration rate. Significant correlations were found between the isotopic method and the measured creatinine clearance (r = 0.71; p less than 0.001); the measured creatinine clearance and the C-G formula (r = 0.81; p less than 0.001), and the isotopic method and the C-G formula (r = 0.70; p less than 0.001). The C-G formula correlated better with both the 99mTc-DTPA clearance and the measured creatinine clearance when the female correction factor was used. This study has shown that in healthy, elderly people, the C-G formula for assessing the creatinine clearance correlated extremely well with the standard clinical tests for measuring the glomerular filtration rate. Whilst the formula has clinical value and allows rapid and accurate assessment of renal function in the elderly, the clinician must be aware that the formula relatively underestimates the true renal clearance.

Effect of aspirin and warfarin on early survival after intracerebral haemorrhage

BackgroundTo determine whether taking aspirin or warfarin at the time of an intracerebral haemorrhage (ICH) has an independent effect on early survival.MethodsAll people with ICH presenting in Christchurch, New Zealand over a three-year period were identified. Independent predictors of mortality at 7, 14 and 28 days were calculated using binary logistic regression.ResultsTwo hundred and fifty three cases were identified. Unadjusted 28-day mortality was 43% overall, but 53 % for warfarin associated ICH and 43% for patients taking aspirin. Haemorrhage volume, haemorrhage location, intraventricular spread and the use of warfarin were all independently and significantly associated with mortality at all three time intervals (7, 14 and 28 days). The effect of warfarin was apparent despite similar volumes of bleed in each group. Aspirin was not associated with increased early mortality. Increasing age was also an independent predictor associated with death at 28 days.InterpretationUse of warfarin (but not aspirin) immediately prior to ICH was independently associated with increased mortality, after controlling for comorbidities. Thus therapeutic efforts to rapidly reverse the warfarin induced coagulopathy may be justified to lower mortality.

A needs‐based study and examination skills course improves students' performance

Background  Adult learning theory suggests that learning is most effective when related to need, when driven by the learner and when it is flexible. We describe the effect of an educational intervention that was driven by student need, and largely designed by students.

Evaluation of strategies to improve nutrition in people with dementia in an assessment unit

Objectives: To evaluate strategies designed to improve nutrition in elderly hospitalised patients with dementia.Design: Observation phase followed by sequential interventions.Setting: A Short stay assessment unit.Participants: Hospital Inpatients with a variety of conditions causing dementia.Interventions: Phase 1: Observation. Phase 2: Encouraging dietary, ‘Grazing’. Phase 3: Using volunteers to feed patients. Phase 4: Improving dining room ambience by playing soothing music.Measurements: Body Mass Index (BMI), mid arm circumference, mini nutrition index and caloric intake by plate waste measurement.Results: BMI fell in the Observation phase 0.6+0.68 kg/m2 (p< 0.001), but increased in each of the Intervention phases. Phase2 0.3+0.86 kg/m2 (p< 0.04), Phase 3 0.37+0.4 kg/m2 (p< 0.04), Phase 4 0.39+0.7 kg/m2 (p< 0.007). Caloric intake increased in the intervention phases.Conclusions: Simple, inexpensive and easy to implement strategies can improve nutrition in hospital inpatients with dementia.

Stroke patients' views on stroke outcomes: death versus disability

Aims: To determine how elderly stroke patients perceive different stroke outcomes, including death, relative to each other and how these views compare with those of age/sex-matched controls. Participants and setting: Twenty-eight elderly patients discharged from hospital with an acute stroke causing hemiplegia. Twenty-eight age/sexmatched control patients from the same hospital who had never had a stroke or transient ischaemic attack. Methods: Patients and controls were asked to rank 11 clinical scenarios of potential stroke outcomes, from the most to the least desirable outcome. Results: There was a striking bimodal distribution for sudden painless death in both groups. Painless death was preferred to even a minor stroke disability in over one-third of elderly individuals, whilst 20% would prefer severe disability rather than painless death. Sixty-nine per cent of stroke patients and 82% of controls ranked death as preferable to severe disability. Stroke patients may be more tolerant of disability (compared to death) than their controls (39% patients and 61% controls preferred death to any disability, p = 0.11). Conclusions: Our results suggest that many elderly individuals would rather die than be alive and severely disabled. This may have important implications for acute stroke treatments such as thrombolysis.