Sociodemographic differences in return to work after stroke: the South London Stroke Register (SLSR).

BACKGROUND: Loss of employment contributes significantly to the burden of stroke on individuals and society. There is limited information on factors influencing return to work after stroke. OBJECTIVES: To investigate the frequency and determinants of return to paid work after stroke in a multi-ethnic urban population. METHODS: Patterns of return to work were examined among people with first ever stroke registered in the population based South London Stroke Register. Employment status and functional outcome (Barthel Index (BI), Frenchay Activity Index (FAI)) were assessed 1 year after stroke. Associations between baseline characteristics and return to paid work were analysed by multivariable logistic regression analysis. RESULTS: Among 2874 patients with first ever strokes in 1995-2004, 400 (15%) were working before the stroke. At 1 year, 94 (35%) of 266 survivors had returned to paid work. Black ethnicity (OR 0.41; 95% CI 0.19 to 0.88), female sex (0.43; 0.21 to 0.91), older age (p<0.001), diabetes (0.25; 0.08 to 0.79) and dependence (BI < or = 19) in the acute phase (0.24; 0.11 to 0.49) were independently associated with lower odds of return to work in multivariable analysis. Better functional outcome at 1 year was associated with return to paid work (p<0.001) but 53% of 161 independent (BI > 19) and 39% of 96 very active (FAI > 30/45) individuals had not resumed work. CONCLUSIONS: There were important sociodemographic differences in return to work after stroke that were independent of clinical and service use variables included in the analysis. A large proportion of patients did not resume work despite excellent functional outcome.

Venous thromboembolism after acute ischemic stroke: a prospective study using magnetic resonance direct thrombus imaging.

BACKGROUND AND PURPOSE: We prospectively evaluated the prevalence and clinical risk factors for venous thromboembolism (VTE) after acute ischemic stroke using magnetic resonance direct thrombus imaging, a highly accurate noninvasive technique that directly visualizes thrombus.Method-102 unselected patients with AIS receiving standard prophylaxis with aspirin and graded compression stockings (GCS) were sequentially recruited, underwent regular clinical assessments, and were screened for VTE. RESULTS: The prevalence of all VTE, proximal deep vein thrombosis (PDVT), and pulmonary embolism (PE) after 21 days were 40%, 18%, and 12%, increasing to 63%, 30%, and 20% in patients with Barthel indices (BI) of < or =9 2 days after stroke (BI-2< or =9). Clinical deep vein thrombosis and PE occurred in 3% and 5% overall; half these events were overlooked by the attending team. The true incidence of clinical events is probably higher because the natural history of subclinical PDVT was modified by screening and anticoagulation. BI-2< or =9 or nonambulatory status 2 days after stroke were the clinical factors most strongly associated with subsequent VTE on univariate analysis. Odds ratios for any VTE and PDVT for BI-2< or =9 versus >9 were 8.3 (95% CI, 2.7 to 25.2) and 8.1 (95% CI, 1.7 to 38.3) on multivariable analysis. CONCLUSIONS: BI < or =9 or nonambulatory status around the time of admission identifies a subgroup of acute ischemic stroke patients at very high risk for VTE in whom the current strategy of thromboprophylaxis may be inadequate. Future thromboprophylactic studies should focus on the patients at high risk defined in this study.

Screening for proximal deep vein thrombosis after acute ischemic stroke: a prospective study using clinical factors and plasma D-dimers.

Deep vein thrombosis (DVT) remains common in patients with acute ischemic stroke (AIS) receiving aspirin and graded compression stockings (considered standard thromboprophylaxis in the UK), most events occurring in patients with Barthel indices (BI) of <9 ('severe stroke') around the time of admission. In the absence of data indicating improved clinical outcomes with use of low-dose anticoagulant thromboprophylaxis, we evaluated the hypothesis that plasma D-dimers (D-d) might be a valuable initial screening test for proximal DVT (PDVT), facilitating selective use of imaging. One hundred and two unselected AIS-patients receiving aspirin/graded compression stockings thromboprophylaxis were screened for DVT using magnetic resonance direct thrombus imaging, a highly accurate non-invasive technique which directly visualizes thrombus. D-d (VIDAS and IL test D-d assays) were measured on recruitment and at weekly intervals. Median D-d were significantly higher throughout the study in patients with severe stroke who developed PDVT vs. those with severe stroke not developing PDVT, differences being most marked around day 9. Depending on the discriminatory threshold used, a single D-d measurement at this time in patients with severe-AIS allowed identification of a subgroup with ~50% prevalence of PDVT. Sensitivity of these strategies for PDVT was 67-83%, at a cost of imaging 22-30% of the entire cohort of patients. A single measurement of BI around the time of admission and D-d level at day 9 in AIS-patients receiving aspirin/graded compression stockings thromboprophylaxis allows identification of a subgroup containing a substantial proportion of all PDVTs who could be selectively imaged.

Reliability and validity of a postal version of the Reintegration to Normal Living Index, modified for use with stroke patients.

OBJECTIVE: To adapt the Reintegration to Normal Living Index (RNLI) for postal use with stroke patients. DESIGN: Reliability was examined using test-retest on 26 stroke patients. Construct validity was tested on 76 patients by examining correlations between the modified RNLI and related scales. SUBJECTS: Patients at three months to one year post stroke. RESULTS: All items demonstrated better than chance agreement between test and retest and seven items substantial agreement (kappa = >0.61). The modified RNLI correlated positively with related scales. Patients with stronger reintegration to normal living had better outcomes in anxiety, depression, daily activity and quality of life. CONCLUSION: This postal instrument appears reliable and valid and may be a useful outcome measure in stroke studies.

Incidence and case fatality rates of stroke subtypes in a multiethnic population: the South London Stroke Register.

OBJECTIVE: To identify sociodemographic differences in the incidence of the subtypes of first ever stroke in a multiethnic population. METHODS: A prospective community stroke register (1995-8) was developed using multiple notification sources and pathological and clinical classifications of stroke. Standardisation of rates was to European and World populations and adjusted for age, sex and socioeconomic status in multivariate analyses. A multiethnic population of 234 533 in south London, of whom 21% are black was studied. RESULTS: A total of 1254 cases were registered. The average age of stroke was 71.7 years with black patients being 11.3 years younger than white patients (p<0.0001). The incidence rate/1000 population was 1.33 (crude) (95% CI 1.26 to 1.41), 1.28 (European adjusted) (95% CI 1.2 to 1.35) with a 2.18 (95% CI 1.86 to 2.56) (p<0.0001) age and sex adjusted incidence rate ratio in the black population. Radiological diagnosis was confirmatory in 1107 (88.3%) with 862 (68.7%) infarction, 168 (13.4%) primary intracerebral haemorrhage, and 77 (6.2%) subarachnoid haemorrhage. Of the cerebral infarction cases 189 (21.9%) were total anterior circulatory, 250 (29%) partial anterior, 141 (16.4%) posterior (POCI) and 282 (32.7%) lacunar infarcts. The black group had a significantly higher incidence of all subtypes of stroke except for POCI and unclassified strokes. The incidence rate ratio (IRR) for men compared with women was 1.34 (95% confidence interval (95% CI) 1.19 to 1.50; p<0.001). The IRR for manual versus non-manual occupations in those aged 35-64 years was 1.64 (95%CI 1.22 to 2.23; p<0.0001). There was a borderline significant increase in adjusted survival at 6 months in the black group 95% (CI 0.61 to 1.03, p=0.078) with a hazard ratio of 0.79 after adjustment and stratification. CONCLUSIONS: Although the black population is at increased risk of stroke and most subtypes of stroke, this is not translated into significant differences in survival. Hence black/white differences in mortality are mainly driven by incidence of stroke. There are striking demographic inequalities in the risk of stroke in this multiethnic inner city population that need to be tackled through interagency working. Although the reasons for the increased risk in the black population are unclear, demographic factors such as socioeconomic status do seem to play a significant independent part.

The inter- and intraobserver reliabilities of a new classification system for ischaemic stroke: the South London Stroke Register.

OBJECTIVES: This study aims to determine the inter- and intraobserver reliabilities of an aetiological classification devised as part of a community-based stroke register. METHODS: Patients with first-ever acute ischaemic stroke were clinically assessed and received investigation according to a set protocol. Results of the clinical assessment and investigations were used to determine an aetiological stroke subtype for each patient by observer 1. Aetiological subtypes consisted of extracranial large artery atherosclerosis (LAAec), intracranial large artery atherosclerosis (LAAic), high-risk cardioembolism (CH), medium-risk cardioembolism (CM), small vessel occlusion (SVO), other aetiology (OTH), no aetiology identified (NA) and multiple probable or multiple possible aetiology (MPA). The same data were distributed to a further four observers along with the criteria for the classification system. Two of the observers were retested on the same patients after of period of 8 weeks. Inter- and intraobserver agreement was determined using the kappa statistic, which gives the chance-adjusted percentage agreement. RESULTS: Forty-five consecutive patients were included. The overall kappa statistic for ischaemic stroke was 0.91 indicating excellent agreement. Kappa statistics were highest for the more frequent subtypes of SVO (0.97) and CH (0.97). Substantially high kappa statistics were also obtained for the less-frequent categories of LAAec (0.91), CM (0.84), NA (0.89) and MPA (0.87). A low kappa statistic was obtained for the category OTH (0.16), which had a low frequency of reporting, indicating poor agreement. The kappa statistic for probable categories was higher than the kappa statistic for all stroke subtypes at 0.96. Intraobserver agreement between first and second assignments of subtype diagnoses for both observers reached excellent agreement with kappa statistics of 0.83 and 0.85. CONCLUSION: The aetiological classification system, designed for use in the investigation of the epidemiology, stroke subtype and their relation to the natural history of stroke in a multiethnic inner city population, allows high inter- and intrarater agreements of subtype diagnosis.

Recovery from poststroke urinary incontinence: associated factors and impact on outcome.

OBJECTIVES: To determine factors associated with recovery from poststroke urinary incontinence and to estimate the impact of this recovery on stroke outcome at 3 months. DESIGN: Prospective, observational study. SETTING: Population-based stroke register. PARTICIPANTS: Three hundred twenty-four incident cases of stroke with incontinence 1 week poststroke were identified from the register between January 1, 1995, and December 31, 1998. MEASUREMENTS: At 3 months, 105 patients were dead and 12 were lost to follow-up. The remaining patients were classified by continence status; those who had regained continence (n = 127) were compared with those who remained incontinent (n = 80) in terms of demographic details, stroke risk factors, premorbid disability, neurological impairments, and Oxfordshire Community Stroke Project stroke subtypes. Data at 3 months included disability using the modified Barthel Index (BI) (without its urinary continence component) and the Frenchay Activity Index (FAI), and institutionalization. RESULTS: Multivariate analysis showed being age 75 and older (odds ratio (OR) = 0.38; 95% confidence interval (CI) = 0.17-0.83) was associated with poor recovery from incontinence. Compared with subjects with total anterior circulatory infarctions, those with lacunar infarctions were more likely to regain continence (OR = 3.66; 95% CI =1.10-12.2), and compared with subjects with a BI between 0 and 14, those with a BI between 15 and 18 were also more likely to regain continence (OR = 21.8; 95% CI = 5.95-79.7). At 3 months, the incontinent group had greater institutionalization rates (27 (34%) vs 9 (7%), P <.001) and worse disability, measured with BI and FAI (BI: P <.001, FAI: P =.002). CONCLUSIONS: Age 75 and older is independently associated with poor recovery from poststroke urinary incontinence. Further clinical trials are required to explore underlying mechanisms and efficacy of possible interventions for this group of stroke survivors. Recovery from poststroke urinary incontinence should be a major goal of stroke professionals because it is associated with lower institutionalization rates and less disability at 3 months.

Estimates of the prevalence of acute stroke impairments and disability in a multiethnic population.

BACKGROUND AND PURPOSE: The goals of the present study were to estimate the prevalence of acute impairments and disability in a multiethnic population of first-ever stroke and to identify differences in impairment and early disability between pathological and Bamford subtypes. Associations between impairments and death and disability at 3 months were identified. METHODS: Impairments that occur at the time of maximum neurological deficit were recorded, and disability according to the Barthel Index (BI) was assessed 1 week and 3 months after stroke in patients in the South London Stroke Register: RESULTS: Of 1259 registered patients, 6% had 1 or 2, 31.1% had 3 to 5, 50.6% had 6 to 10, and 10.6% had >10 impairments. Common impairments were weakness (upper limb, 77.4%), urinary incontinence (48.2%), impaired consciousness (44.7%), dysphagia (44.7%), and impaired cognition (43.9%). Patients with total anterior circulation infarcts had the highest age-adjusted prevalence of weakness, dysphagia, urinary incontinence, cognitive impairment, and disability. Patients with subarachnoid hemorrhage had the highest rates of coma. Patients with lacunar stroke had the high prevalence of weakness but were least affected by disability, incontinence, and cognitive dysfunction. Blacks had higher age- and sex-adjusted rates of disability in ischemic stroke (BI <20, odds ratio 2.76, 95% CI 1.47 to 5.21, P=0.002; BI <15, odds ratio 1.8, 95% CI 1.45 to 2.81, P=0.01) but impairment rates similar to those of whites. On multivariable analysis, incontinence, coma, dysphagia, cognitive impairment, and gaze paresis were independently associated with severe disability (BI <10) and death at 3 months. CONCLUSIONS: The extent of these findings indicates that an acute assessment of impairments and disability is necessary to determine the appropriate nursing and rehabilitation needs of patients with stroke.

Natural history and effects on 2-year outcomes of urinary incontinence after stroke.

BACKGROUND AND PURPOSE: We sought to describe the natural history of poststroke incontinence and estimate its effect on survival and 2-year outcomes in stroke survivors. METHODS: Two hundred thirty-five incident cases of stroke in 1995 were classified by continence status at 10 days after stroke. Age, sex, ethnicity, diabetes, hypertension, atrial fibrillation, premorbid disability, and Oxfordshire Community Stroke Project classification were recorded. Outcome data collected at 3 months and at 1 and 2 years included disability, case-fatality rates, and institutionalization rates. Disability was classified as severe, moderate, mild, or independent using the Barthel Index (without its "continence" component: 0-9, 10-14, 15-17, and 18, respectively) and Frenchay Activity Index (0-15, 16-30, and 31-45). RESULTS: Of 235 cases, 95 were initially incontinent (group 1); 140 were continent (group 2). At the initial, 3-month, and 1- and 2-year assessments, incontinence was recorded in 95 patients (40%), 34 (19%), 23 (15%), and 12 (10%), respectively. In univariate analyses, the 2 groups were not different in terms of demographic factors and risk factors. Compared with group 2, group 1 patients were more likely to have atrial fibrillation (28% versus 16%; P:=0.02). Multivariate analyses showed that age >75 years (OR 15.9; CI 2.2 to 116.2), dysphagia (OR 4.03; CI 1.85 to 8.73), motor weakness (OR 5.41; CI 1.38 to 21.1) and visual field defects (OR 4.78; CI 1.78 to 12.9) were all significantly associated with incontinence. Incontinence was less common in lacunar infarctions (OR 0.12; CI 0.02 to 0.62). At 2 years, compared with group 2, group 1 had higher case-fatality rates (67% versus 20%; P:<0.001), higher institutionalization rates (39% versus 16%; P:=0.007), and greater disability (Barthel [0-9]: 39% versus 5%; P:<0.001; Frenchay [0-15]: 75% versus 37%; P:=0.001). Death or disability at 2 years was worse in subjects with initial incontinence(OR 4.43; CI 1.76 to 11.2). CONCLUSIONS: Incontinence remains a prevalent condition 2 years after stroke. Initial incontinence was associated with age >75 years, dysphagia, visual field defect, and motor weakness. Poststroke incontinence adversely affected 2-year stroke survival, disability, and institutionalization rates.

Impact of the 1991 NHS reforms on the availability and use of coronary revascularisation in the UK (1987-1995)

OBJECTIVE: To describe changes in the availability, utilisation, and waiting times for coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) between 1987/88 and 1994/95 and to review commissioning of these services. DESIGN: A series of cross sectional surveys and interviews with purchasers and providers. SETTING: Four health regions in the United Kingdom. PATIENTS: All residents aged 25 years or more who underwent coronary revascularisation. RESULTS: There has been little change in the availability of consultants in cardiology in specialist centres, while the number of non-consultant cardiologists has risen significantly. The availability of consultant surgeons more than doubled in some regions, while non-consultant surgical staff increased by 40-90%. The NHS rate of use of both CABG and PTCA has increased steadily since 1987/88. In 1994/95, only two districts had CABG rates of less than 300 per million population. The additional contribution of privately funded cases varied between 14-23% for CABG and 7-30% for PTCA. Regional rates varied 1.3-fold for CABG and threefold for PTCA in 1994/95, while district rates of CABG varied 3.6-fold and PTCA 18-fold. Revascularisation rates were higher in districts with least need in 1991/92 and this persisted over the following three years. The overall waiting time for CABG (214 days) was largely unchanged from 1992/93 (234 days). The overall waiting time for PTCA (138 days) was 25% shorter than in 1992/93 (185 days). Prioritisation of patients waiting over a year had not yet adversely affected the waiting time of more urgent patients. Commissioning has faced a complex web of interconnected problems which, in general, caused more problems for purchasers than providers initially but which appear to be of increasing concern to providers. CONCLUSIONS: The 1991 NHS reforms had had no observable impact on the availability and use of coronary revascularisation by 1995. Continued monitoring is necessary to detect any delayed effect.