Leisure-time physical activity and ischemic stroke risk: the Northern Manhattan Stroke Study

In this study we have evaluated the postmortem pharmacokinetics of amitriptyline (Ami) and metabolites in pigs after oral and intravenous administration, and the results are compared with previous studies in rats and humans. In addition a meticulous investigation of blood and tissue concentrations after postmortem intravenous infusion of Ami was undertaken. Of a total of 9 over-night fasted pigs, 3 were given 25 mg/Kg Ami orally, and another 3 pigs received an intravenous infusion lasting 1 h of 3.3 mg/Kg Ami prior to death. The final 3 pigs were sacrificed and then given the intravenous infusion after death. After approximately 5 h at room temperature, all carcasses were subsequently stored at 4-5 degrees C. Postmortem blood samples were collected at 0.25, 1, 2, 4, 8, 24, 48, and 96 h through an indwelling intracardial needle. Postmortem examination with blood and tissue sampling was performed 96 h after death. Analysis was carried out by high performance liquid chromatography with ultraviolet detection. Postmortem blood samples from the heart of the orally dosed animals revealed large and variable concentration increases of 99(30-243)% for Ami and 96(52-429)% for the main metabolite 10-OH-Ami at 96 h. In the intravenously infused live pigs heart blood Ami increased by 55(33-69)% and 10-OH-Ami increased by 232(76-240)%. Blood from the atria had significantly higher Ami concentrations than blood from both ventricles in the animals dosed while alive, and the drug concentration in femoral blood was higher than in heart blood (p < 0.01). In the orally dosed pigs the left lobe of the liver had significantly higher Ami levels than the right lobe. Tissue/blood Ami concentration ratios were generally lower than previously reported in rats and approximating the levels reported in humans. The animals infused intravenously after death demonstrated high drug levels in blood samples from central vessels, heart, lungs as well as cerebrospinal fluid and vitreous humour. This implies that the presence of a lethal concentration of a drug in just one sample of heart blood can prove worthless in a case where agonal drug infusion may have occurred.     

Pressure ulcer risk factors among hospitalized patients with activity limitation

OBJECTIVE: To identify specific demographic, medical, functional status, and nutritional characteristics that predict the development of stage 2 or greater pressure ulcers among patients whose activity is limited to bed or chair. DESIGN: Prospective inception cohort study. SETTING: Tertiary care, urban, university teaching hospital. PATIENTS: A total of 286 patients fulfilling the following criteria: admitted to the hospital within the previous 3 days, age 55 years or more, expected to be confined to bed or chair for at least 5 days or had a hip fracture, and without a stage 2 or greater pressure ulcer. MAIN OUTCOME MEASURE: Time to in-hospital development of a stage 2 or greater pressure ulcer. RESULTS: Total cumulative incidence of pressure ulcers was 12.9% (n = 37) after a median time of 9 days from admission to final skin examination. Age of 75 years or more, dry skin, nonblanchable erythema (a stage 1 pressure ulcer), previous pressure ulcer history, immobility, fecal incontinence, depleted triceps skinfold, lymphopenia (lymphocyte count < 1.50 x 10(9)/L), and decreased body weight (< 58 kg) were significantly associated with pressure ulcer development by univariate Kaplan-Meier survival analyses (P < .05 by log-rank test). Risk ratios (and 95% confidence intervals) for predictors (P < or = .05) of pressure ulcer development after multivariable Cox regression analysis included the following: nonblanchable erythema, 7.52 (1.00 to 59.12); lymphopenia, 4.86 (1.70 to 13.89); immobility, 2.36 (1.14 to 4.85); dry skin, 2.31 (1.02 to 5.21); and decreased body weight, 2.18 (1.05 to 4.52). The 3-week cumulative incidence of pressure ulcers with none, one, two, or three or more of these characteristics was 0%, 11.4%, 39.6%, and 67.9%, respectively (P < .001 by log-rank test). CONCLUSIONS: These results suggest that nonblanchable erythema, lymphopenia, immobility, dry skin, and decreased body weight are independent and significant risk factors for pressure ulcers in hospitalized patients whose activity is limited to bed or chair.     

Delirium risk factors in elderly hospitalized patients

BACKGROUND: The relation of parental smoking to wheezing and asthma occurring after the first year of life was assessed by a systematic quantitative review of case-control and longitudinal studies, complementing earlier reviews of cross sectional surveys and wheezing in early childhood. METHODS: Fifty one relevant publications were identified after consideration of 1593 abstracts selected by electronic search of the Embase and Medline databases using keywords relevant to passive smoking in children. The search was completed in April 1997 and identified six studies of asthma incidence, seven of prognosis, 22 case-control studies, and 10 case series addressing disease severity. RESULTS: Maternal smoking was associated with an increased incidence of wheezing illness up to age 6 (pooled odds ratio 1.31, 95% CI 1.22 to 1.41), but less strongly thereafter (1.13, 95% CI 1.04 to 1.22). The long term prognosis of early wheezing illness was better if the mother smoked. The pooled odds ratio for asthma prevalence from 14 case-control studies was 1.37 (95% CI 1.15 to 1.64) if either parent smoked. Four studies suggest that parental smoking is more strongly associated with wheezing among non-atopic children. Indicators of disease severity including symptom scores, attack frequency, medication use, hospital attendance, and life threatening bronchospasm were in general positively related to household smoke exposure. CONCLUSIONS: The excess incidence of wheezing in smoking households appears to be largely non-atopic "wheezy bronchitis" with a relatively benign prognosis, but among children with established asthma, parental smoking is associated with more severe disease. This apparent paradox may be reconciled if environmental tobacco smoke is considered a co-factor provoking wheezing attacks, rather than a cause of the underlying asthmatic tendency.     

Delirium in hospitalized older patients: recognition and risk factors

Delirium, or acute confusional state, represents a common, serious, potentially preventable and increasing problem for older hospitalized patients. This study is intended to improve overall understanding of the problem of delirium and thus to lessen its adverse impact on the older population. The specific aims of this study are (1) to examine the epidemiology of delirium in older patients; (2) to evaluate barriers to recognition; (3) to present the Confusion Assessment Method (CAM) simplified algorithm to improve recognition; (4) to elucidate predisposing and precipitating factors for delirium; and (5) to propose preventive strategies. Delirium occurs in 10-60% of the older hospitalized population and is unrecognized in 32-66% of cases. The CAM algorithm provides a sensitive (94-100%), specific (90-95%), reliable, and easy to use means for identification of delirium. Four predisposing and five precipitating factors were identified and validated to identify patients at high risk for development of delirium. Primary prevention of delirium should address important delirium risk factors and target patients at intermediate to high risk for delirium at admission.     

Race-ethnicity and determinants of carotid atherosclerosis in a multiethnic population. The Northern Manhattan Stroke Study

BACKGROUND AND PURPOSE: Risk factors for carotid atherosclerosis have been studied in white populations but infrequently in multiethnic cohorts. The aim of this study was to determine the importance of race-ethnicity and other factors associated with carotid atherosclerosis in a mixed population of Hispanics, blacks, and whites. METHODS: As part of the Northern Manhattan Stroke Study, 526 stroke-free community residents (aged > or = 40 years; 41% men, 59% women; 46% Hispanic, 31% black, 23% white) were recruited through random-digit dialing and had vascular risk factor evaluations. Maximum internal carotid artery plaque thickness (MICPT) was measured with B-mode ultrasound. The frequency distribution of MICPT was examined in the three race-ethnic groups, and multivariate regression was performed to identify factors that were independently associated with MICPT. RESULTS: Mean MICPT in the entire sample was 1.5 +/- 1.4 mm, increased directly with age, and was greater in whites and blacks than Hispanics. Other independent determinants of MICPT included smoking, glucose, LDL cholesterol, and hypertension. After we controlled for these covariates, Hispanic (versus non-Hispanic) race-ethnicity was still an independent determinant of less carotid plaque. There was a significant interaction between race-ethnicity and LDL cholesterol, with a greater effect of increasing LDL cholesterol among Hispanics. CONCLUSIONS: Atherosclerotic risk factors were predictive of MICPT in this mixed-ethnic cohort. Hispanics had significantly less carotid plaque after adjustment for other known risk factors, but they also had a greater impact of increasing LDL cholesterol.     

The Greater Cincinnati/Northern Kentucky Stroke Study: preliminary first-ever and total incidence rates of stroke among blacks

In this study a rat self-administration model was used to examine the effects of training dose and time in the session on the dose-effect curve for heroin. Doses of heroin lower than 5.4 microg/inf maintained higher rates of drug intake in animals trained with 5.4 microg/inf compared to 18 microg/inf. Doses greater than 5.4 microg/inf maintained similar rates of intake in both groups of animals. The dose-response curve was shifted downward and to the right as the session progressed for animals trained with 5.4 microg/inf of heroin; however, the shift in the dose-intake curve over the session was less pronounced when the training dose was 18 microg/inf. Naltrexone and naltrindole were administered to animals in which responding was engendered with infusions of 5.4 microg of heroin to determine the effects of these antagonists in the context of time is the session. The potency of naltrexone decreased across the 4 h of the session with a time course that was consistent with literature reports on the elimination kinetics of naltrexone in rat brain. In contrast, there was not a significant interaction between naltrindole dose and session time. Therefore, the rates of heroin intake in rats are dependent not only upon the dose available for self-administration, but upon the session time and training dose as well.     

Sudden death among 1,000 patients with myocardial infarction: incidence and contributory factors. KYSMI Study Group

Clinical indicators and the incidence of sudden death among 1,000 consecutive patients (816 males and 184 females) with myocardial infarction were investigated between 1983 and 1987 after coronary arteriography. Twenty-four patients died suddenly during a study period of 3.3 +/- 2.0 yrs. The yearly incidence of sudden death calculated by the Kaplan-Meier method was 0.7%, nearly half of the incidence of cardiac death (1.5%/yr). Univariate analysis demonstrated statistically significant differences in the number of cases with coronary thrombolysis in the acute phase, degree of coronary artery stenosis, the frequency and degree of congestive heart failure and angina in the acute and chronic phase, the presence of serious post-infarction arrhythmia, ejection fraction, recurrent myocardial infarction, and administration of digitalis and diuretics. between the sudden-death group and the cardiac and other patient groups. There was also a tendency to higher frequency of history of diabetes mellitus, presence of acute mitral regurgitation, nitrates and nicorandil treatment, and coronary artery bypass graft in the sudden-death group. Multivariate analysis revealed that digitalis and nitrates treatment and left anterior descending artery involvement were major contributing factors. Re-infarction, left ventricular ejection fraction, and nicorandil therapy were not significant and minor contributing factors. The incidence of sudden death increased with digitalis therapy (Odds' ratio of 9.59), and left anterior descending artery disease, and decreased with nitrates (0.34).     

Infarct topography and hemiparesis profiles with cerebral convexity infarction: the Stroke Data Bank

The development of natural killer (NK) cell activity was assessed in Fischer 344 (F344) rats sympathectomized as neonates with the neurotoxin, 6-hydroxydopamine (6-OHDA). No NK cell activity was detected in sympathectomized or vehicle-injected control animals at 7 days of age. At 10 and 14 days of age, NK cell activity was reduced in spleens from sympathectomized male and female rats. At 21 days of age, a reduction in NK cell activity was detected only in sympathectomized male rats. Sympathectomy did not alter NK cell activity at 28 and 42 days of age in either gender. At 56 days of age, NK cell activity was increased in neonatally sympathectomized females; rats of both genders acutely sympathectomized at 56 days of age also showed enhanced NK cell activity. No differences were observed at 90 days of age in neonatally or acutely sympathectomized males of females. Prior treatment with desipramine, which blocks uptake of 6-OHDA into nerve terminals and prevents the destruction of sympathetic nerve terminals, prevented these 6-OHDA-induced effects, suggesting that sympathectomy, and not direct toxic effects of 6-OHDA treatment of NK cells, accounted for the alterations in NK cell activity. Together, these results indicate that the sympathetic nervous system is an integral component of the developing lymphoid and hematopoietic microenvironment.     

Estimating risk associated with care in alternative settings: deterioration among children hospitalized

The incidence of ductal carcinoma in situ (DCIS) has increased with the widespread use of screening mammography. DCIS is often suspected when clustered microcalcifications are evidenced on routinely performed mammography. High quality mammographies are required and should be completed with magnification views. Mammographic--pathologic correlations are described according to the new classifications as well as unusual forms of presentation on mammography. Early contrast enhancement in DCIS on dynamic MRI is reported and seems to be related with angiogenesis. A wire localization procedure of non-palpable lesions has to be performed and per-operative specimen radiography is mandatory. Stereotaxic large core needle biopsy is a valuable alternative to surgical biopsy but a multidisciplinary team approach is necessary and follow-up is recommended if no excisional biopsy is done. Quality in the management of DCIS depends on the coherence of the "multidisciplinary team".     

Cigarette smoking and other risk factors for silent cerebral infarction in the general population

Control dried organisms as lenticules are a dependable and convenient alternative to wet cultures for quality assurance and process controls in routine food microbiology. Lenticules are designed to give a fixed, reproducible inoculum over an extended period of time without loss of cultural characteristics or viability. During a period of 23 months, 596 paired counts were performed by both Miles and Misra and spiral plating techniques on lenticule controls. Correlation between the two methods and within batches was excellent. Only 14 counts (2.5%) fell outside the standard operating limit of 0.5 log10. All were within 1.0 log10. On two separate occasions, replicate runs were performed on five reconstituted lenticules from a batch. The counts obtained showed variation within and between lenticules only slightly in excess of what is expected by chance. Lenticule replicates performed by three other laboratories also produced satisfactory results. It is thought that lenticules could improve the accuracy of total plate counts and lead to a better standardization of quantitative methods in food microbiology within and between laboratories.     

基于农村社区人群的心血管危险因素相对效应和性别差异的分层研究

目的:调查北京市房山区农村人群心血管疾病及其相关危险因素的分布,并探讨该人群中主要危险因素与心血管疾病的关联强度.方法:采用普查的方法,对青龙湖镇32个行政村40岁以上人群进行横断面研究;通过问卷调查、体格检查和生化检测收集心血管疾病患病及其相关危险因素的资料,采用分层分析和多因素logistic回归模型进行统计学分析.结果:共计7 577名研究对象中冠心病、脑卒中、糖尿病、高血压、血脂紊乱、超重和肥胖的患病率分别为6.5%、4.1%、10.7%、39.5%、56.7%、44.0%和13.6%.采用多因素logistic回归模型调整变量后比较危险因素对脑卒中/冠心病的现患比值比(prevalence odds ratio,POR),发现高血压与脑卒中的关联更强(POR=2.780,95%CI:2.146～3.602),而糖尿病与冠心病的关联更强(POR=2.671,95%CI:2.121～3.363);按性别分层后各危险因素及数量性状指标与脑卒中的关联存在明显差异,在女性中主要是超重/肥胖(POR=1.652,95%CI:1.122～2.433)、体重指数(POR=1.048,95%CI:1.002～1.096)、收缩压(POR=1.017,95%CI:1.005～1.030)和血糖水平(POR=1.093,95%CI:1.048～1.140),而在男性中主要是血脂紊乱(POR=1.615,95%CI:1.124～2.319)、总胆固醇(POR=3.932,95%CI:1.533～10.086)和HDL-C水平(POR=0.072,95%CI:0.022～0.236).结论:本研究人群中心血管危险因素的聚集影响脑卒中和冠心病的高患病率,不同危险因素对脑卒中和冠心病的影响程度以及在不同性别人群中的影响存在差异.     

Asymptomatic cerebral infarctions in patients with ischemic stroke

We studied 383 consecutive patients with stroke and ischemic lesions on CT scan for the presence of symptomatic cerebral infarction (SCI) and asymptomatic cerebral infarction (ACI). We evaluated risk factors as well as volume, site and number of the lesions. ACIs occurred in 34% of the cases (130/383); 88% of ACIs were lacunes and internal borderzone infarctions, with a volume of less than 2 ml. Larger infarctions were asymptomatic in 27 patients (20.8%); 114 (68.7%) out of 166 patients with two or more SCIs (68.7%) had one or more ACIs. Infarctions in the lateral middle cerebral artery (MCA) territory were SCIs, in the medial MCA territory ACIs. Independent risk factors for ACI were age above 70 years and smoking; cardioembolism prevailed in SCI, small vessel disease in ACI; high levels of disability prevailed in SCIs.     

Using the NIH Stroke Scale to assess stroke patients. The NINDS rt-PA Stroke Study Group

The stroke patient is acutely ill within minutes of symptom onset. Typically, he or she is awake and thus requires a focal neurologic exam to evaluate vision, movement, sensation and language. With the advent of acute stroke treatments that need to be rapidly implemented, it is critical that the nurse be able to assess patients and relay the information accurately and efficiently to other members of the health care team. Performing and documenting the awake stroke exam in the most efficient and useful manner is key to the nursing care of the stroke patient. The National Institutes of Health Stroke Scale (NIHSS) is a systematic assessment tool designed to measure the neurologic deficits most often seen with acute stroke patients. Originally designed as a research tool, it is a nonlinear ordinal scale, with possible scores ranging form 0-42. Exam performance has been timed to take 5-8 minutes. Use of the NIHSS includes documentation of neurologic status and outcome, data collection for planning safe nursing care and standardization of information exchanges between nurse caregivers and other health care professionals.     

Sex differences in the longitudinal relations among family risk factors and childhood externalizing symptoms.

Despite potential sex differences in base rates, predictors, and maintaining processes for children's externalizing behaviors, little prospective research has examined sex differences in the relations between concurrent, proximal family risk factors and children's externalizing behaviors. The current study examined the relations among maternal depressive symptoms, maternal parenting behaviors (i.e., negativity and low warmth), and child externalizing symptoms at 24 months and first grade in a community-based sample of 1,364 children enrolled in the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development. Structural equation modeling revealed that maternal depression and negative parental behaviors were associated with concurrent externalizing behaviors, though maternal depression may be differentially linked to boys' and girls' externalizing problems. The relation between depression and boys' externalizing symptoms was more pronounced at 24 months, and over time, the relation between maternal depression and boys' externalizing symptoms decreased in magnitude, whereas this relation increased among girls. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Risk factors for mortality among hospitalized children with persistent diarrhoea in Pakistan

We evaluated factors associated with mortality among a cohort of malnourished children with persistent diarrhoea (PD) admitted for nutritional rehabilitation with a defined rice-lentil (Khitchri) and yoghurt diet. Of 302 children consecutively admitted with PD, 13 (4 per cent) died, mostly (62 per cent) within 72 h of admission. Univariate analysis of risk factors at admission associated with mortality indicated significantly increased risk of death with severe stunting [relative risk (RR) 3.1, 95 per cent confidence interval (CI) 1.1-9.0], hypoalbuminaemia (RR 4.3, 95 per cent CI 1.5-12.3), stool frequency > 12/day (RR 6.0, 96 per cent CI 2.0-17.6), stool volume > 100 g/kg/day (RR 10.7, 95 per cent CI 3.0-37.6) and severe dehydration (RR 7.5, 95 per cent CI 2.6-21.8). Children who died also had comparatively shorter duration of diarrhoea at admission, and were also associated with higher rate of bacteremia at admission (Fisher's exact test P < 0.01). The logistic regression model evaluating multivariate risk of mortality identified weight-for-age z-score and sepsis as significant risk factors. Our data suggest that severe malnutrition and sepsis are associated with significantly increased risk of mortality in children with PD. Stringent screening for infections and recognition of subgroups with severe malnutrition and severe diarrhoea may improve screening and case management strategies for this disorder.     

Illicit drug-associated ischemic stroke in the Baltimore-Washington Young Stroke Study

BACKGROUND: Limited information exists on the frequency, trends in occurrence, risk factors, mechanisms, and outcome of ischemic stroke associated with illicit drug use among young adults in a geographically defined population. METHODS: We reviewed ischemic stroke in young adults (aged 15 to 44 years) in 46 regional hospitals for 1988 and 1991. We examined stroke mechanisms and outcome in patients with recent drug use. RESULTS: Recent illicit drug use was noted in 51/422 (12.1%) stroke patients. Patients with drug use were more likely than other stroke patients to be black (p=0.01), aged 25 to 39 years (p=0.004), and smokers (p=0.006), and were less likely to have hypertension (p=0.004) or diabetes mellitus (p=0.004). Drug use was the probable cause of stroke in 20 (4.7%) patients. Among 31 (7.3%) patients with drug use as a possible stroke mechanism, more likely diagnoses included cardioembolic stroke in 18, hematologic/collagen vascular in 6, nonatherosclerotic vasculopathy in 5, and atherosclerosis in 3. There was no difference in outcome between drug-associated and non-drug associated stroke. CONCLUSIONS: Recent illicit drug use occurs in 12.1% of young adult stroke patients. Drug-associated young adult stroke seems to relate to vascular mechanisms other than those related to hypertension or diabetes. Case-control studies are needed.     

Gender differences in disability and lifestyle among community-dwelling elderly stroke patients in Kitakyushu, Japan

OBJECTIVE: To examine whether there were differences in lifestyle and performance of activities of daily living (ADL) between men and women in a population of elderly stroke patients. DESIGN: Case-comparison study. MATERIAL AND METHODS: Sixty-eight men and 34 women who were elderly stroke patients living in the community with a spouse or family members were evaluated with the self-rating Barthel Index (SRBI), Frenchay Activities Index (FAI), Stroke Impairment Assessment Set (SIAS), Functional Independence Measure (FIM), and a pedometer for physical activity. Control subjects, 30 men and 30 women, were assessed with the FAI. RESULTS: Among the stroke subjects, there were no significant differences in age, SRBI, motor score of the SIAS, or physical activity between men and women; however, men had significantly lower values than did women for three FIM items and the total FIM score and for 6 FAI items and the total FAI score. Among control subjects, men had significantly lower values than did women for 7 FAI items and the total FAI score (Tukey's test, p < .05). CONCLUSION: Among elderly stroke patients, men received more support from family members in ADL performance and had less active lifestyles than did women, possibly because of cultural gender roles.     

Analysis on the interaction among agents in arteriosclerotic cerebral infarction

An 1:1 matched case-control study including 105 arteriosclerotic cerebral infarction cases and 105 controls was carried out to estimate the etiologic interaction, in Yi-xing city, March 1997. Results showed that the major risk factors were high levels of serum TG, Lp(a) and BMI while serum level of HDL-C was the only protective factor. When several levels were divided on Lp(a) and BMI, a significantly dose response relation was found. Considering the correlation among serum concentration of lipids, we analysed the interaction of different factors, using Log-Linear models. Results showed that there were significant interactions between arteriosclerotic cerebral infarction and TC, TG, HDL-C and Lp(a). There were also interactions between TC, TG, HDL-C and LDL-C. However, the strongest interaction is expected to happen at what level remains further investigations.     

Mitral valve strands and the risk of ischemic stroke in elderly patients. The French Study of Aortic Plaques in Stroke (FAPS) Investigators

BACKGROUND AND PURPOSE: Strands are thin and filamentous attachments on the cardiac valves shown by transesophageal echocardiography. Their nature and their potential for embolization are largely unknown. The objective was to estimate the risk of brain infarction in patients with mitral valve strands. METHODS: Using transesophageal echocardiography, we compared the frequency of strands on native mitral valves in 284 consecutive patients admitted with brain infarction and 276 control patients, all older than 60 years. In a second part, case subjects were followed up over a 2- to 4-year period, and the risk of recurrence of brain infarction was estimated in patients with and without strands. RESULTS: In the case-control study, mitral valve strands were found in 22.5% of the case patients and in 12.1% of the control subjects. In case subjects, mitral valve strands were more frequent in those with mitral valve dystrophy (52.4% versus 37.4%; P = .03). Strands were not associated with mitral valve prolapse, annular calcifications, or left atrial spontaneous echocardiographic contrast. After adjustment for age, sex, and mitral valve dystrophy, the odds ratio for ischemic stroke among patients with mitral strands was 2.2 (95% confidence interval, 1.4 to 3.6; P = .005). The frequency of strands was not different in patients with a known cause of brain infarction (24.4%) from that in patients with no other apparent cause (20.9%). During 646 per 100 person-years of follow-up, the incidence of recurrent brain infarction was 6.0 person-years in patients with strands and 4.2 in those without. In the Cox analysis, including potential confounders and poststroke treatment, mitral valve strands did not appear as independent predictors of recurrent brain infarction (relative risk, 1.3; 95% confidence interval, 0.5 to 3.0; P = .54). CONCLUSIONS: The present study shows an independent association between mitral valve strands and the risk of brain infarction. However, the lack of an increased relative risk of recurrence raises doubts about the potential causal relation with brain infarction in patients aged 60 years or older.