The influence of stroke unit rehabilitation on functional recovery from stroke

BACKGROUND AND PURPOSE: Shorter lengths of hospital stay in stroke units could be due to quicker functional recovery or mechanisms of expediting hospital discharge. METHODS: Stroke survivors with an intermediate prognosis at 2 weeks after stroke (n = 146) were randomized for management in a stroke rehabilitation unit or in general wards. Barthel scores were monitored at weekly intervals until hospital discharge. The duration and type of physiotherapy and occupational therapy received by patients in either setting were also recorded. The rate of change of Barthel scores, therapy input, and the duration of hospital stay were compared between the two settings. RESULTS: Neurological deficits and median initial Barthel scores were comparable between patients in the stroke unit (n = 73) and general wards (n = 68). Median discharge Barthel score of patients managed in the stroke unit was significantly higher than that of patients managed in general wards (15 versus 12). Median Barthel scores in the stroke unit group rose rapidly after 2 weeks, reaching a plateau at 6 weeks. The change in median Barthel score in patients in general wards was significantly slower, reaching a plateau at 12 weeks despite similar therapy input. There was a significant delay in discharging stroke patients in general wards (20 weeks) compared with those in the stroke unit (6 weeks). CONCLUSIONS: Functional recovery is significantly greater and more rapid in a stroke rehabilitation unit compared with general wards despite similar therapy input. These units also shorten hospital lengths of stay by expediting appropriate discharges.     

Medical complications during stroke rehabilitation

BACKGROUND AND PURPOSE: We sought to evaluate the effect of setting on the rate of medical complications during stroke rehabilitation. METHODS: A study of the frequency and nature of medical complications in stroke rehabilitation was undertaken in 245 patients managed either on a stroke rehabilitation unit (n = 124) or on general medical wards (n = 121). The stroke unit setting was characterized by established protocols for prevention, early diagnosis, and management of complications (eg, aspiration, infections, thromboembolism, pressure sores, depression, stroke progression). Similar protocols did not exist on general medical wards except for thromboembolism, pressure sores, and secondary stroke prevention. RESULTS: Medical complications were documented in 147 patients (60%) and were more common in patients with severe strokes (97%). The frequency of reported complications was similar in both settings. Aspiration (33% versus 20%; P < .01) and musculoskeletal pain (38% versus 23%; P < .05) were more commonly documented on the stroke unit, whereas urinary problems (18% versus 7%; P < .01) and infections (49% versus 25%; P < .01) were more commonly seen on general medical wards. The reported frequency of deep vein thrombi, pressure sores, and stroke progression was similar in both settings. Although depression was reported equally in both settings (34% on the stroke unit versus 27% on general wards), patients on the stroke unit were more likely to be treated compared with general wards (67% versus 36%; P < .05). CONCLUSIONS: The study shows that inpatient stroke rehabilitation is a medically active service. Management on specialist units is associated with earlier detection and management of stroke-related problems and prevention of potentially life-threatening complications.     

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.     

A study of stroke patients treated in a non-intensive stroke unit or in general medical wards

To study the representativity and outcome of patients admitted to a stroke unit (SU) (n = 269), a comparison was made with all stroke patients treated in general medical wards (GMW) (n = 225) in the same hospital during two years. There was no difference between the patient groups regarding sex, age, previous cardiovascular diseases or neurological deficit on admission. As expected, more diagnostic examinations were performed in the SU than in the GMW where a diagnosis of ill-defined stroke was very frequent. A higher frequency of lumbar puncture with CSF spectrophotometry would have increased considerably the number of specific diagnoses in the GMW. Acute and, particularly, secondary prophylactic treatment was more often given in the SU. There was no difference between the patient groups regarding mortality or length of hospital stay.     

The apolipoprotein E epsilon4 allele and outcome in cerebrovascular disease

BACKGROUND AND PURPOSE: Polymorphism of the apolipoprotein E gene (APOE) may influence outcome after traumatic brain injury and intracerebral hemorrhage, with the epsilon4 allele being associated with poorer prognosis. We investigated APOE allele distribution in acute stroke and the effect of the epsilon4 allele on outcome. METHODS: APOE genotypes were determined in 714 stroke patients: 640 ischemic stroke and 74 intracerebral hemorrhage patients. The survival effect of the epsilon4 allele was assessed with the use of a stratified log-rank test. A Cox proportional hazards regression model was used to estimate the independent effect of epsilon4 dose (0, 1, or 2) on survival, and logistic regression was used to determine the effect on 3-month outcome (good if alive at home, poor if in care or dead). RESULTS: Allele distribution matched the general population with no difference between the ischemic and hemorrhagic groups. Survival in the entire cohort was unaffected by epsilon4 dose. Improved survival with increasing epsilon4 dose was found in the ischemic group (relative hazard=0.76 per allele; P=0.04). If transient ischemic attacks were excluded, a trend for improved survival persisted (P=0.06). With intracerebral hemorrhage, a trend was seen toward reduced survival with epsilon4 (P=0.07, log-rank test). Three-month outcome in the ischemic group was unaffected by epsilon4 dose, and a trend toward poorer outcome with epsilon4 was seen for intracerebral hemorrhage (P=0.10). CONCLUSIONS: The APOE epsilon4 allele had divergent effects on survival and outcome in ischemic and hemorrhagic strokes in this population. The reported adverse effect on patients with intracerebral hemorrhage was supported. The favorable survival effect on ischemic stroke patients requires further study.     

Do stroke units save lives?

Management of stroke patients in specialist stroke units hastens recovery but is not believed to influence mortality. We did a statistical overview of randomised controlled trials reported between 1962 and 1993 in which the management of stroke patients in a specialist unit was compared with that in general wards. We identified 10 trials, 8 of which used a strict randomisation procedure. 1586 stroke patients were included; 766 were allocated to a stroke unit and 820 to general wards. The odds ratio (stroke unit vs general wards) for mortality within the first 4 months (median follow-up 3 months) after the stroke was 0.72 (95% CI 0.56-0.92), consistent with a reduction in mortality of 28% (2p < 0.01). This reduction persisted (odds ratio 0.79, 95% CI 0.63-0.99, 2p < 0.05) when calculated for mortality during the first 12 months. The findings were not significantly altered if the analysis was limited to studies that used a formal randomisation procedure. We conclude that management of stroke patients in a stroke unit is associated with a sustained reduction in mortality.     

Local intra-arterial thrombolysis in acute ischemic stroke

BACKGROUND AND PURPOSE: We performed a retrospective analysis of the prognostic factors in patients treated with local intra-arterial thrombolysis (LIT). The purpose of this study was to evaluate the safety and efficacy of LIT using urokinase in patients with acute ischemic stroke of the anterior or posterior circulation and to determine the influence of clinical and radiological parameters on outcome. METHODS: Forty-three patients were treated with LIT using urokinase (median dose, 0.75x10(6) IU). The median National Institutes of Health Stroke Scale (NIHSS) score at hospital admission was 18 (range, 9 to 36). Nine patients had occlusions of the internal carotid artery (ICA), 23 of the middle cerebral artery (MCA), 1 of the anterior cerebral artery, and 10 of the basilar artery (BA). Outcome was assessed after 3 months and classified as good for Rankin Scale (RS) scores of 0 to 3 and poor for RS scores of 4 or 5 and death. RESULTS: Nine patients (21%) recovered to RS scores 0 or 1, 17 (40%) to scores of 2 or 3, and 7 (16%) to scores of 4 or 5. Ten patients (23%) died. Outcome was good in 17 patients (80%) with MCA occlusions, in 3 patients (33%) with ICA, and in 5 patients (50%) with BA occlusions. Good outcome was associated with an initial NIHSS score of <20 (P<0.001), improvement by 4 or more points on NIHSS score within 24 hours (P=0.001), and vessel recanalization (P=0.02). Recanalization was more likely if LIT was started within 4 hours (P=0.01). Symptomatic cerebral hemorrhage occurred in 2 patients (4.7%). CONCLUSIONS: LIT was most efficacious in patients with MCA and BA occlusions when the initial NIHSS score was less than 20 and when treated within 4 hours. It is of limited value in patients with distal ICA occlusions.     

Relation between depression and circulating immune products in patients with advanced colorectal cancer

We have previously suggested that colorectal liver metastases might produce 'toxins' that reduce both quality of life (QoL) and survival. In this study we assessed whether QoL in patients with such metastases was related to immune activation, as determined by increased serum levels of interleukin 6 (IL6), soluble tumour necrosis factor receptor 1 (sTNFr1), soluble interleukin 2 receptor alpha (sIL2r alpha) or the interferon-gamma marker neopterin. Serum IL6, sTNFr1, sIL2r alpha, neopterin, alkaline phosphatase and carcinoembryonic antigen levels, liver metastasis volume, and QoL (Hospital Anxiety and Depression [HAD] scale, Rotterdam Symptom Checklist [RSC], and Sickness Impact Profile [SIP]) were measured in 43 patients. There were significant positive correlations between serum sIL2r alpha and HAD depression score (r = 0.66, P = 0.0001), RSC physical symptom score (r = 0.46, P < 0.01), and SIP score (r = 0.47, P = 0.009). Multiple regression analysis suggested that serum sIL2r alpha level was a significant independent predictor of HAD depression score. Although survival was shorter (logrank test P < 0.05) where sIL2r alpha, sTNFr1 and IL6 levels were higher, the ability of sIL2r alpha to predict HAD depression score was independent of survival.     

Does arterial recanalization improve outcome in carotid territory stroke?

BACKGROUND AND PURPOSE: We sought to determine whether early (< 8 hours) or delayed (8 to 24 hours) recanalization after stroke may be an independent variable in the improvement of clinical outcome in patients with occlusion of the middle cerebral artery. METHODS: We prospectively studied 77 patients by combined Scandinavian Stroke Scale score at admission, repeated computed tomography and angiography before and after thrombolytic treatment at < 8 hours after stroke onset, and transcranial Doppler ultrasound 24 hours later. We tested an association between clinical and neuroradiological baseline characteristics, recanalization, and outcome as assessed by the modified Rankin Scale 4 weeks after stroke and determined the effect of recanalization on mortality and good outcome (Rankin Scale grades 0 to 3) by multiple logistic regression analyses. RESULTS: Recanalization rates at 8 and 24 hours after stroke correlated with sites of occlusion (middle cerebral artery branch, 73% and 73%, trunk, 27% and 38%, respectively; intracranial internal carotid artery bifurcation, 14% and 14%; P = .002), collaterals (good, 43% and 51%, respectively; scarce, 17% and 19%, respectively; P = .01), and Scandinavian Stroke Scale score at admission (P = .002). Six of 6 patients with delayed recanalization had good outcomes. Recanalization at < 8 hours after symptom onset had no independent predictive value for good outcome (P = .69). Recanalization at 24 hours increased the proportion of good outcomes from 23% to 75% in a subgroup of patients. Recanalization did not independently affect mortality (P > .15). CONCLUSIONS: Even if delayed, arterial recanalization may improve clinical outcome in a subgroup of patients with middle cerebral artery occlusion.     

Positioning of stroke patients: evaluation of a teaching intervention with nurses

BACKGROUND AND PURPOSE: There is agreement, although little evidence, that consistently positioning stroke patients in allegedly reflex-inhibiting positions is therapeutic and will enhance functional recovery. The nursing staff, therefore, needs to know and implement these postures and understand their potential underlying value. We examined nurses' knowledge of and practice in positioning stroke patients before and after a formal teaching intervention. METHODS: In a quasi-experimental study, 38 stroke patients and 59 nursing staff members (44 trained nurses and 15 healthcare assistants) from 6 wards were studied. The wards were randomly allocated to experimental or control status. Patients were assessed on entry into the study by use of a range of measures to establish group equivalence. Nineteen aspects of their position were documented at intervals throughout their stay with a previously developed observational tool. One thousand sets of observations of patient position were made. Using 2 questionnaires, the nurses' knowledge of the terminology used to denote posture and of issues relating to the moving and positioning of stroke patients was assessed before, immediately after, and 3 months after a package of formal teaching was implemented on the experimental wards. Nurse knowledge and patient position were used as the main outcome measures. RESULTS: Immediately after teaching, nurses in the experimental group scored significantly higher than those in the control group on the terminology questionnaire (P < 0.05) and the moving and positioning questionnaire (P < 0.001). Three months later, the experimental group scored higher on the latter questionnaire only (P < 0.005). The positioning of patients in the experimental group was improved overall after the teaching (P < 0.0005), and improvements to specific parts of the body were noted. CONCLUSIONS: It was possible to effect a degree of change in the nurses' knowledge of and practice in the positioning of stroke patients. However, the quality of patient positioning remained variable. More effective ways of improving positioning need to be developed. Only then can the effects of recommended positioning be evaluated.     

Long-term outcome after discharge from a stroke rehabilitation unit

The evidence is compelling that stroke units are effective when compared to management of patients on general medical wards. However, the evidence remains equivocal that better outcome is sustained in the longer term. This paper reports an investigation of cognitive and emotional outcome, environmental consequences, social activities, and physical outcome in 57 consecutive one-year survivors of a stroke discharged from a stroke and neurological rehabilitation unit. Satisfaction with inpatient and outpatient services was also investigated. Results were compared with previously reported studies of long-term outcome after stroke. Mean Barthel activities of daily living score at one year or more post-stroke was 16.8. Arm function was impaired in 43% of the participants in the study. Nearly half had cognitive and emotional problems, 19% communication problems, and 25% problems with access both inside and outside their house. All but four of the one-year survivors were less active after their stroke than before. More than 40% were dissatisfied with at least one aspect of inpatient and/or outpatient services. The long-term consequences of stroke in all areas investigated were considerable and in line with previous reports. Some suggestions for reducing these effects are made, including better information for patients about stroke and rehabilitation, improved access to psychology services, detailed assessment prior to hospital discharge of the patient's living environment and effective coordination with social services to improve access to their living environment.     

Functional outcome after brain tumor and acute stroke: a comparative analysis

OBJECTIVE: To compare the functional outcome, length of stay, and discharge disposition of patients with brain tumors and those with acute stroke. DESIGN: Case-controlled, retrospective study at a tertiary care medical center inpatient rehabilitation unit. SUBJECTS: Sixty-three brain tumor patients matched with 63 acute stroke patients according to age, sex, and location of lesion. MAIN OUTCOME MEASURES: The functional independence measure (FIM) was measured on admission and discharge. The FIM change and FIM efficiency were also calculated. The FIM was analyzed in three subsets: activities of daily living (ADL), mobility (MOB), and cognition (COG). Discharge disposition and rehabilitation length of stay were compared. RESULTS: Demographic variables of race, marital status, and payer source were comparable for the two groups. No significant difference was found between the brain tumor and stroke populations with respect to total admission FIM, total discharge FIM, change in total FIM, or FIM efficiency. The admission MOB-FIM was found to be higher in the brain tumor group (13.6 vs 11.1, p = .04), whereas the stroke group had a greater change in ADL-FIM score (10.8 vs 8.3, p = .03). The two groups had similar rates of discharge to community at greater than 85%. The tumor group had a significantly shorter rehabilitation length of stay than the stroke group (25 vs 34 days, p < .01). CONCLUSION: Brain tumor patients can achieve comparable functional outcome and rates of discharge to community and have a shorter rehabilitation length of stay than stroke patients.     

Prehospital-initiated vs hospital-initiated thrombolytic therapy. The Myocardial Infarction Triage and Intervention Trial

OBJECTIVE: To determine the effect of prehospital-initiated vs hospital-initiated treatment of myocardial infarction on clinical outcome. DESIGN: Randomized, controlled clinical trial. SETTING: Multicenter study involving 19 hospitals and all paramedic systems in the Seattle, Wash, metropolitan area. PATIENTS: A total of 360 patients with symptoms for 6 hours or less, no risk factors for serious bleeding, and ST-segment elevation were selected by paramedics and a remote physician for inclusion into the trial. They represented 4% of patients with chest pain who were screened and 21% of those with acute infarction. INTERVENTIONS: Patients were allocated to have aspirin and alteplase treatment initiated before or after hospital arrival. Intravenous sodium heparin was administered to both groups in the hospital. MAIN OUTCOME MEASURE: The primary endpoint was a ranked composite score (combining death, stroke, serious bleeding, and infarct size). The relation between time to treatment and outcome (composite score, infarct size, ejection fraction, and mortality) was also assessed. RESULTS: Initiating treatment before hospital arrival decreased the interval from symptom onset to treatment from 110 to 77 minutes (P < .001). Although more patients whose therapy was initiated before hospital arrival had resolution of pain by admission (23% vs 7%; P < .001), there were no significant differences in the composite score (P = .64), mortality (5.7% vs 8.1%), ejection fraction (53% vs 54%), or infarct size (6.1% vs 6.5%). A secondary analysis of time to treatment and outcome showed that treatment initiated within 70 minutes of symptom onset was associated with better outcome (composite score, P = .009; mortality, 1.2% vs 8.7%, P = .04; infarct size, 4.9% vs 11.2%, P < .001; and ejection fraction, 53% vs 49%, P = .03) than later treatment. Identification of patients eligible for thrombolysis by paramedics reduced the hospital treatment time from 60 minutes (for patients not in the study) to 20 minutes (for study patients allocated to begin treatment in the hospital). CONCLUSION: There was no improvement in outcome associated with initiating treatment before hospital arrival; however, treatment within 70 minutes of symptom onset--whether in the hospital or in the field--minimized the infarct process and its complications.     

The intermediate care unit as a cost-effective option for the treatment of medical patients in critical condition

Since the limited accessibility of general intensive care units creates a situation in which medical patients in critical condition continue to be cared for in the regular wards, we conducted a retrospective cohort study to assess the treatment outcomes in such patients referred to the medical intermediate care unit (MICU). At the Soroka Medical Center, a facility with 810 beds, of which 170 beds are in medical wards, including an 8-bed intensive cardiac care unit and a 5-bed general intensive care unit, 119 patients were referred to the MICU, directly from the emergency room or from medical wards, during the first half of 1994. Eighty percent of the patients were admitted to the MICU directly from the emergency room. The mean disease severity, as measured by the APACHE II score, was 12.9, and the mean intensity of care for these patients, as measured by the TISS scale, was 12.6. Twenty-one of the 119 patients died during hospitalization (17.6%). This mortality rate conformed to the mortality risk of 15.5%, which was calculated using prognostic formulae. The ratio of nursing staff to patient in the MICU was approximately 1:3, compared to 2:3 in the general intensive care unit and 1:12 in the wards. The mean cost of one day of hospitalization in the MICU was one-third that in the general intensive care unit and double the cost in a ward. Medical patients in critical condition can be treated in an MICU, with a savings in expenses and without impairing the patient's chances for survival.     

In vitro schedule-dependent interaction between paclitaxel and SN-38 (the active metabolite of irinotecan) in human carcinoma cell lines

METHODS: From 1983 to 1995, 72 patients with necrotizing pancreatitis were treated with a general approach involving planned reoperative necrosectomies and interval abdominal wound closure using a zipper. RESULTS: Hospital mortality was 25%. Multiple organ failure without sepsis caused early mortality in 3 of 4 patients and sepsis caused late mortality in 11 of the remaining 14. The mean number of reoperative necrosectomies/debridements was 2 (0 to 7). Fistulae developed in 25 patients (35%); 64% were treated conservatively. Recurrent intraabdominal abscesses developed in 9 patients (13%) but were drained percutaneously in 5. Hemorrhage required intervention in 13 patients (18%). Prognostic factors included APACHE-II score on admission < 13 (P = 0.005), absence of postoperative hemorrhage (P = 0.01), and peripancreatic tissue necrosis alone (P < 0.05). CONCLUSIONS: The zipper approach effectively maximizes the necrosectomy and decreases the incidence of recurrent intraabdominal infection requiring reoperation. APACHE-II score > or = 13, extensive parenchymal necrosis, and postoperative hemorrhage signify worse outcome.     

Validation and application of the pneumonia prognosis index to nursing home residents with pneumonia

OBJECTIVES: To evaluate the predictability of a pneumonia prognosis index in nursing home residents with pneumonia and to use the index to account for acute severity of pneumonia before comparing the short-term outcome of residents with pneumonia treated with intravenous antibiotic therapy in two different settings: an inpatient geriatrics unit and a nursing home DESIGN: A retrospective chart review of 158 episodes of nursing home-acquired pneumonia treated initially with intravenous antibiotics; 100 episodes were treated in an inpatient acute geriatrics service (AGS), and 58 were treated completely in a nursing home (Nursing Home group) SETTING: The AGS is a 20-bed unit within a 400-bed, public, university-affiliated hospital. The Nursing Home group consisted of residents of two nonproprietary nursing homes. PARTICIPANTS: Nursing home residents with radiographically proven pneumonia who had at least one of the following signs/symptoms: cough, fever, purulent sputum, respiratory rate > or = 25 per minute, localized auscultatory findings, or pleuritic pain. MEASUREMENTS: The pneumonia prognosis index was calculated for each resident at the time of diagnosis of pneumonia; the index has been validated as a predictor of hospital outcome in patients with community-acquired pneumonia and is also considered a measure of acute severity of pneumonia. Status (alive or dead) of each resident at 30 days after diagnosis was the major dependent variable RESULTS: Mean (+/-SD) duration of antibiotic therapy for the Nursing Home group (10.7+/-4.5 days) was not significantly different from that of the AGS group (9.6+/-3.4 days; P = .26). The pneumonia prognosis index stratified the 158 episodes of pneumonia into low- and high-risk groups for 30-day mortality; the mortality rates in each risk strata were not significantly different from those reported in the original derivation and validation studies of the index. In addition, the distribution of episodes among the risk strata of the index was not significantly different for the two study groups, which was an indication that the two groups were similar in terms of acute severity of pneumonia. Thirty-day mortality was not significantly different between the two groups: AGS, 21% and Nursing Home, 24.1% (P = .66). CONCLUSION: The pneumonia prognosis index seems to have the same capability for predicting the outcome in nursing home residents with pneumonia as in residents with community-acquired pneumonia. The index is also a measure of acute pneumonia severity. Nursing home residents with pneumonia, even those who are most acutely ill, can be treated successfully with intravenous therapy in the nursing home; their 30-day mortality was no different than that of those with the same acute severity of illness who were admitted to a hospital for treatment.     

Interconversion of stroke scales. Implications for therapeutic trials

BACKGROUND AND PURPOSE: Stroke scales are intended to measure stroke severity for the purpose of clinical trials. Scores have been used to determine trial entry, to compare patient groups within or between trials, or as a secondary end point. The use of scores as an end point in meta-analysis has not been validated, but such analyses have nevertheless been performed when equivocal results have been obtained using the main outcome measure. The different scale designs suggest that conversion of scores may not be possible. We sought to determine whether scores on different scales could be interconverted. METHODS: A single observer scored 433 consecutive admissions to an acute stroke unit on the Canadian Neurological Scale, the middle cerebral artery Neurological Score (or Orgogozo scale), and the National Institutes of Health stroke scale. Data were separated into training and test sets, and linear regression was used to model conversion between scales. Prediction errors were calculated. Strokes were subdivided according to the Oxfordshire Community Stroke Project classification, and coefficients of determination were calculated for different subtypes. RESULTS: Conversion between Canadian and middle cerebral artery Neurological scales was satisfactory (R2 = 94.7%), and prediction errors were acceptable (absolute prediction error, 5.0 +/- 5). Conversion from the National Institutes of Health scale was worse (R2 = 87.5% to Canadian and 89.0% to Neurological Score), and prediction errors were significantly greater (Neurological Score error, 8.7 +/- 7; Canadian Neurological Scale error, 8.5 +/- 7.3; P < .005 for both). Coefficients of determination for interconversion were significantly worse for dysphasic patients with total anterior circulation strokes than for other stroke types (P < .01). Reweighting the motor component of the National Institutes of Health scale improved coefficients of determination and reduced prediction errors, but prediction error for conversion to the Canadian scale remained significantly greater than other conversions (P = .001). CONCLUSIONS: The Canadian Neurological Scale and the middle cerebral artery Neurological Score may reliably be converted. The National Institutes of Health scale cannot be used to predict these scores reliably, even with reweighting of the motor score. Interconversion is poorest for patients with dysphasia and total anterior circulation strokes. These results suggest that there will be more general difficulty in interconverting scales that use different test items and weighting. Meta-analysis using sequential changes in averaged scores from various stroke scales is not valid.     

The influence of diabetes on neurological outcome and mortality in stroke patients

In a retrospective study of diabetic and non-diabetic patients with acute ischaemic stroke, mortality and neurological outcome were assessed. Mortality was determined 4 weeks after admission. The study population consisted of the consecutive patients (n = 609) admitted to the Department of Neurology with acute stroke between January 1994 and December 1995. There were 80 diabetic and 529 non-diabetic patients. The mortality rate was higher in diabetics (36.3%) than in non-diabetics (27%), but the difference was not significant (p = 0.08). The neurological status on admission, age, history of arterial hypertension, atrial fibrillation and coronary arterial disease were used to select groups of 41 diabetics and 84 non-diabetics with similar risk factors and similar onset of stroke. The neurological status on 10-th, 20-th and 28-th day of the hospital stay in both groups was compared. The study showed that insulin-dependent diabetics and older patients (above 65 years of age) with diabetes demonstrated a worse neurological outcome than non-diabetic patients, although the difference was not significant.     

Seizures in acute apoplexy. Predisposing factors and significance for prognosis

The aim of the study was to determine the relationships between seizures during the early phase of stroke (early seizures, ES) and stroke outcome, and to identify predictors of ES. The study was prospective, consecutive and community-based, and included 1197 patients with acute stroke. We determined the number and type of seizures, initial stroke severity, infarct size, mortality, and outcome in survivors. Stroke severity was measured on admission, weekly, and at discharge using the Scandinavian Stroke Scale (SSS). Multiple logistic and linear regression outcome analyses included relevant confounders and potential predictors. Fifty patients (4.2%) had seizures within 14 days of the stroke. In the multivariate analyses, only initial stroke severity was related to ES. For each 10-point increase in stroke severity (SSS score), the relative risk of ES increased by a factor of 1.65 (95% confidence interval, 1.4 to 1.9) (p < 0.0001). ES did not influence the risk of death during hospital stay (p = 0.56). In survivors, ES was related to a better outcome, equivalent to an improvement in SSS score of 5.7 points (SE [b] = 1.8; p = 0.002). The decisive factor of ES was initial stroke severity. ES per se was not related to mortality. Surprisingly, in survivors, ES predicted a better outcome. We explain this finding by a relatively larger ischaemic penumbra in patients who have ES after a stroke.     

Short and longterm outcomes for patients with systemic rheumatic diseases admitted to intensive care units: a prognostic study of 181 patients

OBJECTIVE: To determine short and longterm outcomes and prognostic factors for patients with systemic rheumatic diseases admitted to intensive care units in 4 teaching hospitals. METHODS: All adult intensive care unit admissions over a 12 year period for systemic rheumatic diseases were retrospectively assessed. One hundred and eighty-one patients with a mean age of 57 +/- 17 years were studied. RESULTS: The death rate in intensive care units was 33% (59/181) and in-hospital mortality was 43% (77/181). One hundred and four patients were discharged alive from hospital; 40 died during followup (mean 105 +/- 7 mo). The estimated 5 year survival rate for the discharged patients was 69%. The 4 factors significantly associated with in-hospital mortality by multivariate analysis were simplified acute physiologic score (p = 10(-4)), poor prior health status (p = 10(-4)), corticosteroid administration (p = 0.005), and the reason for admission; mortality was higher in the group admitted to intensive care for infectious complication (55 versus 34% for others; p = 0.006). In contrast, in-hospital mortality was not influenced by age or by systemic rheumatic diseases. Using Cox's model, only age over 60 years was a prognostic factor significantly associated with an increase in longterm mortality (p = 10(-4)). CONCLUSION: The short term outcome for patients with systemic rheumatic diseases in intensive care units was poor. The longterm prognosis after hospital discharge appeared fair, although the standardized mortality ratio was 5-fold that of a nonselected population. Short and longterm prognoses were similar for different systemic rheumatic disease groups.