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OBJECTIVE: To discover common genetic variants associated with poststroke outcomes using a genome-wide association (GWA) study. METHODS: The study comprised 6,165 patients with ischemic stroke from 12 studies in Europe, the United States, and Australia included in the GISCOME (Genetics of Ischaemic Stroke Functional Outcome) network. The primary outcome was modified Rankin Scale score after 60 to 190 days, evaluated as 2 dichotomous variables (0-2 vs 3-6 and 0-1 vs 2-6) and subsequently as an ordinal variable. GWA analyses were performed in each study independently and results were meta-analyzed. Analyses were adjusted for age, sex, stroke severity (baseline NIH Stroke Scale score), and ancestry. The significance level was p < 5 × 10-8. RESULTS: We identified one genetic variant associated with functional outcome with genome-wide significance (modified Rankin Scale scores 0-2 vs 3-6, p = 5.3 × 10-9). This intronic variant (rs1842681) in the LOC105372028 gene is a previously reported trans-expression quantitative trait locus for PPP1R21, which encodes a regulatory subunit of protein phosphatase 1. This ubiquitous phosphatase is implicated in brain functions such as brain plasticity. Several variants detected in this study demonstrated suggestive association with outcome (p < 10-5), some of which are within or near genes with experimental evidence of influence on ischemic stroke volume and/or brain recovery (e.g., NTN4, TEK, and PTCH1). CONCLUSIONS: In this large GWA study on functional outcome after ischemic stroke, we report one significant variant and several variants with suggestive association to outcome 3 months after stroke onset with plausible mechanistic links to poststroke recovery. Future replication studies and exploration of potential functional mechanisms for identified genetic variants are warranted.
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Isquemia Encefálica/genética , Accidente Cerebrovascular/genética , Isquemia Encefálica/terapia , Estudio de Asociación del Genoma Completo , Humanos , Recuperación de la Función/genética , Accidente Cerebrovascular/terapiaRESUMEN
BACKGROUND: No previous qualitative exploration of urinary incontinence (UI) or post-stroke urinary incontinence (PSUI) has been undertaken in an Australian population. PURPOSE: The purpose of this study is to explore the experiences of community-dwelling stroke survivors who were living with UI/PSUI and understand how context shaped those experiences. METHODS: A pragmatic approach using thematic analysis was employed for this study. FINDINGS: Four themes emerged from the data: "I've got to go": onset and daily experience of UI; "No one ever mentioned it": lack of advice and information from the health system; "You can't enjoy something if you've got to go the toilet": experience of occupational restrictions; and "It's just a matter of planning": management strategies. IMPLICATIONS: UI continued well beyond discharge and was shaped by limited advice, distress, and role loss. Occupational therapists are encouraged to engage in assessment, management, and treatment of UI, including the provision of education that promotes continence, attenuates negative experiences, and enhances community participation.
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Actividades Cotidianas/psicología , Accidente Cerebrovascular/complicaciones , Sobrevivientes/psicología , Incontinencia Urinaria/etiología , Incontinencia Urinaria/psicología , Adaptación Psicológica , Australia , Estudios de Seguimiento , Humanos , Masculino , Terapia OcupacionalRESUMEN
BACKGROUND AND PURPOSE: Smoking may exacerbate the risk of death or further vascular events in those with stroke, but data are limited. METHODS: 1589 cases of first-ever and recurrent stroke were recruited between 1996 and 1999 from a defined geographical region in North East Melbourne. Both hospital and nonhospital cases were included. Over a 10-year period, all deaths, recurrent stroke events, and acute myocardial infarctions that were reported at follow-up interviews were validated using medical records. Cox proportional hazards regression was used to assess the association between baseline smoking status (never, ex, and current) and outcome (death, acute myocardial infarction, or recurrent stroke). RESULTS: Patients who were current smokers (Hazard Ratio [HR], 1.30; 95% Confidence Interval [CI], 1.06-1.60; P=0.012) at the time of their stroke had poorer outcome when compared with those who had never smoked. Among those who survived the first 28 days of stroke, current smokers (HR, 1.42; 95% CI, 1.13-1.78; P<0.003) and ex-smokers (HR, 1.18; 95% CI, 1.01-1.39; P=0.039) at baseline had poorer outcome than those who had never smoked. Current smokers also had a greater risk of recurrent events than past smokers (HR, 1.23; 95% CI, 1.00-1.50; P=0.050). CONCLUSIONS: Patients who smoked at the time of their stroke or had smoked before their stroke had greater risk of death or recurrent vascular events when compared with patients who were never smokers. There are benefits of smoking cessation, with ex-smokers appearing to have a lesser risk of recurrent vascular events than current smokers.
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Cese del Hábito de Fumar/estadística & datos numéricos , Fumar/mortalidad , Accidente Cerebrovascular/mortalidad , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Masculino , Infarto del Miocardio/mortalidad , Modelos de Riesgos Proporcionales , Recurrencia , Factores de RiesgoRESUMEN
Genome-wide association studies (GWAS) have not consistently detected replicable genetic risk factors for ischemic stroke, potentially due to etiological heterogeneity of this trait. We performed GWAS of ischemic stroke and a major ischemic stroke subtype (large artery atherosclerosis, LAA) using 1,162 ischemic stroke cases (including 421 LAA cases) and 1,244 population controls from Australia. Evidence for a genetic influence on ischemic stroke risk was detected, but this influence was higher and more significant for the LAA subtype. We identified a new LAA susceptibility locus on chromosome 6p21.1 (rs556621: odds ratio (OR)=1.62, P=3.9×10(-8)) and replicated this association in 1,715 LAA cases and 52,695 population controls from 10 independent population cohorts (meta-analysis replication OR=1.15, P=3.9×10(-4); discovery and replication combined OR=1.21, P=4.7×10(-8)). This study identifies a genetic risk locus for LAA and shows how analyzing etiological subtypes may better identify genetic risk alleles for ischemic stroke.
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Infarto Cerebral/genética , Cromosomas Humanos Par 6 , Arteriosclerosis Intracraneal/genética , Polimorfismo de Nucleótido Simple , Estudios de Casos y Controles , Predisposición Genética a la Enfermedad , Estudio de Asociación del Genoma Completo , Humanos , Desequilibrio de Ligamiento , Oportunidad RelativaRESUMEN
BACKGROUND AND PURPOSE: Ischemic stroke (IS) shares many common risk factors with coronary artery disease (CAD). We hypothesized that genetic variants associated with myocardial infarction (MI) or CAD may be similarly involved in the etiology of IS. To test this hypothesis, we evaluated whether single-nucleotide polymorphisms (SNPs) at 11 different loci recently associated with MI or CAD through genome-wide association studies were associated with IS. METHODS: Meta-analyses of the associations between the 11 MI-associated SNPs and IS were performed using 6865 cases and 11 395 control subjects recruited from 9 studies. SNPs were either genotyped directly or imputed; in a few cases a surrogate SNP in high linkage disequilibrium was chosen. Logistic regression was performed within each study to obtain study-specific ßs and standard errors. Meta-analysis was conducted using an inverse variance weighted approach assuming a random effect model. RESULTS: Despite having power to detect odds ratio of 1.09-1.14 for overall IS and 1.20-1.32 for major stroke subtypes, none of the SNPs were significantly associated with overall IS and/or stroke subtypes after adjusting for multiple comparisons. CONCLUSIONS: Our results suggest that the major common loci associated with MI risk do not have effects of similar magnitude on overall IS but do not preclude moderate associations restricted to specific IS subtypes. Disparate mechanisms may be critical in the development of acute ischemic coronary and cerebrovascular events.
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Isquemia Encefálica/genética , Estudio de Asociación del Genoma Completo , Desequilibrio de Ligamiento , Infarto del Miocardio/genética , Polimorfismo de Nucleótido Simple , Accidente Cerebrovascular/genética , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
OBJECTIVE: To report Australian outcomes from the Safe Implementation of Thrombolysis in Stroke International Stroke Thrombolysis Register (SITS-ISTR). DESIGN: Observational study using data collected prospectively from December 2002 to December 2008. SETTING: Centres administering thrombolysis for acute stroke in Australia and worldwide. PATIENTS: All patients treated with recombinant tissue plasminogen activator for acute stroke in participating centres, regardless of stroke severity, time of treatment and other clinical factors. INTERVENTION: Thrombolysis for acute stroke, administered according to local protocol. MAIN OUTCOME MEASURES: Functional outcome as 3-month modified Rankin score (mRS), and frequency of symptomatic intracerebral haemorrhage (ICH). RESULTS: During the study period, a total of 32 countries participated, and confirmed baseline data were available for 581 Australian patients and 20 953 patients in the rest of the world. Australian patients were older (median age, 73 v 69 years; P < 0.001), were less independent before stroke (premorbid mRS of 0-1, 87.5% v 91.2%; P < 0.005), and had more comorbidities and more severe strokes. Comparing the Australian cohort with the rest of the world, the odds ratio of 3-month mRS of 0-2 was 0.98 (95% CI, 0.88-1.08; P = 0.63), the odds ratio of symptomatic ICH was 0.98 (95% CI, 0.83-1.16; P = 0.85 [by the definition used by the National Institute of Neurological Disorders]) and the odds ratio of death was 1.04 (95% CI, 0.91-1.19; P = 0.54). Good outcome in the Australian cohort was predicted by younger age, presence of hyperlipidaemia, lower premorbid mRS, absence of infarct on early brain imaging, less severe stroke, and lower baseline blood glucose level. CONCLUSION: Clinical outcomes after thrombolysis in Australia were similar to those worldwide.
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Fibrinolíticos/uso terapéutico , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica , Activador de Tejido Plasminógeno/uso terapéutico , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Australia , Femenino , Fibrinolíticos/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Sistema de Registros , Terapia Trombolítica/efectos adversos , Activador de Tejido Plasminógeno/efectos adversos , Resultado del TratamientoAsunto(s)
Protección a la Infancia , Etnicidad , Accidente Cerebrovascular/etnología , Accidente Cerebrovascular/epidemiología , Salud de la Mujer/etnología , Niño , Protección a la Infancia/etnología , Preescolar , Femenino , Humanos , Incidencia , Masculino , Embarazo , Factores de Riesgo , Accidente Cerebrovascular/etiologíaRESUMEN
BACKGROUND: Handicap is rarely comprehensively examined after stroke. We examined handicap among 5-year stroke survivors from an 'ideal' stroke incidence study. METHODS: Survivors were assessed with the London Handicap Scale [LHS, score range: 0 (greatest handicap) to 100 (least handicap)]. Multivariable regression was used to examine demographic, risk and stroke-related factors associated with handicap. RESULTS: 351 of 441 (80%) survivors were assessed. Those assessed were more often Australian born than those not assessed (p < 0.05). The mean LHS score was 73 (SD = 21). The greatest handicap was present for physical independence and occupation/leisure items. Handicap was associated with older age, manual occupations, smoking, initial stroke severity, recurrent stroke and mood disorders. CONCLUSION: Reducing recurrent stroke, through better risk factor management, is likely to reduce handicap. The association between handicap and mood disorders, which are potentially modifiable, warrants further investigation.
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Personas con Discapacidad/estadística & datos numéricos , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/epidemiología , Factores de Edad , Anciano , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Trastornos del Humor , Análisis Multivariante , Recuperación de la Función/fisiología , Factores de Riesgo , Índice de Severidad de la Enfermedad , Fumar , Accidente Cerebrovascular/fisiopatología , Victoria/epidemiologíaRESUMEN
BACKGROUND AND PURPOSE: Incidence rates of stroke subtypes may be imprecise when samples are small. We aimed to determine the incidence of stroke subtypes in a large geographically defined population. METHODS: Multiple overlapping sources were used to ascertain all strokes occurring in 22 postcodes (population of 306,631) of Melbourne, Australia, between 1997 and 1999. Stroke subtypes were defined by CT, MRI and autopsy. The Mantel-Haenszel age-adjusted rate ratio (MH RR) was used to compare incidence rates between men and women. RESULTS: We identified 1,421 strokes among 1,337 residents, 1,035 (72.8%) being first-ever strokes. Incidence (number/100,000 population/year), adjusted to the European population 45-84 years, was 197 (95% confidence interval, CI, 169-224) for ischemic stroke (IS), 47 (95% CI 33-60) for intracerebral haemorrhage (ICH) and 19 (95% CI 10-27) for subarachnoid haemorrhage (SAH). Compared with women, men in this age group had a greater incidence of IS (MH RR 1.65, 95% CI 1.39-1.96, p < 0.0001) and ICH (MH RR 1.46, 95% CI 1.01-2.10, p = 0.0420), but lesser rates of SAH (MH RR 0.34, 95% CI 0.16-0.69, p = 0.0031). CONCLUSIONS: In this population-based study, the incidence of IS and ICH was greater among men than women, while women had a greater incidence of SAH. More effort may need to be directed at modifying risk factors for IS and ICH in men.
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Caracteres Sexuales , Accidente Cerebrovascular/clasificación , Accidente Cerebrovascular/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Vigilancia de la Población/métodos , Factores de Riesgo , Accidente Cerebrovascular/patología , Victoria/epidemiología , Adulto JovenRESUMEN
BACKGROUND: Specific information about the nature of recurrent events that occur after each subtype of index stroke may be useful for refining preventive therapies. We aimed to determine whether stroke recurrence rates, the pattern of subtype recurrence, and prescription of secondary prevention agents differed according to initial stroke subtype. METHODS: Multiple overlapping sources were used to recruit all first-ever stroke patients from a geographically defined region of Melbourne, Australia over a 3-year period from 1996 to 1999. Potential stroke recurrences (fatal and nonfatal) occurring within 2 years of the initial event were identified following patient interview and follow up of death records. Subjects were classified into the different Oxfordshire groups and the type of first-ever stroke was compared with recurrent stroke events. RESULTS: One thousand, three hundred and sixteen first-ever strokes were registered during the 3-year period (mean age 74.4 years). A total of 103 first recurrent stroke events (fatal and nonfatal) occurred among those with a first-ever ischemic stroke or intracerebral hemorrhage (ICH) during the 2-year follow-up period. The recurrent stroke subtype was different to the index stroke subtype in most (78%) patients. People with partial anterior circulation infarct had the greatest proportion of recurrences (13%), with a third of these being the more severe total anterior circulation infarct subgroup. The relative risk of ICH after an index lacunar infarct (LACI) compared with an index non-LACI was 4.06 (95% CI 1.10-14.97, P=0.038). Prescription of secondary prevention agents was greater at 2 years after stroke than at hospital discharge, and was similar between ischemic stroke subtypes. CONCLUSION: Approximately 9% of people with first-ever stroke suffered a recurrent event, despite many being prescribed secondary prevention agents. This has implications for the uptake of current preventive strategies and the development of new strategies. The possibility that ICH is greater among index LACI cases needs to be confirmed.
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Accidente Cerebrovascular/epidemiología , Consumo de Bebidas Alcohólicas/efectos adversos , Complicaciones de la Diabetes , Cardiopatías/complicaciones , Humanos , Hipertensión/complicaciones , Incidencia , Recurrencia , Factores de Riesgo , Fumar/efectos adversos , Accidente Cerebrovascular/prevención & control , Victoria/epidemiologíaRESUMEN
BACKGROUND AND PURPOSE: There are few data on the prevalence or treatment of depression from unselected populations long-term poststroke. We assessed the prevalence of depression and antidepressant use at 5-years poststroke in an unselected stroke population. METHODS: Five-year survivors from a prospective community-based stroke incidence study were assessed for depression with the Irritability, Depression and Anxiety Scale. Medications indicated primarily for treatment of depression were recorded. RESULTS: At 5-years poststroke, 441 (45%) of 978 incident cases were alive (mean age=74+/-15 years, 49% female). Seventeen percent of those assessed were depressed. Twenty-two percent with depression were taking an antidepressant medication. Of those taking an antidepressant, 72% were not depressed. CONCLUSIONS: Although nearly one-fifth of survivors were depressed, few were taking antidepressants. Further exploration of this low level of treatment is warranted.
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Antidepresivos/uso terapéutico , Trastorno Depresivo/tratamiento farmacológico , Trastorno Depresivo/epidemiología , Accidente Cerebrovascular/tratamiento farmacológico , Accidente Cerebrovascular/epidemiología , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Trastorno Depresivo/psicología , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Prospectivos , Accidente Cerebrovascular/psicología , Victoria/epidemiologíaRESUMEN
INTRODUCTION: Brief cognitive tests such as the Mini-mental State Examination (MMSE) and the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) have been used to detect cognitive impairment and dementia in studies of stroke patients. However, there are few data on their validity for such use. We have evaluated their validity in detecting cognitive impairment not dementia (CIND) and dementia in a community-based sample of first-ever stroke patients. METHODS: The standardized MMSE (S-MMSE) and the 16-item IQCODE were administered to 79 patients 1 year after a first-ever stroke. CIND and dementia were diagnosed independently using a comprehensive cognitive battery. The performances of the two tests were evaluated using receiver operating characteristic (ROC) analyses. Combined performance was evaluated when their scores were used in parallel (the "or rule"), in series (the "and rule") or as a weighted sum (the "weighted sum rule"). RESULTS: Both tests were extremely poor at detecting CIND individually and in combination. For dementia, at traditional cut-points, the S-MMSE (< or =23) was insensitive (0.50, 95% CI 0.16-0.84) and the IQCODE (> or =3.30) nonspecific (0.63, 95% CI 0.51-0.75). An acceptable balance between sensitivity and specificity was achieved for dementia using the "or rule" combination, but with only modest positive predictive value. CONCLUSIONS: The S-MMSE and the IQCODE were individually poor at detecting CIND and dementia after a nonaphasic first-ever stroke. The combination was useful in detecting dementia but it does not replace the need for detailed neuropsychological tests.
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Enfermedad de Alzheimer/diagnóstico , Trastornos del Conocimiento/diagnóstico , Demencia/diagnóstico , Accidente Cerebrovascular/complicaciones , Anciano , Enfermedad de Alzheimer/clasificación , Enfermedad de Alzheimer/etiología , Australia/epidemiología , Trastornos del Conocimiento/clasificación , Trastornos del Conocimiento/etiología , Demencia/clasificación , Demencia/etiología , Diagnóstico Diferencial , Humanos , Incidencia , Tamizaje Masivo/métodos , Pruebas Psicológicas , Análisis de Regresión , Reproducibilidad de los Resultados , Accidente Cerebrovascular/epidemiologíaRESUMEN
BACKGROUND AND PURPOSE: Greater stroke mortality has been reported among lower socioeconomic groups. We aimed to determine whether fatal, nonfatal, and overall stroke incidence varied by socioeconomic status. METHODS: All suspected strokes occurring in 22 postcodes (population of 306,631) of Melbourne, Australia, during a 24-month period between 1997 and 1999 were found and assessed. Multiple overlapping sources were used to ascertain cases with standard clinical definitions for stroke. Socioeconomic disadvantage was assigned in 4 bands from least to greatest using an area-based measure developed by the Australian Bureau of Statistics. RESULTS: Overall stroke incidence (number per 100,000 population per year), adjusted to the European population 45 to 84 years of age, increased with increasing socioeconomic disadvantage: 200 (95% CI, 173 to 228); 251 (95% CI, 220 to 282); 309 (95% CI, 274 to 343); and 366 (95% CI, 329 to 403; chi2 for ranks; P<0.0001). Similar incidence patterns were observed for both fatal and nonfatal stroke. Nonfatal stroke contributed most to this incidence pattern: 146 (95% CI, 122 to 169); 181 (95% CI, 155 to 207); 223 (95% CI, 194 to 252); and 280 (95% CI, 247 to 313; chi2 for ranks; P<0.0001). CONCLUSIONS: In this population-based study, both fatal and nonfatal stroke incidence increased with increasing socioeconomic disadvantage. The greater contributor to this incidence pattern was nonfatal stroke incidence. This may have implications for service provision to those least able to afford it. Area-based identification of those most disadvantaged may provide a simple and effective way of targeting regions for stroke prevention strategies.
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Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/prevención & control , Anciano , Australia , Trastornos Cerebrovasculares/diagnóstico , Trastornos Cerebrovasculares/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Oportunidad Relativa , Control de Calidad , Clase Social , Factores de TiempoRESUMEN
BACKGROUND AND PURPOSE: Although much is known about the long-term outcome of stroke patients in terms of mortality and disability, there has been little research on the patient-centered outcome of health-related quality of life (HRQoL). There are limited natural history data on HRQoL beyond 2 years after stroke and no data on those factors present at stroke onset that predict HRQoL beyond 2 years after stroke. For these reasons, we aimed to examine these aspects of HRQoL in an unselected population of stroke patients. METHODS: All cases of first-ever stroke from a prospective community-based stroke incidence study (excluding subarachnoid hemorrhage) were assessed 5 years after stroke. HRQoL was measured with the assessment of quality of life instrument. ANOVA was used to determine baseline predictors of HRQoL. RESULTS: In total, 978 cases were recruited, 45% were male, and the mean age (+/-SD) was 75.5+/-13.8 years. Five years after stroke, 441 (45.1%) were alive and 356 were assessed (80.7%). Those assessed were more often born in Australia and older in age (both P<0.05). Seventy-one survivors (20%) had a very low HRQoL (score < or =0.1). The independent baseline predictors of low HRQoL at 5 years after stroke were increasing age, lower socioeconomic status, and markers of stroke severity. CONCLUSIONS: At 5 years after stroke, we found that a substantial proportion of survivors were suffering from poor HRQoL. As our population ages, the number of strokes and, thus, stroke survivors with poor HRQoL is likely to increase. Therefore, strategies to improve HRQoL should be vigorously pursued.
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Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/terapia , Factores de Edad , Anciano , Análisis de Varianza , Australia , Ensayos Clínicos como Asunto , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Calidad de Vida , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores Socioeconómicos , Accidente Cerebrovascular/diagnóstico , Encuestas y Cuestionarios , Sobrevivientes , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Although a number of acute stroke interventions are of proven efficacy, there is uncertainty about their community benefits. We aimed to assess this within a defined population. METHODS: Eligibility for tissue plasminogen activator (tPA), aspirin, stroke unit management and neuroprotection were assessed among incident stroke cases within the community-based North East Melbourne Stroke Incidence Study. RESULTS: Among 306,631 people, there were 645 incident strokes managed in hospital. When eligible patients were extrapolated to the Australian population, for every 1,000 cases, 46 (95% CI 17-69) could have been saved from death or dependency with stroke unit management, 6 (95% CI 1-11) by using aspirin, 11 (95% CI 5-17) or 10 (95% CI 3-16) by using tPA at 3 and 6 h, respectively. CONCLUSIONS: Although tPA is the most potent intervention, management in stroke units has the greatest population benefit and should be a priority.
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Aspirina/uso terapéutico , Fibrinolíticos/uso terapéutico , Unidades Hospitalarias/estadística & datos numéricos , Accidente Cerebrovascular/tratamiento farmacológico , Activador de Tejido Plasminógeno/uso terapéutico , Enfermedad Aguda , Anciano , Australia/epidemiología , Servicios Médicos de Urgencia , Femenino , Humanos , Incidencia , Masculino , Fármacos Neuroprotectores/uso terapéutico , Evaluación de Resultado en la Atención de Salud , Factores de Riesgo , Accidente Cerebrovascular/mortalidadRESUMEN
Viral encephalitis is associated with significant morbidity and mortality, particularly when appropriate management is omitted as a result of delayed diagnosis. A case of herpes simplex virus type 1 (HSV-1) encephalitis is presented, demonstrating that the presentation of confusion, speech difficulties and fever with non-specific early brain CT appearances can easily be misdiagnosed as pneumonia with stroke. This case highlights the need for increased awareness of HSV-1 encephalitis among emergency physicians and radiologists, given that the early spectrum of clinical and CT findings can mimic the more common diagnoses of sepsis and stroke.
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Encefalitis por Herpes Simple/diagnóstico , Herpesvirus Humano 1 , Accidente Cerebrovascular/diagnóstico , Aciclovir/uso terapéutico , Anciano de 80 o más Años , Confusión/etiología , Diagnóstico Diferencial , Encefalitis por Herpes Simple/líquido cefalorraquídeo , Encefalitis por Herpes Simple/complicaciones , Encefalitis por Herpes Simple/virología , Femenino , Herpesvirus Humano 1/aislamiento & purificación , Humanos , Resultado del TratamientoRESUMEN
BACKGROUND AND PURPOSE: Health-related quality of life (HRQoL) data are scarce from unselected populations. The aims were to assess HRQoL at 2 years poststroke, to identify determinants of HRQoL in stroke survivors, and to identify predictors at stroke onset of subsequent HRQoL. METHODS: All first-ever cases of stroke in a population of 306 631 over a 1-year period were assessed. Stroke severity, comorbidity, and demographic information were recorded. Two-year poststroke HRQoL was assessed using the Assessment of Quality of Life (AQoL) instrument (deceased patients score=0). Handicap, disability, physical impairment, depression, anxiety, living arrangements, and recurrent stroke at 2 years were documented. If necessary, proxy assessments were obtained, except for mood. Linear regression analyses were performed to identify factors independently associated with HRQoL. RESULTS: Of 266 incident cases alive at 2 years, 225 (85%) were assessed. The mean AQoL utility score for all survivors was 0.47 (95% CI, 0.42 to 0.52). Almost 25% of survivors had a score of < or =0.1. The independent determinants of HRQoL in survivors were handicap, physical impairment, anxiety and depression, disability, institutionalization, dementia, and age. The factors present at stroke onset that independently predicted HRQoL at 2 years poststroke were age, female sex, initial NIHSS score, neglect, and low socioeconomic status. CONCLUSIONS: A substantial proportion of stroke survivors have very poor HRQoL. Interventions targeting handicap and mood have the potential to improve HRQoL independently of physical impairment and disability.
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Calidad de Vida , Accidente Cerebrovascular/fisiopatología , Sobrevivientes , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Perfil de Impacto de EnfermedadRESUMEN
BACKGROUND AND PURPOSE: Handicap, although more relevant to the patient than impairment or disability, has received little attention in people with stroke. The aim of this study was to identify, in an unselected population, factors determining handicap at 2 years after stroke. METHODS: All first-ever cases of stroke in a population of 306 631 over a 1-year period were assessed. Stroke severity, comorbidity, and demographic information was recorded. Among survivors, 2-year poststroke handicap was assessed with the London Handicap Scale. Disability, physical impairment, depression, anxiety, living arrangements, and recurrent stroke at 2 years were documented. If necessary, proxy assessments were obtained, except for mood. Linear regression analyses were performed to identify factors independently associated with handicap. First, all assessments (proxy and nonproxy) were examined; then, the nonproxy assessments were used to examine the effects of mood. RESULTS: Of 266 patients with incident stroke who were alive at 2 years, 226 (85%) were assessed. Significant determinants of handicap on univariable analysis were age, female sex, socioeconomic status, alcohol intake, stroke subtype, initial stroke severity; 2-year physical impairment, disability, depression and anxiety scores; institutionalization; and recurrent stroke. On multivariable analysis, the independent determinants of handicap were age and 2-year physical impairment and disability. In analysis restricted to nonproxy data, depression and anxiety were also independently associated with handicap. CONCLUSIONS: Age, concurrent disability, and physical impairment were more important determinants of handicap than other demographic factors or initial stroke severity. Because depression and anxiety were independently associated with handicap, their treatment may potentially reduce handicap in stroke patients.
Asunto(s)
Evaluación de la Discapacidad , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/fisiopatología , Población Urbana/estadística & datos numéricos , Adulto , Distribución por Edad , Factores de Edad , Anciano , Anciano de 80 o más Años , Consumo de Bebidas Alcohólicas/epidemiología , Ansiedad/diagnóstico , Ansiedad/epidemiología , Australia/epidemiología , Comorbilidad , Depresión/diagnóstico , Depresión/epidemiología , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Análisis Multivariante , Calidad de Vida , Recurrencia , Índice de Severidad de la Enfermedad , Factores Sexuales , Clase Social , Accidente Cerebrovascular/clasificación , TiempoRESUMEN
BACKGROUND AND PURPOSE: Generic utility health-related quality of life instruments are useful in assessing stroke outcome because they facilitate a broader description of the disease and outcomes, allow comparisons between diseases, and can be used in cost-benefit analysis. The aim of this study was to validate the Assessment of Quality of Life (AQoL) instrument in a stroke population. METHODS: Ninety-three patients recruited from the community-based North East Melbourne Stroke Incidence Study between July 13, 1996, and April 30, 1997, were interviewed 3 months after stroke. Validity of the AQoL was assessed by examining associations between the AQoL and comparator instruments: the Medical Outcomes Short-Form Health Survey (SF-36); London Handicap Scale; Barthel Index; National Institutes of Health Stroke Scale; and Irritability, Depression, Anxiety scale. Sensitivity of the AQoL was assessed by comparing AQoL scores from groups of patients categorized by severity of impairment and disability and with total anterior circulation syndrome (TACS) versus non-TACS. Predictive validity was assessed by examining the association between 3-month AQoL scores and outcomes of death or institutionalization 12 months after stroke. RESULTS: Overall AQoL utility scores and individual dimension scores were most highly correlated with relevant scales on the comparator instruments. AQoL scores clearly differentiated between patients in categories of severity of impairment and disability and between patients with TACS and non-TACS. AQoL scores at 3 months after stroke predicted death and institutionalization at 12 months. CONCLUSIONS: The AQoL demonstrated strong psychometric properties and appears to be a valid and sensitive measure of health-related QoL after stroke.
Asunto(s)
Entrevista Psicológica/normas , Pruebas Psicológicas/normas , Calidad de Vida/psicología , Perfil de Impacto de Enfermedad , Rehabilitación de Accidente Cerebrovascular , Accidente Cerebrovascular/psicología , Adulto , Anciano , Anciano de 80 o más Años , Australia/epidemiología , Evaluación de la Discapacidad , Femenino , Estudios de Seguimiento , Humanos , Institucionalización , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Recuperación de la Función , Sensibilidad y Especificidad , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/mortalidad , Resultado del TratamientoRESUMEN
Although precipitation of seizures by exercise has been described, the reproducible induction of temporal lobe seizures by exercise is unusual. The authors report two patients with left temporal lobe seizures induced by exercise. In one patient the family history suggested autosomal-dominant inheritance. Prolonged hyperventilation, simple movements, and visualization of a competitive game did not produce epileptiform discharges on the interictal EEG.