Education

References



Pepe, P.E., Zachariah, B.S., Sayre, M.R. and Floccare, D. (1998), Ensuring the chain of

recovery for stroke in your community. Academic Emergency Medicine, 5 (4),

352-358.

Abstract: Until recently, the prehospital and ED management of nonhemorrhagic stroke

was largely supportive care, Studies have now demonstrated the potential of certain

therapeutic interventions to reverse the debilitating consequences of such strokes,

The clinical benefit for such interventions and the risk of significant therapeutic

complications are highly time- dependent, To optimize the chances of a better

outcome fan, the patient with stroke, each community must establish and continue to

refine a chain of recovery for stroke patients, The chain of recovery is a metaphor

that describes a series of sequential actions that must take place in a timely fashion to

optimize the chances of recovery from stroke, Each of these sequential actions forms

an individual link in the chain, and each link must be intact. The links include:

identification of the onset of stroke symptoms by the patient or bystanders; dispatch

life support services, which preferably include enhanced 9-1-1 and medically

supervised and trained dispatchers who can rapidly deploy the closest responders and

transport units; emergency medical services (EMS) personnel who can rapidly assess

and transport the stroke patient to the closest appropriate center capable of providing

advanced stroke diagnostics and interventions; en route notification of the receiving

facility so that appropriate personnel can be readied for rapid diagnosis and

intervention; and receiving facilities capable of providing rapid diagnosis and

advanced treatment of stroke, including the availability of specialists who can

evaluate underlying etiologies as well as plan future therapies and rehabilitation. To

ensure that the chain of recovery is in place, aggressive public education campaigns

should be implemented to increase the probability that stroke symptoms and signs

will be recognized as soon as possible by patients and bystanders, In addition,

because most of the current training programs for EMS dispatchers and EMS

personnel are lacking with regard to stroke, it is recommended that such personnel

and their EMS system managers be updated on current management and treatment

strategies for stroke

Keywords: 9-1-1/ACUTE ISCHEMIC

STROKE/ambulance/AMERICAN-HEART-ASSOCIATION/CARE/cerebral

vascular accident/community/community

intervention/diagnosis/education/EMERGENCY/emergency medical

services/emergency medicine/EMS/MANAGEMENT/neurologic

disorder/paramedics/PROFESSIONALS/rehabilitation/STATEMENT/stroke/stroke

patients/symptoms/THERAPY/TIME/training

Nasisi, D., Bruns, J., Baumlin, K., Wilets, I. and Jagoda, A. (2000), Out-of-hospital

management of stroke: Surveying local practice with implication for change.

Academic Emergency Medicine, 7 (4), 402-405

Keywords: education/emergency medical technicians/paramedics/practice/prehospital

care/stroke/thrombolytics

Casebeer, L.L., Klapow, J.C., Centor, R.M., Stafford, M.A., Renkl, L.A., Mallinger,

A.P. and Kristofco, R.E. (1999), An intervention to increase physicians' use of

adherence- enhancing strategies in managing hypercholesterolemic patients.

Academic Medicine, 74 (12), 1334-1339.

Abstract: Purpose. Patients' lack of adherence to medical regimens frustrates many

practicing physicians. This study was conducted to determine the effectiveness of a

combined continuing medical education intervention in increasing physicians'

adherence- enhancing skills and improving hypercholesterolemic patients' health.

Method. A prospective, randomized, controlled trial was designed using a nested

cohort of 28 community physicians throughout Alabama and 222 of their

hypercholesterolemic outpatients, The intervention, carried out in 1998, consisted of

three interactive case audio-conferences plus chart reminders. Physicians' learning

was measured by unannounced standardized patients, and patients' health by serum

cholesterol levels, weight, knowledge of hypercholesterolemia, self-reported dietary

habits, and health status. Results. No significant difference was found in the numbers

of physician adherence-enhancing strategies, although the number did increase

within the treatment group. There were significant differences in the intervention

group's patients' knowledge of cholesterol management (p =.008) and significant

reductions in their self-reported consumption of dietary fats (p =.002). A significant

difference was found in the serum cholesterol level of men in the intervention group

nine months after the intervention (p =.02), Conclusion. Combining a series of

interactive case audio-conferences with charr reminders shows promise in increasing

physicians' adherence-enhancing strategies. In chronic disease management, the

problem of enhancing adherence remains complex

Keywords: adherence/cholesterol/chronic

disease/cohort/community/education/health/knowledge/medical/medical

education/men/physician/PREVENTION/standardized patients/STROKE

MORTALITY/treatment/UNITED-STATES

Giampaoli, S., Poce, A., Sciarra, F., LoNoce, C., Dima, F., Minoprio, A., Santaquilani,

A., DeSanctis, P.C., Volpe, R., Menditto, A., Menotti, A. and Urbinati, G.C. (1997),

Change in cardiovascular risk factors during a 10-year community intervention

program. Acta Cardiologica, 52 (5), 411-422.

Abstract: The study describes changes in cardiovascular risk factors during 10 years of a

community intervention program conducted in a rural area in Central Italy. Two

areas were involved, one for treatment and one for reference. In 1983-84, 739 men

and 859 women in the treatment area and 942 men and 1045 women in the control

area, aged 20-69 years, were screened; total and HDL cholesterol, systolic and

diastolic blood pressure, fasting blood glucose, smoking habit, weight and height

were measured. Between 1983 and 1993 several intervention activities based on

community medicine were carried out in the treatment area. They were based on

interaction with the local socio-sanitary institutions and school system in order to

influence individual persons, small groups and entire community. Major effort was

addressed to mass health education, nutrition education, antismoking-propaganda

and detection and treatment of hypertension, diabetes and hyperlipidemia

Keywords: blood pressure/cardiovascular risk factors/community/community

intervention/community medicine/CORONARY

HEART-DISEASE/education/health education/hypertension/MEN/PROJECT/risk

factors/smoking/STROKE/women

Farina, E., Magni, E., Ambrosini, F., Manfredini, R., Binda, A., Sina, C. and Mariani, C.

(1997), Neuropsychological deficits in asymptomatic atrial fibrillation. Acta

Neurologica Scandinavica, 96 (5), 310-316.

Abstract: Objective - To assess the preclinical effects on cognitive functions of

nonrheumatic atrial fibrillation (NRAF) in patients with negative history for

cerebrovascular disease. Materials and methods - The study included 37 consecutive

patients with chronic (n=16, mean age 65.3+/-6.6 years) or paroxysmal (n=21, mean

age 58.3+/-9.5 years) NRAF and an equal number of control subjects in sinus rhythm,

who were matched for age, education and presence of hypertension, A

comprehensive neuropsychological battery including tests of attention, memory,

language and visuospatial skills was administered. Results - Patients with chronic

NRAF showed significantly poorer performances in tasks exploring attention and

verbal memory functions, while the paroxysmal group was significantly impaired in

a long-term memory task, The neuropsychological findings were confirmed

excluding from both groups patients viith CT evidence of cerebrovascular damage. A

small subgroup of patients was also submitted to cerebral MRI. Conclusion -

Neurologically asymptomatic NRAF is related to a subclinical but significant

impairment in attention and memory. These deficits could be produced by minor

ischemic lesions due to microembolization, or by diffuse hypoxic damage due to

hypoperfusion

Keywords: age/atrial fibrillation/CEREBRAL BLOOD-FLOW/cerebrovascular

disease/cognitive

impairment/COMPLICATIONS/DISEASE/education/EPIDEMIOLOGIC

FEATURES/HYPERTENSION/INFARCTION/ischemic/memory/MRI/neuropsycho

logical tests/PREVENTION/RISK/STROKE/VASCULAR DEMENTIA

Giaquinto, S., Buzzelli, S., Di Francesco, L., Lottarini, A., Montenero, P., Tonin, P. and

Nolfe, G. (1999), On the prognosis of outcome after stroke. Acta Neurologica

Scandinavica, 100 (3), 202-208.

Abstract: Objectives - The study was aimed at improving the accuracy of prognosis for

recovery of function in patients suffering a first stroke. Materials and methods -

Two-hundred and forty- eight patients were enrolled. The mean interval since the

stroke was 23 days. Patients entered a rehabilitation program lasting 60 days. The

predictive value of 12 factors were analysed, namely motor, cognitive and sphincter

subitems of Functional Independence Measure at admission (FIM-a), age, sex,

education, body mass index (BMI), depression, neglect, aphasia, ideomotor and

constructive apraxia. FIM score at discharge was the dependent variable. Results - A

multiple regression revealed that only age, cognitive and sphincter subitems of

FIM-a, neglect and ideomotor apraxia were significantly associated with outcome.

Moreover, these factors accounted for only 72% of the variance in outcome scores. A

decision of unfavourable prognosis on the basis of a FIM-a value lower than 40 was

incorrect in 2.8% of the patients in this study and in 8.2% of those having a FIM

score lower than 40. Conclusions - The use of statistical methods to examine the

outcome after stroke is useful for expressing probability on a group basis but is

unsuitable for determining the prognosis of individual patients. Such data should not

be used for fiscal management. A significant minority of patients presenting with a

FIM lower than 40 can regain a useful measure of independence. The errors in

prognosis based upon available methods, although small, have unacceptable effects

in human terms if they lead to the clinical decisions which deny patients

rehabilitation. All of the patients should therefore be admitted for rehabilitation after

their first stroke. Severe comorbidity requires special attention

Keywords: cerebrovascular disorders/depression/DISABILITY/FUNCTIONAL

INDEPENDENCE MEASURE/HEMISPHERIC STROKE/PREDICTIVE

FACTORS/prognosis

rehabilitation/PROGRESS/QUALITY/RECOVERY/rehabilitation/REHABILITATI

ON INPATIENTS/SCALES/stroke/UNIT

Ahlqwist, M., Bengtsson, C., Lapidus, L., Bergdahl, I.A. and Schutz, A. (1999), Serum

mercury concentration in relation to survival, symptoms, and diseases: results from

the prospective population study of women in Gothenburg, Sweden. Acta

Odontologica Scandinavica, 57 (3), 168-174.

Abstract: A prospective population study of women in Gothenburg, Sweden was started

in 1968-69 and comprised 1462 women aged 38, 46, 50, 54, or 60 years at baseline.

Follow-up studies were carried out in 1974-75, 1980-81, and 1992-93. The baseline

study included an extensive medical and dental examination. Serum mercury

concentration (S-Hg) was determined in deep-frozen samples from all participants in

1968-69 and in a random subsample of sera from participants in 1980-81, about 20

years after the baseline examinations;. S-IIIS was statistically significantly correlated

with number of amalgam Is at both examinations. Of 30 defined symptoms and 1

different clusters of symptoms, no one was independently correlated with S-Hg

measured in the samples from 1968-69, while there was a negative statistically

significant correlation with over- exertion and poor appetite in 1980-81. Blood

hemoglobin and serum B-12 concenntrations in 1968-69 were statistically

significantly and positively correlated with S-Hg, while erythrocyte sedimentation

rate and the serum concentrations of potassium and triglycerides were significantly

and negatively correlated with S-Hg, also after including potential confounders.

Blood hematocrit examined in 1980-81 was negatively correlated with S-Hg. When

including potential confounders, serum IgA was also statistically significantly

correlated with S-Hg, but not in univariate analysis. No statistically significant

correlation was observed between S- Hg, on the one hand, and the incidence of

diabetes, myocardial infarction. stroke, or cancer on the other, while a statistically

significant negative correlation was observed with overall mortality when age and

education were included as background variables. There were some correlations

between biological variables and S-Hg probably of no negative clinical significance,

and we conclude that there is no association between disease and S-Hg on a

population basis in middle-ag ed and elder women

Keywords: ABSORPTION/DENTAL

AMALGAM/epidemiology/EXPOSURE/FILLINGS/FISH

CONSUMPTION/GLUTATHIONE-PEROXIDASE/IMMUNE-SYSTEM/INORGA

NIC MERCURY/laboratory

variables/mercury/morbidity/mortality/SELENIUM/stroke/SWEDISH

ADOLESCENTS/symptoms

Li, G., Shen, Y.C., Chen, C.H., Zhau, Y.W., Li, S.R. and Lu, M. (1991), A 3-Year

Follow-Up-Study of Age-Related Dementia in An Urban Area of Beijing. Acta

Psychiatrica Scandinavica, 83 (2), 99-104.

Abstract: A 3-year follow-up study of 1090 people aged 60 years or over in an urban

area of Beijing, China, was conducted to determine the incidence of dementia and its

characteristics of distribution. This cohort had been studied first in a cross- sectional

survey of dementia in 1986. The follow-up examination employed the same

interviewers, psychiatrists, instruments (Mini-Mental State Examination and the

Crichton Royal Behavior Rating Scale) and diagnostic criteria for dementia

(modified DSM-III) in 1989. The respondent rate in this study was 75.7%. The

average annual incidence rate of moderate and severe dementia for

greater-than-or-equal-to 60 years was 0.3% (95% confidence interval 0.08-0.52%).

As expected, the rate increased sharply with aging. No sex difference was found. The

prevalence rate of moderate and severe dementia was 1.10% among those aged

greater-than-or- equal-to 65 years, similar to that (1.82%) in the first survey. Our

results showed that the multi-infarct dementia was somewhat more common than

primary degenerative dementia (ratio 3:2), both among incident cases and current

prevalent ones. The average duration of dementia in the community was 8.0 years

(SD 3.4). The risk for death in demented patients was 3 times higher than in the

whole cohort (standardized mortality ratio = 2.95), and no specific cause of death

was observed. In addition, our study showed that elderly people with less education,

a history of consistent unemployment, limited physical activity and stroke history

had a higher risk for developing dementia

Keywords:

aged/aging/China/community/COPENHAGEN/DEMENTIA/education/elderly/incid

ence/LONGITUDINAL

STUDY/MORBIDITY/MORTALITY/POPULATION/PREVALENCE/RISK

FACTOR/stroke/survey

Cruickshank, J.M. and Mcainsh, J. (1992), Patient Compliance on Taking

Cardiovascular Drug-Therapy. Acta Therapeutica, 18 (1), 53-60.

Abstract: The treatment of hypertension which is a very common, generally

asymptomatic condition, leads to a reduction in fatal and non- fatal stroke of the

order of 40-50% and a more modest degree of primary prevention from myocardial

infarction, probably in the region of 10-15 % compared with placebo. There is thus

little doubt that anti-hypertensive therapy is of clinical benefit, assuming of course

that an asymptomatic patient is compliant in taking the tablets. Patient education by

the physician and/or the pharmacist may help to improve compliance as can an

absence of serious drug-induced side effects. However, simplicity of the dosing

schedule is possibly the major factor in achieving good patient compliance. In

particular convenience of once- daily tablet taking has been shown to improve

compliance. To this end some cardiovascular drugs have pharmacokinetic and

pharmacodynamic profiles which support once-daily dosing, while those that do not

can often be successfully formulated in sustained release preparations to achieve this

end

Keywords: education/hypertension/myocardial infarction/prevention/primary

prevention/stroke/treatment

Tallis, R., Hall, G., Craig, I. and Dean, A. (1991), How Common Are Epileptic Seizures

in Old-Age. Age and Ageing, 20 (6), 442-448.

Abstract: A large primary-care computerized database was searched to determine the

incidence and prevalence of epilepsy and epileptic seizures in old age compared with

the general population. The prevalence of subjects with a diagnosis of epileptic

seizures was higher in older age groups: 10.9/1000 for sexagenarians, 12.0 for

septuagenarians and 13.1 for those over 80, compared with 9.0/1000 in the overall

population. The overall prevalence in subjects aged over 60 was 11.8. Annual

incidence rose even more sharply in old age: 76/100000 for sexagenarians, 147 for

septuagenarians, and 159 for those over 80, compared with an overall population

incidence of 69/100000. The overall incidence in subjects over 60 was 117. Of

incident cases requiring treatment, 35.5% were over 60 years old. Our findings are in

keeping with other recent epidemiological studies and in part reflect the

age-associated increase in the prevalence of cerebrovascular disease. They have

implications for the organization of services for elderly people, for the education of

general practitioners and hospital doctors and for directing epilepsy research

Keywords: AGE/aged/cerebrovascular

disease/diagnosis/DISEASE/education/elderly/ELDERLY

PEOPLE/ETIOLOGY/FREQUENCY/incidence/ONSET/prevalence/STROKE/treat

ment

Baskett, J.J., Marshall, H.J., Broad, J.B., Owen, P.H. and Green, G. (1996), The good

side after stroke: Ipsilateral sensory-motor function needs careful assessment. Age

and Ageing, 25 (3), 239-244.

Abstract: Twenty subjects were examined 4-6 weeks after stroke to establish whether a

sensory-motor ipsilateral deficit occurs early after stroke. Each underwent a timed

test of repetitive side-to-side movement of both the upper and lower limbs ipsilateral

to the cerebral infarct, and an assessment of motor disability using the Motor

Assessment Scale. Results were compared with a group studied almost a year after

their stroke, and with 41 age-matched healthy volunteers. There was a significantly

worse performance (p 70% excess rate of death from coronary heart disease, and

an elevated risk of sudden death. These risks are compounded in the presence of

hypertension, hypercholesterolemia, glucose intolerance, and diabetes, all of which

exhibit a synergistic effect with smoking. The relationship between smoking and the

risk of peripheral vascular disease has also been well documented. Smokers account

for approximately 70% of patients with atherosclerosis obliterans and virtually all

those with thromboangiitis obliterans. An association between smoking and

cerebrovascular disease remains a matter of debate, although a higher risk of stroke

and stroke-related mortality has been observed in smokers than in nonsmokers.

Smoking has also been implicated in the development of cor pulmonale, but a direct

association with congestive heart failure has not been established. Nicotine and

carbon monoxide appear to play major roles in the cardiovascular effects of smoking.

Both components adversely alter the myocardial oxygen supply/demand ratio and

have been shown to produce endothelial injury, leading to the development of

atherosclerotic plaque. Adverse effects on the lipid profile have been noted as well,

but the relationship between these changes and the risk of cardiovascular disease

remains to be confirmed. Notably, smoking cessation results in a dramatic reduction

in the risk of mortality from both coronary heart disease and stroke. In light of the

fact that the incidence of smoking has declined primarily among educated sectors of

the U.S. population, future efforts must focus on providing effective education,

including smoking cessation techniques, to the less-educated groups

Keywords: ATHEROSCLEROSIS/cardiovascular disease/cerebrovascular

disease/CIGARETTE-SMOKING/coronary/coronary heart

disease/diabetes/education/hypertension/incidence/morbidity/mortality/peripheral

vascular disease/smoking/stroke/TWINS DISCORDANT/vascular disease

Elias, M.F., Wolf, P.A., Dagostino, R.B., Cobb, J. and White, L.R. (1993), Untreated

Blood-Pressure Level Is Inversely Related to Cognitive-Functioning - the

Framingham-Study. American Journal of Epidemiology, 138 (6), 353-364.

Abstract: It was hypothesized that blood pressure would be inversely related to

cognitive functioning, if unconfounded with antihypertensive medication and

measured over many occasions prior to neuropsychological testing. For stroke-free

Framingham Study participants aged 55-88 years (n = 1,702), blood pressure levels

were averaged over five biennial examinations (1956- 1964) when few hypertensives

were being treated, and examined in relation to neuropsychological tests

administered between 1976 and 1978. With age, education, occupation, cigarette

smoking, alcohol consumption, and gender controlled, blood pressure levels and

chronicity of hypertension were inversely related to the composite score and

measures of attention and memory. This was true for the full sample, for a subsample

untreated during blood pressure measurement (n = 1,485), and for a subsample

untreated throughout the entire study period (n = 1,038). For example, decline per 10

mmHg increment in blood pressure ranged from -0.04 to -0.07 standard score units (z)

for the composite score. A negative finding previously was most likely due to blood

pressure measurement concurrently with neuropsychological testing, or too few

measurements. Hypertension-associated pathogenic processes may cause mild

cognitive impairment, but other mechanisms need to be considered

Keywords: age/aged/alcohol/ANTIHYPERTENSIVE AGENTS/BLOOD

PRESSURE/COGNITION/cognitive

impairment/education/gender/HEALTH/HYPERTENSION/memory/MEN/neuropsy

chological testing/neuropsychological tests/PERFORMANCE/smoking

Wilson, T.W., Kaplan, G.A., Kauhanen, J., Cohen, R.D., Wu, M., Salonen, R. and

Salonen, J.T. (1993), Association Between Plasma-Fibrinogen Concentration and 5

Socioeconomic Indexes in the Kuopio Ischemic-Heart-Disease Risk Factor Study.

American Journal of Epidemiology, 137 (3), 292-300.

Abstract: The association between five socioeconomic indices (lifetime occupation,

education, income, ownership of material possessions, and childhood socioeconomic

status) and plasma fibrinogen levels was investigated in middle-aged Finnish men

who were part of the Kuopio Ischemic Heart Disease Risk Factor Study. The Kuopio

Ischemic Heart Disease Risk Factor Study is based on a representative age-stratified

sample of 2,682 men aged 42, 48, 54, and 60 years. The data were collected between

1984 and 1989. The present analysis is restricted to the 2,011 men for whom

information on fibrinogen and all covariates was available. The covariates were

alcohol consumption, body mass index, physical fitness, smoking, coffee

consumption, high density lipoprotein cholesterol, low density lipoprotein

cholesterol, blood leukocyte count, and prevalent disease (at least one sign of

ischemic heart disease, hypertension, diabetes, or previous stroke). An age-adjusted

inverse association was found between levels of plasma fibrinogen and four of the

five socioeconomic indices: current income, education, lifetime occupation status,

and current material possessions. After adjustment for the covariates, the association

persisted for education, current income, and lifetime occupation. Analysis of the joint

effect of childhood and adult socioeconomic status indicated that those who were

economically disadvantaged at both times had the highest fibrinogen levels, but the

fibrinogen levels of those who were not poor as adults had no variation by childhood

socioeconomic status

Keywords: aged/alcohol/ANALYSIS/CARDIOVASCULAR

DISEASES/CONSORTIUM/diabetes/education/FIBRINOGEN/HEALTH/HEMOS

TATIC FUNCTION/hypertension/ischemic/MEN/MIDDLE

AGE/MYOCARDIAL-INFARCTION/physical fitness/POSSIBLE LINK/RISK

FACTORS/smoking/SOCIAL

CLASS/SOCIAL-CLASS/socioeconomic/SOCIOECONOMIC

FACTORS/socioeconomic status/STROKE

Guralnik, J.M., Lacroix, A.Z., Abbott, R.D., Berkman, L.F., Satterfield, S., Evans, D.A.

and Wallace, R.B. (1993), Maintaining Mobility in Late-Life .1. Demographic

Characteristics and Chronic Conditions. American Journal of Epidemiology, 137 (8),

845-857.

Abstract: To assess the role of demographic tactors and chronic conditions in

maintaining mobility in older persons, this study utilized longitudinal data collected

as part of the Established Populations for Epidemiologic Studies of the Elderly

between 1981 and 1987 on 6,981 men and women aged 65 years and older in East

Boston, Massachusetts; Iowa and Washington counties, Iowa; and New Haven,

Connecticut. Results are presented for those who at baseline reported intact mobility,

defined as the ability to climb stairs and walk a half mile without help, and who were

followed annually for up to 4 years for changes in mobility status. Age, income,

education, and chronic conditions present at baseline and occurring during follow-up

were evaluated for their association with loss of mobility. Over the follow-up period,

55.1% of subjects maintained mobility, 36.2% lost mobility, and 8.7% died without

evidence of mobility loss prior to death. In both men and women, increasing age and

lower income levels were associated with increased risk of losing mobility, even

after controlling for the presence of chronic conditions at baseline. After adjustment

for age, income, and chronic conditions, lower education levels were a significant

risk factor for mobility loss in men, but not in women. Baseline reports of previous

heart attack, stroke, high blood pressure, diabetes, dyspnea, and exertional leg pain

were associated with small but significant risks for mobility loss. There was a

stepwise increase in the risk of mobility loss according to the number of chronic

conditions present at baseline that was very consistent between men and women. The

occurrence during the study of a new heart attack, stroke, cancer, or hip fracture was

associated with a substantially greater risk of mobility loss than was associated with

the presence of these conditions at baseline

Keywords: ACTIVITIES OF DAILY LIVING/age/AGED/blood pressure/CHRONIC

DISEASE/COMMUNITY/CORONARY

HEART-DISEASE/DEMOGRAPHY/diabetes/EDUCATION/ELDERS/HEALTH/H

IP

FRACTURE/IMPACT/INCOME/men/PHYSICAL-DISABILITY/PREDICTORS/P

ROSPECTIVE STUDIES/RECOVERY/RISK-FACTORS/STROKE/women

Launer, L.J., Wind, A.W. and Deeg, D.J.H. (1994), Nonresponse Pattern and Bias in A

Community-Based Cross- Sectional Study of Cognitive-Functioning Among the

Elderly. American Journal of Epidemiology, 139 (8), 803-812.

Abstract: The demographic, health, and mental functioning characteristics of

nonresponders to a community-based cross-sectional study of cognitive functioning

among the elderly in Amsterdam, the Netherlands (Amsterdam Study of the Elderly

(AMSTEL), October 1990 to May 1991), were examined and compared with

responders. The randomly selected age-stratified (65-74, 75-84 years) sample was

drawn from nonresponders listed with a subsample (n = 8) of general practitioners

whose lists served as the sampling frame for the main study. The general

practitioners approached and interviewed the responding nonresponders using the

same standardized questions that were used in the main study. Nonresponders (n =

115) and responders (n = 999) from the same medical practices were compared by

means of chi-square and odds ratios. Compared with responders, these

nonresponders more often reported a history of psychiatric illness, heart attack,

stroke, and diabetes, and were more likely to be unmarried, to have a lower education,

and to do poorly on the cognitive test (odds ratio = 1.6, 95% confidence interval 1.0-

2.6). Most significant physical and mental health differences by response status were

seen among the persons aged 25

points) or impaired (less than or equal to 25 points). Logistic regression analysis was

used to estimate the odds ratio (OR) and 95% confidence interval (CI) for cognitive

impairment. After adjustment for age, education, sex, smoking, total caloric intake,

and intake of other antioxidants, a lower intake of beta-carotene was associated with

impaired cognitive function (1 stroke was associated with

an odds ratio of 50 (95% confidence limits 10.5 to 238.3). There was no significant

association between cognitive performance and greater than or equal to 1 prior MI or

history of CABG. Time between events and cognitive function testing did not affect

results. Analyses support a significant association between clinical stroke and

persistent cognitive impairment, but fail to implicate CABG or MI. (C) 1998 by

Excerpta Medica, Inc

Keywords: age/ALZHEIMERS-DISEASE/ASSOCIATION/cognitive

impairment/COMMUNITY POPULATION/education/MINI-MENTAL

STATE/myocardial infarction/stroke/surgery/VASCULAR DEMENTIA

Bergmann, M.M., Byers, T., Freedman, D.S. and Mokdad, A. (1998), Validity of

self-reported diagnoses leading to hospitalization: A comparison of self-reports with

hospital records in a prospective study of American adults. American Journal of

Epidemiology, 147 (10), 969-977.

Abstract: The authors compared interview reports with hospitalization records of

participants in a nationally representative survey to determine the accuracy of

self-reports of ischemic heart disease, stroke, gallbladder disease, ulcers, cataract, hip

fracture, colon polyps, and cancers of the colon, breast, prostate, and lung. The study

cohort consisted of 10,523 participants from the First National Health and Nutrition

Examination Survey in 1971-1975 who were aged 25-74 years at the baseline

examination and who completed a follow-up interview in 1982-1984, Self-reports of

hospitalization for breast cancer were confirmed as accurate for 100% of cases where

a hospital record was available. Self-report accuracy was also high for ischemic heart

disease (84%), cataract (83%), and hip fracture (81%); it was moderate for lung

cancer (78%), prostate cancer (75%), gallbladder disease (74%), colon cancer (71%),

and stroke (67%); but it was low for ulcers (54%) and colon polyps (32%). Some of

the self-reports of ulcers (20%), hip fracture (9%), ischemic heart disease (7%), and

stroke (7%) were found to reflect diagnoses of other conditions of anatomic

proximity. Accuracy of self-reports improved with higher levels of education, but

was not generally related to age, gender, race, alcohol use, or smoking. The results

suggest that self- reports of some diseases can be taken as accurate, but self- reports

of other conditions might require medical record verification in epidemiologic

follow-up studies

Keywords: ACCURACY/age/chronic disease/DISEASE/education/epidemiologic

methods/gender/HEALTH/hip fracture/hospital

records/hospitalization/INFORMATION/ischemic/MEDICAL

RECORDS/MYOCARDIAL-INFARCTION/PROSPECTIVE COHORT/prospective

studies/QUESTIONNAIRE/questionnaires/race/RECALL/reproducibility of

results/smoking/stroke/VALIDATION/WOMEN

Wick, M., Muller, E.J., Ekkernkamp, A. and Muhr, G. (1998), The motorcyclist: Easy

rider or easy victim? An analysis of motorcycle accidents in Germany. American

Journal of Emergency Medicine, 16 (3), 320-323.

Abstract: This report reviews the findings from 86 motorcycle accidents during a I-year

period at the Trauma Center "Bergmannsheil" in Bochum, Germany A study of the

case histories supplemented by telephone conversations yielded the following results:

90.7% of the patients were men, and the average age was 28.8 years; most of the

accidents occurred in the 25 to 30-year-old age group (27.9%). Motorcycle accidents

happened mostly during recreational rides on weekends in the summertime,

Although there was a high rate of helmet use (98.8%), the head region was affected

in 12 victims. Two patients died because of their severe head injuries (2.3%), Lower

extremity injuries (46%), especially open tibia fractures (19.7%), were among the

most common injuries sustained. Fractures of the distal radius constituted the largest

portion of upper extremity injuries (18.8%), The average stay in our hospital was

35.4 days; 23.4% of the patients had to change jobs after the accident. Fifty percent

of the crashes happened with motorcycles between 500 and 750 cc stroke volume.

Although 34.5% possessed their driver's licenses for more than 8 years, they had not

had much experience handling a motorbike. These results underline the fact that

motorcycle accidents are sustained by young men in their working prime; as a result,

these accidents pose a tremendous burden to individuals and society and every

attempt should be made to offer highly qualified surgical and trauma care to

minimize the damage to the motorbiker. A plea is made for more prevention

measures like driver education, better road conditions, or legislative changes to

prevent motorcycle crashes. The wearing of a helmet is strongly advocated,

Copyright (C) 1998 by W.B. Saunders Company

Keywords: age/ALCOHOL/burden/costs/education/HELMET-USE-LAW/injury

patterns/LEG INJURIES/lower extremity injuries/motorcycle

accident/PREVENTION/stroke

Olney, R.S. (1999), Preventing morbidity and mortality from sickle cell disease - A

public health perspective. American Journal of Preventive Medicine, 16 (2),

116-121.

Abstract: Context: Sickle cell disease is a group of conditions characterized by

production of abnormal hemoglobin, with clinical manifestations that vary by

genotype and age. Objective: To discuss current public health issues associated with

sickle cell disease, and approaches to preventing complications from these conditions

in die United States. Design: Literature review. Results: Most clinical interventions

for people with sickle cell disease discussed in the medical literature can be classified

as tertiary prevention: for example, therapy to ameliorate anemia, reduce the

frequency of pain crises, or prevent stroke I recurrences. A form of secondary

prevention, newborn screening, has emerged as an important public health approach

to identifying affected children before they develop complications. Newborn

screening is the starting point, for simple public health strategies such as parental

education, immunization, and penicillin prophylaxis. Identification of affected

families by newborn or community screening programs has also been an entry point

for genetic counseling, although utilization of prenatal testing has varied by factors

such as geographic location. Public health agencies have had significant involvement

with funding, policy making, and formulation of laboratory and clinical guidelines

for sickle cell disease. Since the introduction of penicillin prophylaxis policies,

newborn screening, new immunizations, and comprehensive medical care centers,

the survival of young children with sickle cell disease has improved. Conclusions:

Although the efforts of preventive medicine providers in public health programs are

not solely responsible for the improved survival of children with sickle cell disease,

such programs remain an important component in preventing sickle cell

complications

Keywords: age/ANEMIA/anemia/child health

services/CHILDREN/COST-EFFECTIVENESS/education/EXPERIENCE/GENE/H

EMOGLOBINOPATHIES/hemoglobinopathies/HOSPITALIZATIONS/MANAGE

MENT/morbidity/mortality/neonatal screening/PRENATAL-DIAGNOSIS/public

health/sickle cell prevention and control/stroke/TRIAL

Ganguli, M.C., Grimm, R.H., Svendsen, K.H., Flack, J.M., Grandits, G.A. and Elmer,

P.J. (1999), Urinary sodium and potassium profile of blacks and whites in relation to

education in two different geographic urban areas. American Journal of

Hypertension, 12 (1), 69-72.

Abstract: The high Na/low K environment of modern society is related to the genesis of

hypertension and stroke. There is prior evidence of racial, geographical, and social

class differences in Na and K intake and blood pressure, Baseline data from the

Treatment of Mild Hypertension Study (TOMHS) was used to assess urinary Na and

K excretion profiles by race, clinic geographic area, and education. Participants were

adult black and white hypertensive patients from the Birmingham, Alabama, and

Chicago, Illinois, area. Level of education was categorized as: less than college

graduate and college graduate or more. Two overnight urine samples were collected

and analyzed for Na and K at entry from 154 blacks and 281 whites. The urinary

Na:K ratio was significantly higher in both blacks (5.1 v 3.8, P 50% of regional adults, broadly distributed by site, gender, and age,

Interventions: From 1974 to 1994, a community program, integrated with primary

medic;ll care and staffed by professional nurses, provided education, screening,

counseling, referral, tracking, and followup for cardiovascular risk factors. Main

Outcome Measures: Age-adjusted mortality rates (total, heart, coronary,

cerebrovascular, cancer) for three counties and Maine, plus annual program

encounters. Results: Relative to Maine, the Franklin heart disease death rate was 0.97

at baseline (1960-1969; 95% confidence interval, 0.91 to 1.03), 0.91 during the

program (0.85 to 0.97), 0.83 during the 11 years of program growth (0.78 to 0.88),

but 1.0 during the 10 years of decreasing encounters. Franklin's total death rate was

1.01 at baseline, 0.95 during the program (0.92 to 0.98), and 0.90 during program

growth (0.86 to 0.94). Results were similar for coronary disease, stroke, and cancer.

Relative death rates did not fall in either comparison county. Nurse- client encounters

totaled 120,280 over 21 years. Relative to Maine, heart disease death rates correlated

inversely with program encounters (r = -0.53) but not with unemployment or

physician supply. Conclusions: Integrated with primary medical care, a

comprehensive, nurse-mediated community cardiovascular health program in rural

Maine has been associated with significant time-dependent and dose-dependent

reductions in cardiovascular and total mortality. (C) 2000 American Journal of

Preventive Medicine

Keywords: ACUTE MYOCARDIAL-INFARCTION/age/cardiovascular

disease/cardiovascular diseases/cardiovascular risk

factors/community/coronary/coronary disease/CORONARY

HEART-DISEASE/COST-EFFECTIVENESS/DEATH/education/EDUCATION-PR

OGRAM/gender/health/impact/medical/mortality/NORTH-KARELIA/nursing/physi

cian/PREVENTION/primary prevention/PROJECT/public health/residence

characteristics/risk/risk factors/RISK- FACTORS/screening/stroke/TRENDS

Morris, M.S., Jacques, P.F., Rosenberg, I.H. and Selhub, J. (2001),

Hyperhomocysteinemia associated with poor recall in the third National Health and

Nutrition Examination Survey. American Journal of Clinical Nutrition, 73 (5),

927-933.

Abstract: Background: High circulating total homocysteine (tHcy) concentrations are

associated with stroke, which is a major cause of cognitive dysfunction. Blood

homocysteine concentrations are inversely correlated with performance on some

cognitive-function tests and a relation was recently shown between

hyperhomocysteinemia and Alzheimer disease. Objective: The objective was to

evaluate the relation between serum tHcy concentrations and performance on short

delayed-recall tests of elderly men and women participating in the third National

Health and Nutrition Examination Survey, phase 2 (1991-1994). Design: Subjects

were aged 260 5. Subjects reported no previous stroke, completed greater than or

equal to8 y of education, and took a test of delayed recall of story ideas (n = 1200) or

words (n = 1270). Results: After adjustment fur sex, age, race- ethnicity, income,

years of education, and serum creatinine concentration, subjects in the upper half of

the folate distribution recalled, on average, >4 of 6 story ideas; subjects with lower

folate status recalled significantly fewer ideas (P 12 vs. less

than or equal to 12 (odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.2-0.8);

smoking greater than or equal to 20 cigarettes/day vs. nonsmokers (OR = 2.8, 95%

CI = 1.1-7.3); and the regular use of multivitamins (OR = 0.4, 95% CI = 0.2-0.9).

CONCLUSIONS: These results suggest that a substantial proportion of healthy

young premenopausal women have tHcy levels that increase their risk for vascular

disease. A number of potentially modifiable behavioral and environmental factors

appear to be significantly related to elevated tHcy levels in young women

Keywords: COMMON MUTATION/CORONARY-ARTERY

DISEASE/correlates/DETERMINANTS/FOLATE/FOLIC-ACID/homocysteine/HO

RDALAND HOMOCYSTEINE/METHYLENETETRAHYDROFOLATE

REDUCTASE/PLASMA HOMOCYSTEINE CONCENTRATIONS/race/RISK

FACTOR/smoking/stroke/VASCULAR- DISEASE/women

Howard, G., Anderson, R.T., Russell, G., Howard, V.J. and Burke, G.L. (2000), Race,

socioeconomic status, and cause-specific mortality. Annals of Epidemiology, 10 (4),

214-223.

Abstract: PURPOSE: Life expectancy for black Americans is five to eight years less

than for Whites. The socioeconomic status (SES) of Blacks is also less than for

Whites, and SES is associated with early mortality. This paper estimates the

proportion of the racial difference in mortality attributable to SES by specific causes

of death. METHODS: Data on 453,384 individuals in the National Longitudinal

Mortality Study were used to estimate the hazard ratio associated with black race,

with and without adjustment for income and education (measures of SES), in 38

strata defined by cause of death and age. RESULTS: For women, SES accounted for

much (37-67%) of the black excess mortality for accidents, ischemic heart disease

(ages 35-54), diabetes, and homicide; but not for hypertension, infections, and

stomach cancers (11-17%). For men, SES accounted fur much of the excess risk

(30-55%) for accidents, lune cancer, stomach cancer, stroke, and homicide; but not

for prostate cancer, pulmonary diseases, hypertension, and cardiomyopathy (0-17%).

CONCLUSIONS: These results confirm those specific causes of death likely to

underlie the overall excess mortality of Blacks, and identify those causes where SES

may play a large role. (C) 2000 Elsevier Science Inc. All rights reserved

Keywords: age/blacks/BLACKS/diabetes/DISEASE/diseases/education/family

characteristics/HEALTH/hypertension/INCOME/ischemic/life

expectancy/men/mortality/race/risk/socioeconomic/socioeconomic

factors/socioeconomic status/stroke/STROKE MORTALITY/WHITES/women

Manolio, T.A., Furberg, C.D., Wahl, P.W., Tracy, R.P., Borhani, N.O., Gardin, J.M.,

Fried, L.P., Oleary, D.H. and Kuller, L.H. (1992), Eligibility for Cholesterol Referral

in Community-Dwelling Older Adults - the Cardiovascular-Health-Study. Annals of

Internal Medicine, 116 (8), 641-649.

Abstract: Objectives: To assess the proportion of community-dwelling adults aged 65

years or older who are eligible for referral for lipoprotein analysis and intervention

according to the National Cholesterol Education Program (NCEP) guidelines. Design:

Cross- sectional study based on examinations and questionnaires collected in 1989

and 1990. Setting: Four communities in the U.S. in the Cardiovascular Health Study

(CHS), a study of risk factors for heart disease and stroke in older adults. Participants:

A sample of 4810 men and women ages 65 to 100 randomly selected and recruited

from Health Care Financing Administration Medicare eligibility lists for the four

communities; not institutionalized, not wheelchair-bound, not currently receiving

therapy for cancer, not currently taking lipid-lowering medications, and not having

eaten in the preceding 9 hours. Measurements: Total cholesterol and lipoprotein

analysis measured in all participants. Results: Total cholesterol levels were less than

5.17 mmol/L (200 mg/dL) in 37% of participants, 5.17 to 6.19 mmol/L (200 to 239

mg/dL) in 39%, and 6.20 mmol/L (240 mg/dL) or greater in 24%. Compared with

their counterparts, older participants, especially those over 80 years of age, were

more likely to have levels below 5.17 mmol/L, as were men, nonwhites, and those

with coronary heart disease or two or more coronary heart disease risk factors (P 40 kg/m(2)). Middle age, lower education and joblessness predicted a higher

risk for obesity. Patients living in rural areas had greater BMIs than those living in

urban areas (P 220 mm Hg, or mean arterial blood pressure (MABP) > 140 mm Hg]. As

a general guide, MABP should be lowered by decrements no larger than 15 mm Hg.

Antihypertensive agents should be chosen appropriately to avoid increases in

cerebrovascular blood volume or ICP. An antipyretic and/or an antibiotic should be

given immediately for raised temperature, possibly with a cooling blanket, and

subcutaneous or intravenous insulin should be used for markedly elevated blood

glucose levels. Prophylaxis against deep vein thrombosis and pulmonary embolism is

indicated in all acute stroke patients, but anticoagulation should be avoided in those

with large intracranial haemorrhage and in selected neurosurgical patients.

Physiotherapy as well as speech and occupational therapy should be started as early

as possible. The Need for Neurological Intensive Care: Neurological ICUs can

improve the survival and outcome of those acute stroke patients who require

intensive care. Aggressive approaches to acute stroke therapy, e.g. hypervolaemic-

hypertensive therapy, ventricular drainage, decompressive surgery, or experimental

use of thrombolytic agents, require management in a specialized neurological ICU.

About 10% of hospitalized acute stroke patients require ICU care, which is best

provided by staff with specialized training in neurological care. The minimum

requirements for optimal neurological intensive care are a 24-hour neurologist or

neurointensivist shift sei-vice, 1 nurse per patient in attendance at all times, and

facilities for advanced haemodynamic, neurological and ICP monitoring

Keywords: acute/ACUTE ISCHEMIC STROKE/acute stroke management/blood

pressure/costs/education/EMERGENCY/emergency care

organization/HEMISPHERIC

INFARCTION/HYPERTENSION/incidence/INTRACRANIAL-

PRESSURE/MANAGEMENT/monitoring/mortality/myocardial

infarction/neurointensive care/outcome/protocols/RANDOMIZED CONTROLLED

TRIAL/rehabilitation/stroke/stroke intensive care/stroke patients/stroke

units/surgery/TISSUE-PLASMINOGEN-ACTIVATOR/training/UNIT/URGENT

THERAPY

Wang, X.D., Guo, H., Zhang, X.Y., Zhu, H., Li, Y.H. and Zhou, G. (1997), An

observation on the time of hospital arrival and correct diagnosis with CT in acute

cerebral stroke patients. Cerebrovascular Diseases, 7 (2), 89-93.

Abstract: Objective: Ischemic cerebral stroke should be treated as early as possible to

improve therapeutic effects and decrease disability rate. This study was performed to

investigate the time of presentation of acute stroke and the time of establishment of

definite diagnosis. Method: Four hospitals of different types in the Beijing area

participated. Eight hundred and thirty-three patients were observed prospectively.

The time from symptom onset of acute stroke to hospital arrival and the time of CT

scanning were recorded. Results: Five hundred and ninety-one (70.9%) were

ischemic stroke patients and 242 (29.1%) were hemorrhagic stroke patients. In

Beijing Hospital the time of presentation of acute stroke was shortest among the four

hospitals. The rates of patients who arrived at hospital within 3 and 6 h after acute

stroke were higher for Beijing Hospital than for the other three hospitals, accounting

for 42.5 and 58.8%, respectively. The time of presentation after acute ischemic

stroke was longer than that after hemorrhagic stroke in all four hospitals. CT

scanning was conducted most timely in Beijing Hospital. The rates of CT scanning

within 3 and 6 h also were higher in Beijing Hospital, accounting for 23.5 and 40.0%,

respectively. Conclusion: In the Beijing area, even in a large hospital at the city

center, only half of the patients with ischemic stroke arrived at hospital within 6 h

after stroke onset. The patients who were examined with CT scan within 6 h were

less than half. It is suggested that for early treatment of ischemic stroke a great deal

of work, such as public and professional education in the community, should be done

Keywords: acute/ACUTE ISCHEMIC

STROKE/ADMISSION/China/community/diagnosis/disability/education/ischemic/st

roke/stroke onset/stroke patients/timing

Hacke, W. (1997), Management of acute ischaemic stroke - Is there a consensus?

Cerebrovascular Diseases, 7 2-6.

Abstract: Although there is currently no generally accepted consensus on the

management of acute ischaemic stroke, several organisations are working towards

producing guidelines for this disease. A major step in ensuring the rapid presentation

and treatment of sufferers would be to promote stroke as a medical emergency,

especially, since early thrombolytic therapy has been shown to be the first successful

treatment of stroke. Public and professional education would also raise the profile of

this condition and improve knowledge of the stages of treatment. The instigation of

stroke units, teams or even stroke pathways would offer optimal patient care and

provide the facilities necessary for effective diagnosis and management. Increasing

patient and physician awareness of stroke and encouraging prompt patient referral to

such units may mean that patients are best placed to receive early treatment with the

neuroprotective agents currently in the late stages of clinical evaluation

Keywords: acute/acute ischaemic stroke/ACUTE ISCHEMIC

STROKE/diagnosis/education/guidelines/neuroprotective agents/stroke/stroke

management/stroke team/stroke unit/stroke units/thrombolytic therapy

Kaste, M., Olsen, T.S., Orgogozo, J.M., Bogousslavsky, J. and Hacke, W. (2000),

Organization of stroke care: Education, stroke units and rehabilitation.

Cerebrovascular Diseases, 10 1-11

Keywords: ACUTE ISCHEMIC

STROKE/ADMISSION/AMERICAN-HEART-ASSOCIATION/CONTROLLED

TRIAL/COPENHAGEN-STROKE/COUNCIL/Finland/GUIDELINES/MANAGEM

ENT/rehabilitation/SPECIAL WRITING GROUP/STATEMENT/stroke/stroke units

Becker, K.J., Fruin, M.S., Gooding, T.D., Tirschwell, D.L., Love, P.J. and Mankowski,

T.M. (2001), Community-based education improves stroke knowledge.

Cerebrovascular Diseases, 11 (1), 34-43.

Abstract: Background and Purpose: Despite advances in stroke therapy, the public

remains uninformed about stroke, and few stroke patients present to the hospital in

time to receive treatment. Health education campaigns can increase community

awareness and may decrease time to hospital presentation among stroke patients.

Methods: We conducted a community-based education campaign utilizing television

and newspapers to inform the residents of King County, Wash., USA, about stroke

and the need to call 911. The effectiveness of the campaign was assessed, using a

pretest-posttest design, through telephone interviews with residents of King County.

Results: Prior to the education campaign, 59.6% of persons in King County could

name a risk factor for stroke, but only 45.2% knew that the brain was the organ of

injury. And while 68.2% of persons stated that they would call 911 in the event of

stroke, only 38.6% could name a symptom of stroke. The knowledge deficit was

greatest among Asian-Americans, men, the less educated and low-income residents.

There was a significant increase in stroke knowledge following the education

campaign; respondents were 52% (p = 0.005) more likely to know a risk factor for

stroke and 35% (p = 0.032) more likely to know a symptom of stroke after the

campaign. Conclusions: Baseline knowledge about stroke among the public is poor,

but can be increased through public education campaigns. Copyright (C) 2001 S.

Karger AG, Basel

Keywords: ACUTE ISCHEMIC STROKE/Asian

Americans/ATRIAL-FIBRILLATION/awareness/BEHAVIOR-CHANGE/brain/CA

RE/CHEST PAIN/community/CONTROLLED TRIAL/DELAYING HOSPITAL

ADMISSION/education/ethnic

groups/gender/HEART-ATTACK/hospital/knowledge/MASS-MEDIA

CAMPAIGNS/men/patient education/risk/risk factor/risk

factors/RISK-FACTORS/stroke/stroke patients/treatment

Barba, R., Castro, M.D., Morin, M.D., Rodriguez-Romero, R., Rodriguez-Garcia, E.,

Canton, R. and Del Ser, T. (2001), Prestroke dementia. Cerebrovascular Diseases,

11 (3), 216-224.

Abstract: Objective: To determine the frequency, associated factors and outcome of

dementia previous to a stroke. Design: Cross- sectional study of a cohort of 324

consecutive unselected stroke patients (mean age 70.9 years, range 20-98; 255

ischaemic, 46 haemorrhagic and 25 indefinite). Methods: Cognitive and functional

status prior to stroke were assessed by means of an interview to a relative, a short

version of the Informant Questionnaire on Cognitive Decline in the Elderly and the

Barthel Index. The DSM-III-R criteria were used to establish the diagnosis of

prestroke dementia. Clinical and CT features of patients with and without prestroke

dementia were compared. Results: Forty-nine patients (15%) were demented before

stroke; they were significantly older, less well educated, they had more frequently

female gender, prior cerebrovascular disease, cerebral and medial temporal lobe

atrophy and leukoaraiosis in the CT scan, and they had a higher mortality rate.

Female sex (OR 3.7, CI 95% 1.2-12), low education (OR 2.1, Cl 95% 1.1-4.2),

previous stroke (OR 3.6, Cl 95% 1.2-11), and cerebral atrophy (OR 3.8, Cl 95%

1.7-8.3) were independently associated with prestroke dementia in the logistic

regression analysis. Conclusions: Fifteen percent of stroke patients have prestroke

dementia and they have a worse outcome. Factors associated with prestroke dementia

are reminiscent both of degenerative and vascular brain pathology. Copyright (C)

2001 S. Karger AG. Basel

Keywords: age/ALZHEIMERS-DISEASE/BASE-LINE

FREQUENCY/brain/cerebrovascular disease/COGNITIVE

DECLINE/COMPUTED-

TOMOGRAPHY/CT/dementia/diagnosis/education/functional

status/gender/HOSPITALIZED COHORT/INFORMANT

QUESTIONNAIRE/leukoaraiosis/mortality/outcome/POSTSTROKE

DEMENTIA/risk factors/RISK-FACTORS/SPANISH VERSION/stroke/stroke

patients/vascular/VASCULAR DEMENTIA

Ciccone, A., Sterzi, R., Crespi, V., Defanti, C.A. and Pasetti, C. (2001), Thrombolysis

for acute ischemic stroke: The patient's point of view. Cerebrovascular Diseases, 12

(4), 335-340.

Abstract: Background. The use of thrombolytic therapy for acute ischemic stroke is still

controversial. A major problem is balancing the improvement in functional ability

against the risk of early death from cerebral hemorrhage. Our aim was to assess

whether patients who have had a stroke, and their proxies, would give consent to

thrombolysis if this therapy were introduced into clinical practice for acute ischemic

stroke in Italy. Methods:A 10-item questionnaire was administered by personnel not

directly involved in the care of patients in 12 Italian hospitals. Interviews were

carried out with at least 10 consecutive stroke inpatients per center in the postacute

phase and to their proxies. Results: There were 685 responders (377 female), median

age 58 years (range 18-98); 332 were patients and 353 proxies. Responders were

representative of the Italian population as a whole as regards mean age and sex,

education and marital status; 59% of responders (95% confidence interval 55-62%)

would agree to thrombolysis in the case of stroke. There was more uncertainty

among proxies than patients, especially when the decision had to be taken for a

relative (41 vs. 17% could not decide, p 5 years since last menstruation (0.75 mm)

(P>.05). Although hormone replacement therapy use was associated with a more

favorable lipid and hemostasis profile than nonuse, its use was not associated with

intima-media thickness in postmenopausal women aged 55 to 64 years (adjusted

average=0.74 mm for current users of estrogen alone and approximate to 0.75 mm

each for current users of estrogen plus progestin, former users, and never users).

Conclusions The data suggest that the well-known associations of hormone

replacement therapy with reductions in atherosclerotic cardiovascular disease may be

attributable more to acute physiological effects, such as hemodynamic changes or

reduced thrombosis, than to atherosclerosis itself

Keywords: acute/age/aged/atherosclerosis/ATHEROSCLEROSIS/blood

pressure/CARDIOVASCULAR-DISEASE/CORONARY

HEART-DISEASE/diabetes/education/estrogen/FOLLOW-UP/hormones/menopause

/MYOCARDIAL-INFARCTION/POSTMENOPAUSAL ESTROGEN

USE/PROGESTOGEN

REPLACEMENT/race/RISK-FACTORS/smoking/STROKE/WOMEN

Qureshi, A.I., Suri, M.F.K., Guterman, L.R. and Hopkins, L.N. (2001), Cocaine use and

the likelihood of nonfatal myocardial infarction and stroke - Data from the Third

National Health and Nutrition Examination survey. Circulation, 103 (4), 502-506.

Abstract: Background-Numerous case series have implicated cocaine use as a cause of

both myocardial infarction (MI) and stroke on the basis of the temporal relationship

between drug use and event onset. Increasing cocaine use in the US population,

especially in younger individuals, mandates a more extensive investigation of this

relationship. Methods and Results-We determined the association of cocaine use with

self-reported physician diagnosis of MI or stroke in a nationally representative

sample of 10 085 US adults aged 18 to 45 years who participated in the Third

National Health and Nutrition Examination Survey. A total of 46 nonfatal MIs and

33 nonfatal strokes were reported. After adjusting for differences in age, sex,

race/ethnicity, education, hypertension, diabetes mellitus, cholesterol level, body

mass index, and cigarette smoking, persons who reported frequent lifetime cocaine

use had a significantly higher likelihood of nonfatal MI than nonusers (odds ratio, 6.9;

95% confidence interval, 1.3 to 58) but not stroke. In this age group, the

population-attributable risk percent of frequent cocaine for nonfatal MI was

estimated as 25%, Conclusion- Regular cocaine use was associated with an increased

likelihood of MI in younger patients. Approximately 1 of every 4 nonfatal MIs in

persons aged 18 to 45 years was attributable to frequent cocaine use in this survey.

Behavior modification by public awareness and education may reduce the

cardiovascular morbidity associated with cocaine use

Keywords: age/aged/awareness/cholesterol/cigarette

smoking/cocaine/CORONARY-ARTERY

VASOCONSTRICTION/diabetes/diabetes

mellitus/diagnosis/DRUG-ABUSE/education/hypertension/INTRACEREBRAL

HEMORRHAGE/INTRANASAL COCAINE/morbidity/MORTALITY/myocardial

infarction/odds

ratio/physician/population/PREVALENCE/QUESTIONNAIRE/risk/risk

factors/SELF-REPORTS/smoking/stroke/SUBARACHNOID

HEMORRHAGE/survey/US/VALIDITY

Klatsky, A.L. (1996), Alcohol and hypertension. Clinica Chimica Acta, 246 (1-2),

91-105.

Abstract: Epidemiologic studies in the past two decades have firmly established a

relationship between regular, heavier alcohol consumption and hypertension. This

association has been demonstrated in both cross-sectional and prospective studies. It

is found in both sexes and several races and is independent of the type of alcoholic

beverage, adiposity, education, smoking, salt intake, and several other traits. Clinical

experiments show that blood pressure falls in days to weeks with abstinence from

alcohol and that it rises again within days after resuming drinking. No mechanism

has been demonstrated for this alcohol/blood pressure effect. Alcohol withdrawal

symptoms have not been seen in the clinical experiments; thus, this is not likely to be

the major explanation. Studies of the role of alcohol in hypertension sequelae, such

as coronary heart disease and stroke, have been difficult because of the effects of

alcohol, independent of blood pressure, in these conditions. Overall, it is likely that

this alcohol-hypertension relation is causal. Restriction of intake by heavier drinkers

lowers blood pressure in some, and heavy alcohol ingestion should always be

considered by clinicians as a possible hypertension risk factor

Keywords: alcohol/alcohol drinking/blood

pressure/BLOOD-PRESSURE/CARE/CONSUMPTION/coronary/coronary heart

disease/education/epidemiology/HEALTH/hypertension/lifestyle/MEN/NETHERLA

NDS/prospective studies/risk factors/smoking/stroke/symptoms

Hennekens, C.H. (2001), Current perspectives on lipid lowering with statins to decrease

risk of cardiovascular disease. Clinical Cardiology, 24 (7), II2-II5.

Abstract: Although guidelines for individual risk factors for cardiovascular disease

(CVD) assist the healthcare provider, management of the global risk profile of

patients is the optimal means to minimize risk. Regardless of whether patients have

one or more risk factors, elevated lipid values are generally considered to be a major

contributor to global CVD risk. Therefore, reduction of lipid levels is one of the most

effective methods to reduce risk of CVD. The 3-hydroxy-3-

methyl-glutaryl-coenzyme A reductase inhibitor class of drugs (also known as statins)

has documented clinical benefits for reducing the incidence of myocardial infarction,

stroke, death from CVD, and total death. Despite widespread acknowledgment of the

very favorable benefit-to-risk ratio of the statins, most at-risk patients either are not

being treated or are not at the goals defined by the National Cholesterol Education

Program

Keywords: AVERAGE CHOLESTEROL LEVELS/cardiovascular

disease/CLINICAL-TRIALS/CORONARY

HEART-DISEASE/COST-EFFECTIVENESS/EVENTS/guidelines/high-density

lipoprotein cholesterol/HYPERCHOLESTEROLEMIA/incidence/low-density

lipoprotein cholesterol/methods/MORTALITY/myocardial

infarction/PRAVASTATIN/PRIMARY PREVENTION/risk/risk

factors/statin/statins/stroke/THERAPY/triglycerides

Winblad, B., Bonura, M.L., Rossini, B.M. and Battaglia, A. (2001), Nicergoline in the

treatment of mild-to-moderate Alzheimer's disease - A European multicentre trial.

Clinical Drug Investigation, 21 (9), 621-632.

Abstract: Objective: To assess the long-term efficacy and tolerability of nicergoline

30mg twice daily in the treatment of mild-to- moderate Alzheimer's disease. Design:

Multicentre, randomised, double-blind, placebo-controlled study of 6 months'

duration. Setting: 33 investigational sites in five European countries (Italy, Sweden,

UK, Belgium and Germany). Patients: 346 patients with mild-to-moderate probable

Alzheimer's disease (as defined by the National Institute of Neurological and

Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders

Association), with Mini-Mental State Examination scores of 12 to 24, aged > 50

years. Interventions: Patients were randomised to either nicergoline 30mg tablets

twice daily or to matching placebo treatment for 6 months. Main Outcome Measures

and Results: Primary efficacy measures were the cognitive portion of the Alzheimer's

Disease Assessment Scale (ADAS-cog) and the Clinical Global Impression of

Change (CGIC); the ADAS non-cognitive portion (ADAS non-cog) and total score,

the Instrumental Activities of Daily Living (IADL), and the Physical

Self-Maintenance Scale (PSMS) were considered as secondary measures. The

completion rate was 83.6% for nicergoline and 81.1% for the placebo group. The two

groups were well balanced for all demographic and disease characteristics, except

education, which was higher in the placebo group. Cognitive function (ADAS-cog)

at endpoint was significantly improved by nicergoline (mean change from baseline

was -0.17 in the nicergoline group and 1.38 in the placebo group, p = 0.04). The

CGIC rating revealed a non- significantly reduced rate of deterioration in the

nicergoline group; the same applied to IADL and PSMS results. ADAS non-cog

non-significantly favoured the nicergoline group and fewer nicergoline patients

developed newly emergent non-cognitive symptoms during the study. The ADAS

total score closely reflected ADAS-cog changes. 59.9% of nicergoline and 60.9% of

placebo recipients reported adverse events, usually of mild severity and self-limiting;

adverse events determined discontinuation in 8.5% of nicergoline and 8.3% of

placebo patients. The metabolic system was most frequently affected in nicergoline

patients due to the high incidence of hyperuricaemia; psychiatric adverse events were

more frequently represented in the placebo group. Serious adverse events occurred in

22 patients per treatment group. Conclusion: Nicergoline was well tolerated and

exerted a positive effect on the cognitive symptoms of mild-to-moderate Alzheimer's

disease, indicating a therapeutic potential that needs to be confirmed with further

investigations

Keywords: aged/Alzheimer's

disease/DOUBLE-BLIND/education/function/incidence/SENILE

DEMENTIA/severity/SIGNS/Sweden/symptoms/TACRINE/treatment

Brown, M.M. (2002), Brain attack: a new approach to stroke. Clinical Medicine, 2 (1),

60-65.

Abstract: 'Brain attack' is a new term to describe the acute presentation of stroke which

emphasises the need for urgent action. The article describes the basis for this new

approach to acute stroke treatment. Rational treatment requires individual causes of

stroke to be identified early and treatment targeted at the mechanism. Acute stroke

treatment aims to preserve the ischaemic penumbra, protect neurons against further

ischaemia and enhance brain plasticity to maximise recovery. There is a strong

evidence base supporting the routine use of aspirin, but not heparin, in acute

ischaemic stroke. There is also convincing evidence supporting intravenous

thrombolysis using recombinant tissue plasminogen activator in selected patients

within 3 hours of stroke onset. Surprisingly, as many as 33% of suspected-stroke

patients arrive in Accident & Emergency departments in the UK within 3 hours of

onset. New techniques in MR imaging, particularly diffusion weighted imaging, are

transforming the approach to diagnosis of acute stroke. Although neuroprotective

drugs have proved disappointing, active neuroprotection in acute stroke should

include control of blood pressure within certain limits, antipyretic therapy,

maintenance of blood glucose, and early feeding and fluid replacement. Surgical

hemicraniectomy should be considered in patients with malignant cerebral oedema.

There is good evidence that the best way to enhance recovery from stroke is to admit

the patient to a stroke unit. To enable patients to benefit from the early active

approach outlined in the article, the following are needed: the development of acute

stroke units; imaging protocols; and education of patients, general practitioners and

the ambulance services. Stroke care has become a specialised field, requiring input

from stroke physicians, as well as the multidisciplinary rehabilitation team. The

British Association of Stroke Physicians (BASP) has therefore developed a

curriculum which is designed to lead to the development of a new sub-specialty of

stroke medicine

Keywords: acute/acute ischaemic stroke/ACUTE ISCHEMIC STROKE/acute

stroke/ambulance/aspirin/blood pressure/brain attack/British Association of Stroke

Physicians/cerebral

ischaemia/diagnosis/ECASS-II/education/ENGLAND/INTRAVENOUS

ALTEPLASE/ischaemic penumbra/ischaemic

stroke/medicine/neuroprotection/PENUMBRA/plasminogen

activator/PLASMINOGEN-ACTIVATOR/plasticity/protocols/RANDOMIZED

CONTROLLED TRIAL/recombinant tissue plasminogen/rehabilitation/stroke/stroke

onset/stroke treatment/stroke unit/stroke units/thrombolysis/TISSUE/tissue

plasminogen activator/treatment

Hantson, L., Gheuens, J., Tritsmans, L. and Dekeyser, J. (1994), Hospital Referral of

Stroke Patients - A Survey of Attitudes in General-Practice, and Consideration of

Entry Times for Clinical-Trials. Clinical Neurology and Neurosurgery, 96 (1), 32-37.

Abstract: Two major issues in clinical trials in stroke are the criteria used for the

selection of patients expected to benefit from the proposed treatment, and the entry

time of those patients. We surveyed 507 Belgian general practitioners (GPs) on their

opinions on referral of stroke patients to hospital and also on their actual referral

behaviour. The feasibility of a 6-hour- entry time was included in the investigation.

Stroke is considered to require an urgent response: 88% of GPs visited the patient

immediately on concluding that such an event had occurred. The mean time between

the onset of the first clinical symptoms and the arrival of the GP at the patient's

residence was about 30 minutes. Within 6 h of the insult, 95% of the patients referred

to hospital had been admitted. Information on the GP's most recent stroke patient

revealed that 72.4% of these stroke patients were admitted to hospital. Patients

referred to hospital were significantly younger, had a significantly more severe

stroke, and were significantly more likely to have had a first stroke and to have lived

independently before the insult than patients not admitted to hospital. We think that

Belgian GPs need to change their referral behaviour with respect to stroke patients

and refer more of those who have suffered more mildly. There is every reason to be

optimistic about this re-education, since the patients whom GPs do refer to hospital

are referred rapidly enough to profit from a possibly efficacious treatment

Keywords: ADMISSION TIME/clinical trials/GENERAL

PRACTITIONER/INCLUSION TIME/NETHERLANDS/REFERRAL

BEHAVIOR/STROKE/stroke patients/symptoms/treatment

Cohen, M.J., Branch, W.B., Mckie, V.C. and Adams, R.J. (1994), Neuropsychological

Impairment in Children with Sickle-Cell- Anemia and Cerebrovascular Accidents.

Clinical Pediatrics, 33 (9), 517-524.

Abstract: Neuropsychological functioning of children with sickle cell anemia (HbSS)

who have experienced a single stroke has not been extensively investigated. In this

study, the neuropsychological functioning of 10 children with HbSS who were

receiving transfusion therapy following stroke with no identifiable recurrence was

examined. The patients were subgrouped into children with only left hemisphere

stroke (LCI), N = 4, and those with only right hemisphere stroke (RCI), N = 6.

Results indicated that these youngsters experienced significant impairments of

cognitive functioning following stroke. It was found that the LCI and RCI children

tended to perform more like adult stroke patients than what has been typically

reported in children with infantile hemiplegia. These findings support the need for

periodic neuropsychological evaluation following stroke in order to identify patterns

of higher cortical dysfunction and assist in the development of appropriate

rehabilitation and special education programs. Further, pediatricians, child

neurologists, and psychologists who care for these children must act as strong

advocates on their behalf in order to ensure that they receive appropriate

rehabilitation and the special education services necessary for maximal recovery and

future educational success

Keywords:

anemia/APHASIA/DEFICITS/DISEASE/education/LESIONS/rehabilitation/sickle

cell anemia/stroke/stroke patients

Mant, J., Carter, J., Wade, D.T. and Winner, S. (1998), The impact of an information

pack on patients with stroke and their carers: a randomized controlled trial. Clinical

Rehabilitation, 12 (6), 465-476.

Abstract: Objectives: To assess the impact of information packs on patients with stroke

and their carers, and to pilot some of the methodology for a trial of a Family Support

Organiser (FSO). Subjects. Seventy-one patients admitted to Oxford hospitals with

acute stroke during February-July 1995, and 49 informal carers of these patients.

Design: Randomized controlled trial. Intervention group received an information

pack containing various Stroke Association publications one month after their stroke,

or at discharge from hospital, whichever was sooner. Control group received nothing.

Follow-up was by interview at the place of residence of the patients six months after

their stroke. Measures: Outcome measures assessed knowledge about stroke;

satisfaction with information received; patient behaviour in terms of access to

community services and benefits; and health status and quality of life. Results.

Patients and carers in the intervention group tended to know more about stroke, but

these differences were not significant once adjusted for age. Patients in the

intervention group (but not carers) tended to be more satisfied with the information

that they had received, but the differences were not significant. There were no

differences with regard to any aspects of quality of life in patients in the intervention

group, though carers in the intervention group were found to have significantly better

mental health (p = 0.04). Conclusion:: While the study was too small to generate firm

conclusions, information leaflets may lead to improved knowledge about stroke

several months after they have been distributed. This finding is worth following up

with larger studies. The stroke knowledge questionnaire that was piloted in this trial

seems to be able to detect differences between groups

Keywords:

age/DISEASE/EDUCATION/QUESTIONNAIRE/SATISFACTION/SCALE/stroke

Hanger, H.C., Walker, G., Paterson, L.A., McBride, S. and Sainsbury, R. (1998), What

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

Clinical Rehabilitation, 12 (1), 45-52.

Abstract: Objective: To clarify what issues are important to stroke patients and their

carers. To determine whether these issues change over lime. Design: Prospective

study of consecutive patients admitted to hospital with a diagnosis of an acute stroke.

Each participant had interviews al six and 24 months. In addition, a subgroup of

these patients (consecutive discharges over a two-month period) were also seen at

two weeks post discharge. Setting and subjects: Hospital-based cohort of stroke

survivors. interviewed in their own homes. Main outcome measures: Documentation

of the questions asked. Results: At two weeks, six and 24 months, a median of three,

two and three questions were asked by each patient respectively. Enquiries about

basic aspects of stroke were common but diminished over time. Fear of recurrence

was apparent al all three interview periods, Enquiries about the psychological

sequelae of stroke became more prevalent at six and 24 months. At two years, 32%

of respondents asked about concentration/memory difficulties with smaller numbers

commenting on tiredness, depression and frustration. At two years, 18% of the

sample were still uncertain of their chances of further recovery. Conclusions:

Patients with stroke continue to have unanswered questions even two years after their

stroke. The types of questions asked changed over time

Keywords: BURDEN/depression/diagnosis/EDUCATION/stroke/stroke

patients/SURVIVORS

Thomas, L., Harrington, K., Rogers, H., Langhorne, P., Smith, M. and Bond, S. (1999),

Development of a scale to assess nurses' knowledge of stroke: A pilot study. Clinical

Rehabilitation, 13 (6), 518-526.

Abstract: Objective: To develop and rest an evidence-based scale to assess nurses

knowledge of stroke. Design: Question development by a multidisciplinary group of

experts in stroke. Two self- completion questionnaire surveys. Setting: Two stroke

units, one general medical and two elderly care wards in three hospitals in the

North-East of England. Subjects: Fifty-eight qualified nurses. Interventions: Scale to

assess nurses' knowledge of stroke. Results: The overall response rate was 60%,

Nurses on stroke units knew more about stroke than those in medical/elderly care

wards. The scale was capable of discriminating between stroke units and

medical/elderly care wards: mean difference was 4.18 (95% confidence intervals

1.68- 6.69; p 24

hrs before presenting to the emergency department. The most commonly cited

primary reason for delays were beliefs that symptoms were not serious enough for

emergency care (31%) and that symptoms would resolve spontaneously (29%). Most

(55%) sought medical treatment only at the urging of family members or other

advocates. Although variables such as lack of insurance and low educational level

were not associated with delayed presentation, male gender and having sought

medical advice before presenting to the emergency department were significantly

associated with delay (p = .036 for each). Conclusions. Because of poor

understanding of the gravity and natural progression of their symptoms, most

critically ill patients waited > 24 hrs to present to our emergency department

Education on warning symptom recognition for serious illnesses may be warranted

not only for patients themselves but also for family members and caregivers

Keywords: acute/acute myocardial infarction/ACUTE

MYOCARDIAL-INFARCTION/ACUTE

STROKE/adult/advice/age/angina/blacks/CARE/caregivers/CHEST

PAIN/COMMUNITY INTERVENTION/critical illness/decision making/delayed

presentation/emergency care/emergency medical services/emergency

service/gender/HEALTH-CARE/hospital/intensive care units/male/myocardial

infarction/patient acceptance of health care/patient admission/prehospital

care/PREHOSPITAL DELAY/RAPID EARLY

ACTION/stroke/SYMPTOMS/TIME/time factors/treatment/TREATMENT REACT

TRIAL/unstable angina

Main, A., Abu-Saad, H., Salt, R., Vlachonikolis, I. and Dowson, A. (2002),

Management by nurses of primary headache: A pilot study. Current Medical

Research and Opinion, 18 (8), 471-478.

Abstract: Primary headache is a very common condition and one that nurses encounter

in many different care settings. Yet there is a lack of evidence as to whether advice

given to sufferers is effective and what improvements may be expected in the

condition. The aim of this study was to evaluate the advice given by a nurse to

primary headache sufferers. The design was quasi-experimental. An experimental

group (n = 19) and a control group (n = 25) of primary headache sufferers had their

headache parameters of frequency, severity duration and disability (Migraine

Disability Assessment) over the previous six months assessed. The experimental

group then received advice in the form of health education from a nurse. Both groups

kept a headache diary for six months. After six months both groups had their

headache parameters assessed again. Compared to the control group, there was a

significant reduction in the severity of headaches experienced by the experimental

group (p = 0.006). Although there were reductions in frequency and duration of

headaches experienced by the experimental group compared to the control group,

these were not significant (p = 0.664 and p = 0.235, respectively). The Migraine

Disability Assessment showed a trend towards reduced scores in the experimental

group compared to controls which were not significant (p = 0.535). This pilot study

suggests that health education can be effective in reducing the severity of headaches.

However, a larger study over a longer period is needed to evaluate improvements in

headache parameters

Keywords: advice/DISABILITY/education/headache/health/health

education/HEALTH-CARE

UTILIZATION/IMPACT/migraine/MIGRAINE/severity/STROKE

Athyros, V.G., Papageorgiou, A.A., Mercouris, B.R., Athyrou, V.V., Symeonidis, A.N.,

Basayannis, E.O., Demitriadis, D.S. and Kontopoulos, A.G. (2002), Treatment with

atorvastatin to the National Cholesterol Educational Program goal versus 'usual' care

in secondary coronary heart disease prevention - The GREek Atorvastatin and

Coronary-heart-disease Evaluation (GREACE) Study. Current Medical Research

and Opinion, 18 (4), 220-228.

Abstract: Background.-Atorvastatin is very effective in reducing plasma low-density

lipoprotein cholesterol (LDL-C) levels. However, there is no long-term survival

study that evaluated this statin. Patients - Methods: To assess the effect of

atorvastatin on morbidity and mortality (total and coronary) of patients with

established coronary heart disease (CHD), 1600 consecutive patients were

randomised either to atorvastatin or to 'usual' medical care. The dose of atorvastatin

was titrated from 10 to 80 mg/day, in order to reach the National Cholesterol

Education Program (NCEP) goal of LDL-C >optimal care>complete

medical treatment>action time3

SDs above the normal mean (5.05 + 3 x 0.50 = >6.55%). Standard control is

achieved with insulin and intensive control with a step-up regimen including insulin

alone or insulin/glipizide combinations. Education and management of

cardiovascular risk factors are handled similarly in both groups. Primary

macrovascular end points are nonfatal myocardial infarction, congestive heart failure,

stroke, amputation, and cardiovascular death. Primary microvascular

Keywords: ACUTE MYOCARDIAL-INFARCTION/age/assessment/BEDTIME NPH

INSULIN/cardiovascular risk

factors/CARE/community/DESIGN/diabetes/DISEASE/FOLLOW-UP/MELLITUS/

METABOLIC CONTROL/MORTALITY/myocardial

infarction/PROGRESSION/risk factors/SAMPLE-SIZE/stroke/THERAPY

Vitelli, L.L., Shahar, E., Heiss, G., McGovern, P.G., Brancati, F.L., Eckfeldt, J.H. and

Folsom, A.R. (1997), Glycosylated hemoglobin level and carotid intimal-medial

thickening in nondiabetic individuals - The atherosclerosis risk in communities study.

Diabetes Care, 20 (9), 1454-1458.

Abstract: OBJECTIVE - People with diabetes are at increased risk for cardiovascular

events. However, questions remain about what role, if any, homeostatic glucose

control plays in the development of cardiovascular disease among nondiabetic

individuals. we investigated the relationship between HbA(1c) level and carotid

intimal-medial thickening in normoglycemic individuals. RESEARCH DESIGN

AND METHODS - We conducted a case- control study among 208 normoglycemic

individuals (fasting glucose less than or equal to 6.4 mmol/l and no history of

diabetes) who had carotid intimal-medial thickening (case subjects) and 208

normoglycemic control subjects individually matched for age, sex, race, field center,

and date of exam. Subjects were free-living men and women, aged 45-64 years at

baseline, who participated in the Atherosclerosis Risk in Communities (ARIC) Study.

RESULTS - HbA(1c), levels, expressed as percent of total hemoglobin, ranged from

4 to 7% and correlated only modestly with single measurements of fasting glucose (r

= 0.16) and fasting insulin (r = 0.14). The mean level of HbA(1c) was 5.18% among

case subjects and 5.07% among control subjects (P = 0.004, paired t test). As

compared with the first quartile of HbA(1c), the matched relative odds of being a

case were 1.15, 1.33, and 2.30 for the second, third, and fourth quartiles, respectively

(P = 0.005 for linear trend). After multivariate adjustment for age, fasting glucose,

fasting insulin, BMI, smoking status, hypertension, LDL cholesterol, HDL

cholesterol, fibrinogen, and education level, the respective relative odds estimates

were 0.98, 1.07, and 1.88 (P = 0.16 for linear trend). When modeled linearly as a

continuous variable and after adjustment for the above- mentioned covariates, a 1%

point increment in HbA(1c) level was associated with 1.77 greater odds of being a

case (95% CI, 0.9- 3.5). CONCLUSIONS - These data provide some support to the

hypothesis that in the absence of diabetes, homeostatic glycemic control is a risk

factor for atherosclerosis

Keywords:

age/aged/ATHEROGENESIS/atherosclerosis/BLOOD-GLUCOSE/BMI/cardiovascu

lar events/CARDIOVASCULAR-DISEASE/CARE/CORONARY

HEART-DISEASE/DEATH/diabetes/education/FUTURE/HYPERGLYCEMIA/hyp

ertension/INSULIN/MORTALITY/race/smoking/STROKE/women

Folsom, A.R., Rasmussen, M.L., Chambless, L.E., Howard, G., Cooper, L.S., Schmidt,

M.I. and Heiss, G. (1999), Prospective associations of fasting insulin, body fat

distribution, and diabetes with risk of ischemic stroke. Diabetes Care, 22 (7),

1077-1083.

Abstract: OBJECTIVE - We tested the hypothesis that diabetes, body fat distribution,

and (in nondiabetic subjects) fasting insulin levels are positively associated with

ischemic stroke incidence in the general population RESEARCH DESIGN AND

METHODS - As part of the Atherosclerosis Risk in Communities (ARIC) Study we

measured diabetes by using fasting glucose criteria, waist and hip circumferences,

and fasting insulin levels with a radioimmunoassay in >12,000 adults aged 45-64

years who had no cardiovascular disease at baseline. We followed them for 6-8 years

for ischemic stroke occurrence (n = 191). RESULTS - After adjustment for age, sex,

race, ARIC community, smoking, and education level, the relative risk of ischemic

stroke was 3.70 (95% CI 2.7-5.1) for diabetes, 1.74 (1.4-2.2) for a 0.11 increment of

waist-to-hip ratio, and 1.19 (1.1-1.3) for a 50- pmol/l increment of fasting insulin

among nondiabetic subjects. Ischemic stroke incidence was nor statistically

significantly associated with BMI (comparably adjusted relative risk = 1.15, 95% CI

0.97-1.36). With adjustment for other stroke risk factors (some of which may

mediate the effects of diabetes, fat distribution, and hyperinsulinemia), the relative

risks for diabetes, waist-to-hip ratio, and fasting insulin level were 2.22 (95% CI

1.5-3.2), 1.08 (0.8-1.4), and 1.14 (1.01-1.3), respectively CONCLUSION - Diabetes

is a strong risk factor for ischemic stroke. Aspects of insulin resistance, as reflected

by elevated waist-to-hip ratios and elevated fasting insulin levels, may also

contribute to a greater risk of ischemic stroke

Keywords: ADIPOSE-TISSUE/ATHEROSCLEROSIS

RISK/CARDIOVASCULAR-DISEASE/CARE/COMMUNITIES/ENZYMATIC

DETERMINATION/FOLLOW/HYPERTENSION/IMPROVED LIPOLYTIC

EFFICIENCY/ischemic/MEN BORN/PARTICIPANTS/race/smoking/stroke

Vaaler, S. (2000), Optimal glycemic control in type 2 diabetic patients - Does including

insulin treatment mean a better outcome? Diabetes Care, 23 B30-B34.

Abstract: Type 2 diabetes is a progressive disease with a significant risk for developing

late complications. This article presents evidence related to the effect of glycemic

control on the outcome of daily symptoms, microvascular complications, and

macrovascular complications. literature limited to Medline and the Cochrane Library

was searched primarily for randomized clinical trials. In terms of education, present

intervention studies indicate a positive effect on surrogate end points such as

glycemic control, knowledge, practical skills, and psychological performance.

Studies show improved glycemic control and plasma lipid profiles after moderate

weight reduction. However, this positive effect is limited in time because weight is

regained. With regard to oral blood glucose- lowering drugs, clinical trials show a

significant blood glucose-lowering effect of different available drugs. Both

sulfonylurea and metformin have been shown to significantly reduce the risk of

microvascular complications. In the U.K. Prospective Diabetes Study intensive

treatment with metformin in obese subjects reduced the risk for any diabetes-related

event and stroke. A major problem is that many patients gradually experience

increasing hyperglycemia, creating the need for combined treatment with several

drugs including insulin. Insulin treatment has been shown to be effective in achieving

satisfactory glycemic control over several years. There is also a positive effect on

hard end points such as microvascular disease in the eye, kidney, and nerves. In

conclusion, present evidence shows that optimal glycemic control can be attained in

people with type 2 diabetes, resulting in fewer disease-related symptoms and a

reduced risk of late complications

Keywords: CARE/clinical

trials/COMPLICATIONS/control/diabetes/DISEASE/education/intervention

studies/knowledge/LONG-TERM/MELLITUS/METAANALYSIS/MORTALITY/O

BESITY/outcome/performance/risk/stroke/SYMPTOMS/treatment/TRIAL/Type 2

diabetes/WEIGHT-LOSS

Sinclair, A.J., Girling, A.J. and Bayer, A.J. (2000), Cognitive dysfunction in older

subjects with diabetes mellitus: impact on diabetes self-management and use of care

services. Diabetes Research and Clinical Practice, 50 (3), 203-212.

Abstract: Objective: To determine whether cognitive impairment is associated with

changes in self-care behaviour and use of health and social services in older subjects

with diabetes mellitus. Research design and methods: This was a community based,

case-control study of subjects registered with general practices participating in the

All Wales Research into Elderly (AWARE) Diabetes Study. The 396 patients aged

65 years or older with known diabetes mellitus were compared with 393 age- and

sex-matched, non-diabetic controls. Adjusted odds ratio estimates of normal

performance on Mini-Mental State Examination (MMSE) and Clock Drawing Test

(numbers and hands) were determined. Information on self-care behaviours and use

of services was obtained. Results: A total of 283 (71%) diabetic subjects scored 24 or

more on MMSE, compared with 323 (88%) of controls (OR 0.54, P

0.9 mmol/l). Glucose self-monitoring (either urine or blood) was only practiced by

50% of patients. Glycaemic control (HbAlc) was unsatisfactory as majority of

patients had HbAlc > 7.4% (73%) and 50% had fasting blood glucose (FBG) > 7.8

mmol/l. Cataract (26%), neuropathy (42%) and cerebral stroke (6%) were the most

frequently reported complications. Clearly, the level of glycaemic control in majority

of patients is below satisfaction. Effective education must be emphasised in the

management of diabetes. (C) 2000 Published by Elsevier Science Ireland Ltd

Keywords:

age/assessment/BMI/cholesterol/combination/COMPLICATIONS/complications/con

trol/diabetes/diabetes mellitus/diet/education/glycaemic control/GLYCEMIC

CONTROL/medical/oral antidiabetic drugs

(OADs)/self-monitoring/stroke/triglycerides

Hu, G., Qiao, Q., Silventoinen, K., Eriksson, J.G., Jousilahti, P., Lindstrom, J., Valle,

T.T., Nissinen, A. and Tuomilehto, J. (2003), Occupational, commuting, and

leisure-time physical activity in relation to risk for Type 2 diabetes in middle-aged

Finnish men and women. Diabetologia, 46 (3), 322-329.

Abstract: Aim/hypothesis. Leisure-time physical activity can reduce the risk of Type 2

diabetes, but the potential effect of different types of physical activity is still

uncertain. This study is to examine the relationship of occupational, commuting and

leisure-time physical activity with the incidence of Type 2 diabetes. Methods. We

prospectively followed 6898 Finnish men and 7392 women of 35 to 64 years of age

without a history of stroke, coronary heart disease, or diabetes at baseline. Hazards

ratios of incidence of Type 2 diabetes were estimated by levels of occupational,

commuting, and leisure-time physical activity. Results. During a mean follow-up of

12 years, there were 373 incident cases of Type 2 diabetes. In both men and women

combined, the hazards ratios of diabetes associated with light, moderate and active

work were 1.00, 0.70 and 0.74 (p=0.020 for trend) after adjustment for confounding

factors (age, study year, sex, systolic blood pressure, smoking, education, the two

other types of physical activity and BMI). The multivariate-adjusted hazards ratios of

diabetes with none, 1 to 29, and more than 30 min of walking or cycling to and from

work were 1.00, 0.96, and 0.64 (p=0.048 for trend). The multivariate-adjusted

hazards ratios of diabetes for low, moderate, high levels of leisure-time physical

activity were 1.00, 0.67, and 0.61 (p=0.001 for trend); after additional adjustment for

BMI, the hazards ratio was no longer significant. Conclusions/interpretation.

Moderate and high occupational, commuting or leisure-time physical activity

independently and significantly reduces risk of Type 2 diabetes among the

middle-aged general population

Keywords: age/blood pressure/BMI/commuting/coronary/coronary heart

disease/CORONARY

HEART-DISEASE/diabetes/DIETARY/education/EXERCISE/Finland/HYPERTEN

SION/IMPAIRED GLUCOSE-TOLERANCE/incidence/leisure

time/MELLITUS/men/occupational/physical

activity/POPULATION/PREVENTION/smoking/stroke/Type 2

diabetes/WALKING/WEIGHT- GAIN/women

Laatsch, L. and Shahani, B.T. (1996), The relationship between age, gender and

psychological distress in rehabilitation inpatients. Disability and Rehabilitation, 18

(12), 604-608.

Abstract: Although commonly accepted as the dominant emotional reaction to

functional loss, the reported occurrence of depression in rehabilitation patients varies

widely. Rather than focusing solely on depressive symptoms, this study furthers our

understanding of emotional distress following a functional loss by assessing a range

of psychiatric symptoms. A series of rehabilitation patients admitted to an urban

hospital inpatient unit is used as the sample (n = 48). Demographic,

neuropsychological, and a functional independence measure were included as

independent variables. The statistical analysis revealed that - although age was not

correlated with years of education, functional status, or neuropsychological

impairment - there was a significant inverse relationship between age and reported

emotional distress. Utilizing MANCOVA to explore the impact of age and gender on

specific groups of psychiatric symptoms revealed that both younger and male

patients tended to express psychiatric symptoms more frequently. The importance of

considering age and gender in evaluation of emotional distress in rehabilitation is

supported in this comprehensive study of psychiatric symptoms

Keywords: age/DEPRESSION/education/emotional distress/gender/psychiatric

symptoms/rehabilitation/STROKE/symptoms

Lennon, S., Baxter, D. and Ashburn, A. (2001), Physiotherapy based on the Bobath

concept in stroke rehabilitation: a survey within the UK. Disability and

Rehabilitation, 23 (6), 254-262.

Abstract: Purpose : The Bobath concept is one of the most widely used approaches in

stroke rehabilitation within Europe. This survey aimed to provide an expert

consensus view of the theoretical beliefs underlying current Bobath practise in the

UK. Method: Questionnaires (with sections related to: therapist background,

physiotherapy management, theoretical beliefs and gait re- education strategies used)

were posted to all senior level physiotherapists working in stroke care (n = 1022).

Results : The majority of respondents had more than 10 year's experience overall and

at least 5 years experience in stroke care. The Bobath concept was the preferred

approach (n = 67%) followed by an 'eclectic' approach (n = 31%). Despite a high

level of consensus between groups, there were 13 significant differences highlighted

between Bobath and 'eclectic' groups related to recovery, control of tone, the analysis

and facilitation of normal movement and function. In summary, Bobath therapists

considered that patients needed to have normal tone and use normal movement

patterns in order to perform functional tasks. They would delay patients from

performing tasks independently if abnormal tone and movement would be reinforced

by task practice. They were not opposed to the use of walking aids and orthotics.

Conclusions : This survey has raised several issues for debate within physiotherapy

such as the automatic translation of movement into function, carry over outside

therapy, and the way in which tasks should be practiced. The dominance of the

Bobath concept needs to be justified by establishing that it is both effective and

efficient at achieving its treatment aims of : normalizing tone, improving intrinsic

recovery of the affected side and function within everyday tasks

Keywords: Bobath/CANE/education/ENGLAND/function/HEMIPLEGIC

GAIT/physiotherapy/rehabilitation/stroke/stroke

rehabilitation/survey/treatment/WALKING

Kersten, P., Low, J.T.S., Ashburn, A., George, S.L. and McLellan, D.L. (2002), The

unmet needs of young people who have had a stroke: results of a national UK survey.

Disability and Rehabilitation, 24 (16), 860-866.

Abstract: Background. Most stroke-related studies have consisted of people over the age

of 65. This study examined the unmet needs of young people with stroke, living in

community housing in the UK. Method: People with a stroke (> 1 year ago), in two

age bands (18-45; 46-65) were sent the Southampton Needs Assessment

Questionnaire for people with Stroke. Results: 315 out of 639 (49%) questionnaires

were returned (mean age 55, SD 9; 189 males, 126 females). The median number of

unmet needs reported was two (IQR 0-6). The most frequently reported unmet needs

were: provision of information about the responders' stroke (45%); assistance with

finances (24%); non-care activities (19%); and intellectual fulfilment (17%).

Responders in the younger age group reported significantly more unmet needs than

responders in the older age group (for a holiday, intellectual fulfilment and family

support). Responders with poor mobility reported significantly more unmet needs

than responders with average and good mobility for 15 unmet needs (three most

pressing: respite care/short breaks; adaptations; and access to community

environment). Responders who did not return to work reported significantly more

unmet needs than responders who had reduced hours or changed jobs and people

who returned to the same job with the same hours for seven unmet needs (three most

pressing: help with finances; a holiday and speech therapy). Conclusion: People of

younger age, with poorer mobility and those unable to return to work, report most

unmet needs, Further work needs to be done within the community, with employers

and professionals, in relation to education and the provision of specifically targeted

information in order to facilitate participation and autonomy for people with stroke

Keywords: age/CARE/COMMUNITY/DISABLED

PEOPLE/education/ENGLAND/INFORMATION/PROFESSIONALS/questionnaire

s/RANDOMIZED CONTROLLED TRIAL/REHABILITATION/stroke/survey

Lennon, S. (2003), Physiotherapy practice in stroke rehabilitation: a survey. Disability

and Rehabilitation, 25 (9), 455-461.

Abstract: Objective: This survey aimed to provide an expert consensus view of the

theoretical beliefs underlying physiotherapy practice in stroke rehabilitation the

United Kingdom. Method: Questionnaires (with sections related to: therapist

background, physiotherapy management, theoretical beliefs and gait re- education

strategies used) were posted to all senior level physiotherapists working in stroke

care (n=1022). Results: The majority of respondents had more than 10 years

experience overall, and at least 5 years experience in stroke care. The Bobath concept

was the preferred approach (n=67%) followed by an 'eclectic' approach (n=31%).

This survey identified four theoretical themes underlying current practice in

neurological physiotherapy: the promotion of normal movement, the control of tone,

the promotion of function, and the recovery of movement with optimization of

compensation. Conclusions: A consensus was obtained on 16 theoretical beliefs;

however the evidence base underlying these beliefs remains sparse. Many of these

beliefs require further debate within the physiotherapy profession such as the amount

of time spent on preparation for function, the automatic translation of movement into

function, carry over outside therapy, and the way in which tasks should be practised

Keywords: BOBATH CONCEPT/education/function/rehabilitation/stroke/stroke

rehabilitation/survey

Broderick, J.P. (1997), Logistics in acute stroke management. Drugs, 54 109-116.

Abstract: Results from the two National Institute of Neurological Disorders and Stroke

(NINDS) studies indicate that administration of alteplase (recombinant tissue-type

plasminogen activator; rt-PA) within 3 hours of symptom onset to appropriately

selected patients with acute ischaemic stroke improves patient outcome. Several

factors that delay time to treatment in patients with stroke have been identified, the

roost important of which is probably the failure of the patient (or family member) to

recognise I:he signs and symptoms of stroke. Once the need for help is recognised,

the initial point of access to emergency medical systems should be the local

emergency number (e.g. 911 in the US) rather than the family physician. Patients

with suspected stroke should be evaluated and treated by a physician as soon as

possible, but this will depend to some extent on the level of expertise of the attending

physicians and on available resources. The NINDS- sponsored National Symposium

on the Rapid Identification and Treatment of Acute Stroke has recommended ideal

time goals for all hospitals that treat patients with acute stroke. These goals include

25 minutes from arrival at an emergency department to computerised tomography

scan, and 60 minutes from arrival to treatment. Recommendations for enhancing the

logistics of treatment for patients with stroke may involve the following: improved

education programmes for at-risk populations and their families and emergency

medical system personnel identification of acute stroke as a level one emergency

similar to acute myocardial infarction or trauma, and modelling of treatment

algorithms accordingly acceptance of, and commitment to, the time guidelines

recommended by the National Symposium on the Rapid Identification and Treatment

of Acute Stroke. Effective and safe use of alteplase will also depend on rapid access

to the highest level of neurological and radiological expertise. This may require

major changes in the educational curriculum of emergency department residency and

ongoing continuing education programmes, and/or more intensive radiological

training for neurologists and neurologists-in- training

Keywords: ACCURACY/acute myocardial infarction/DELAYING HOSPITAL

ADMISSION/DIAGNOSIS/education/EMERGENCY/guidelines/myocardial

infarction/RABBIT MODEL/stroke/stroke

management/symptoms/THROMBOEMBOLIC

STROKE/THROMBOLYSIS/TIME/TISSUE-PLASMINOGEN-ACTIVATOR/train

ing

Howard, P.A. (1999), Guidelines for stroke prevention in patients with atrial fibrillation.

Drugs, 58 (6), 997-1009.

Abstract: Atrial fibrillation (AF) is a major independent risk factor for stroke, AF is

most commonly associated with nonvalvular cardiovascular disease and is especially

frequent among the elderly, The annual risk for stroke in patients with AF is

approximately 5% with a wide range depending on the presence of additional risk

factors, For patients who cannot successfully be converted and maintained in normal

sinus rhythm (NSR), antithrombotic therapy is an effective method for preventing

stroke, The 2 drugs which are indicated for stroke prophylaxis in patients with AF

are warfarin and aspirin, For primary prevention, warfarin reduces the risk of stroke

approximately 68%. Aspirin therapy is less effective, resulting in a 20 to 30% risk

reduction, Combination therapy with aspirin and low intensity warfarin adjusted to

an International Normalised Ratio (INR) of 1.2 to 1.5 has not been shown to be

superior to standard intensity warfarin with a target INR of 2.0 to 3.0. In patients

with AF and a prior history of stroke or transient ischaemic attack (TIA), the absolute

risk reduction with warfarin is even greater because of the high risk of stroke in this

population, In contrast, aspirin has not been shown to significantly reduce the risk of

stroke in patients with AF when used for secondary prevention, When appropriately

managed, warfarin is associated with a low risk of major bleeding, In controlled trials

of highly selected patients, the annual rate of intracranial haemorrhage (ICH) with

warfarin was approximately 0.3%. Studies have shown that specialty anticoagulation

clinics can achieve similar low rates of major bleeding. However, these results

cannot be extrapolated to the general population. Factors which have been identified

as predictors of bleeding include advanced age, number of medications and most

importantly the intensity of anticoagulation. INR values above 4.0 have been

associated with an increased risk of major bleeding while values below 2.0 have been

associated with thrombosis. Slow careful dosage titration, regular laboratory

monitoring and patient education can substantially reduce the risk of complications.

In patients with AF, antithrombotic therapy has been shown to be cost effective. For

high risk patients, warfarin is the most cost- effective therapy, provided the risks for

bleeding are minimised. In contrast, aspirin is the most cost-effective agent for low

risk patients. Current practice guidelines for stroke prophylaxis recommend warfarin

(target INR 2.5; range 2.0 to 3.0) for AF patients at high risk for stroke including

those over 75 years of age or younger patients with additional risk factors. Aspirin

should be reserved for low risk patients or those unable to take warfarin. Although

these recommendations are strongly supported by the clinical trial evidence, studies

show that many patients are net receiving appropriate antithrombotic therapy. Ln

particular, warfarin is underutilised in high risk elderly patients. Additional studies

are needed to identify barriers that prevent implementation of the clinical trial

findings into clinical practice

Keywords: age/anticoagulation/ANTITHROMBOTIC THERAPY/ASPIRIN/atrial

fibrillation/barriers/cardiovascular disease/CLINICAL-

TRIALS/complications/cost/COST-EFFECTIVENESS/DRUG/DRUGS/education/el

derly/guidelines/implementation/ISCHEMIC STROKE/monitoring/NATIONAL

PATTERNS/ORAL ANTICOAGULANTS/patient

education/population/practice/predictors/prevention/primary

prevention/prophylaxis/risk/risk factor/risk factors/RISK-FACTORS/SECONDARY

PREVENTION/stroke/stroke prevention/TIA/transient/warfarin/WARFARIN USE

O'Loughlin, G. and Shanley, C. (1998), Swallowing problems in the nursing home: A

novel training response. Dysphagia, 13 (3), 172-183.

Abstract: Various studies suggest that between 50% and 75% of nursing home residents

have some difficulty in swallowing. Some of these residents are assessed and treated

by speech pathologists, but many are managed by nursing staff without specialist

input. A training program called Swallowing... on a Plate (SOAP) has been

developed by the Centre for Education and Research on Ageing and the Inner West

Geriatrics and Rehabilitation Service to help address swallowing-related problems in

local nursing homes (Inner West of Sydney, Australia), The training program teaches

nursing staff how to identify, assess, and manage swallowing problems, including

making appropriate referrals. Several new instruments were developed specifically

for this program including two assessment checklists, a set of management

guidelines, and a swallowing care plan. Evaluation of the program-including 3

months follow-up-showed it to be highly successful, A stand- alone training resource

has been produced for wide distribution to help staff implement the program as a

permanent aspect of their nursing care. This paper describes the development,

content, presentation, resource, and evaluation of the above program

Keywords: deglutition/deglutition disorders/dysphagia/ELDERLY

PATIENTS/guidelines/MANAGEMENT/nurse education/nursing

home/STROKE/swallowing problems/training

Sayre, M.R. (2002), Damage control: past, present, and future of prehospital stroke

management. Emergency Medicine Clinics of North America, 20 (4), 877-+.

Abstract: Accurate identification of acute stroke patients by emergency medical services

(EMS) professionals can speed initiation of treatment. EMS professionals need to

ascertain the time of onset of the stroke, perform a focused physical examination

using a prehospital stroke screening tool, check the patient's blood sugar, expedite

evaluation of the patient, and communicate early with the receiving emergency

department. Hypertension in the prehospital setting should be treated with watchful

waiting. EMS professionals need additional education about the identification and

treatment of acute stroke. They may serve an important role as initiators of therapy as

neuroprotective agents are developed in the future

Keywords: acute/ACUTE ISCHEMIC STROKE/ACUTE

MYOCARDIAL-INFARCTION/acute

stroke/ANTAGONIST/CARDIAC-ARREST/education/emergency medical

services/EMS/HEMORRHAGE/KNOWLEDGE/NEUROPROTECTION/neuroprote

ctive agents/REPERFUSION THERAPY/RESUSCITATION/stroke/stroke

management/stroke patients/treatment/TRIAL

Fleck, L.M. and Hayes, O.W. (2002), Ethics and consent to treat issues in acute stroke

therapy. Emergency Medicine Clinics of North America, 20 (3), 703-+.

Abstract: Adapting information from research trials to clinical practice is difficult.

Decisions must be made about whether benefits in randomized clinical trials (RCTs)

justify widespread application of the therapy. One important issue is how to explain

treatment options to patients and their families in a manner that includes them in the

decision-making process. Can emergency physicians secure ethically acceptable

informed consent from stroke patients or their surrogates for acute intravenous

thrombolytic therapy? Although this question may strike many emergency physicians

as odd, thoughtful consideration is important for sociological and medical reasons.

Sociological reasons pertain to the broad public education campaign organized

around the notion of stroke as a "brain attack" [1], analogous to a heart attack and

requiring prompt lay recognition and response. The medical community, similarly, is

called on to provide prompt assessment and intervention based on the evidence from

the National Institute of Neurological Disorders and Stroke's (NINDS) rt-PA study [2]

that intravenous thrombolytic therapy must be administered within 3 hours of the

onset of stroke symptoms for a medical benefit without unacceptable complications

Keywords: acute/ACUTE ISCHEMIC STROKE/acute

stroke/assessment/CENTERS/clinical

trials/community/education/EXPERIENCE/informed consent/INTRAVENOUS

THROMBOLYTIC

THERAPY/MANAGEMENT/MORTALITY/OUTCOMES/stroke/stroke

patients/symptoms/thrombolytic therapy/TISSUE-PLASMINOGEN

ACTIVATOR/TPA/treatment/TRIALS

Cabrera, C., Helgesson, O., Wedel, H., Bjorkelund, C., Bengtsson, C. and Lissner, L.

(2001), Socioeconomic status and mortality in Swedish women: Opposing trends for

cardiovascular disease and cancer. Epidemiology, 12 (5), 532-536.

Abstract: We examined relations between socioeconomic status and cardiovascular

disease, cancer, and diabetes mellitus in a 24- year prospective study of 1,462

Swedish women. Two socioeconomic indicators were used: the husband's

occupational category for married women and a composite indicator combining

women's educational level with household income for all women. The husband's

occupational category was strongly associated with cardiovascular disease and

cancer mortality in opposite directions, independent of age and other potential

confounders. Women with husbands of lower occupational categories had an

increased risk of cardiovascular disease mortality [relative risk (RR) = 1.60, 95%

confidence interval (95% CI) = 1.09-2.33] while experiencing lower rates of all-site

cancer mortality (RR = 0.69; 95% CI = 0.50-0.96). A similar relation was seen with

the composite variable: women with low socioeconomic status had an increased risk

of cardiovascular disease (RR = 1.37; 95% CI = 1.01-1.84) but a somewhat lower

risk for cancer of all sites (RR = 0.86; 95% CI = 0.66-1.11). Finally, morbidity data

(diabetes mellitus, stroke, and breast cancer) yielded results that were consistent with

the mortality trends, and breast cancer appeared to account for a major part of the

association between total cancer and high socioeconomic status. In summary, higher

socioeconomic status was associated with decreased cardiovascular disease mortality

and excess cancer mortality, in such a way that only a weak association was seen for

all- cause mortality

Keywords: 12 YEAR FOLLOW/age/BREAST/cardiovascular

disease/DEATH/diabetes/diabetes

mellitus/education/EPIDEMIOLOGY/gender/GOTHENBURG/HEALTH/income/IN

EQUALITIES/marital

status/morbidity/mortality/MYOCARDIAL-INFARCTION/neoplasms/occupational/

PARTICIPANTS/POPULATION/prospective

study/risk/socioeconomic/socioeconomic status/stroke/SWEDEN/women

Kohler, C., Norstrand, J.A., Baltuch, G., O'Connor, M.J., Gur, R.E., French, J.A. and

Sperling, M.R. (1999), Depression in temporal lobe epilepsy before epilepsy surgery.

Epilepsia, 40 (3), 336-340.

Abstract: Purpose: This study examined the association of depression with laterality of

epilepsy surgery in patients with temporal lobe epilepsy before standard lobectomy.

Methods: Forty-nine patients presented for EEG telemetry for localization of

epilepsy and eventual temporal lobectomy. Patients underwent routine

neuropsychiatric evaluation blinded for epileptic focus, including ratings on

depression. Patients were grouped according to right (n = 25, M = 10/F = 15) and left

(n = 24, M = 13/F = 11) temporal lobectomy. Analysis of variance included side of

surgery as grouping variable and sex, general depressive, cognitive depressive, and

vegetative depressive symptoms as dependent variables. chi(2) Analyses included

categoric variables of sex, handedness, education, neuropathologic findings, and

current affective disorders. t Tests were performed on variables of age, epilepsy

duration, and cognitive function. Results: Right and left temporal epilepsy groups did

not differ with regard to sex, handedness, age, duration of epilepsy, education,

cognitive function, and neuropathology. Patients with right temporal epilepsy rated

higher on general, cognitive, and vegetative depression scores. Women scored higher

on general, cognitive, and vegetative depression scores. Current affective disorders

were more common in the right temporal epilepsy group. Conclusions: Depression

ratings and diagnoses were more prominent in patients with light temporal lobe

epilepsy and in women in particular. The strength of this laterality finding lies in the

selection of patients, as all underwent epilepsy surgery. The finding on Sender

difference partly reflects the higher incidence of depression in women and needs

further exploration. The laterality finding contrasts with recent findings in epilepsy,

stroke, and trauma that associate depression with left hemispheric lesions. However,

our results are consistent with findings in electrically hyperactive lesions such as

gelastic and dacrystic epilepsy

Keywords: age/ANXIETY/CHILDREN/COMPLEX PARTIAL

SEIZURES/depression/DISEASE/education/epilepsy

surgery/FRONTAL-LOBE/gender/HYPOMETABOLISM/LATERALITY/LESION/

MOOD DISORDERS/PHENOMENOLOGY/stroke/symptoms/temporal lobe

epilepsy/women

Katz, M.L., Smith-Whitley, K., Ruzek, S.B. and Ohene-Frempong, K. (2002),

Knowledge of stroke risk, signs of stroke, and the need for stroke education among

children with sickle cell disease and their caregivers. Ethnicity & Health, 7 (2),

115-123.

Abstract: Objectives. This study assessed stroke knowledge and the need for stroke

education among children with sickle cell disease (SCD) and their caregivers.

Methods. A cross-sectional study was conducted and includes: (1) structured

interviews of 44 children with SCD and their 50 caregivers, and (2) a self-

administered survey completed by medical directors of 22 SCD centers. The

participants were interviewed regarding stroke knowledge and stroke educational

materials. Results. Among the caregivers, only 34% named stroke as a complication

associated with SCD, 36% were aware that their children were at higher risk, and

46% were not able to identify any warning signs of stroke. Only 11% of the children

could accurately describe a stroke. Although 82% of the medical directors provided

stroke information to caregivers, only 50% provided stroke educational materials to

children. Caregivers and children were interested in receiving information about

stroke. The preferred format for the educational material was a pamphlet for adults

and a video for the children. Conclusions. Children with SCD, caregivers, and

healthcare providers need and desire educational materials about stroke. Educational

materials to improve knowledge about stroke may be an important strategy to

increase completion of stroke screening tests

Keywords: ANEMIA/caregivers/cerebrovascular

accident/education/HEALTH/knowledge/risk/sickle cell

disease/stroke/survey/TRANSFUSIONS/warning signs

Freidl, W., Schmidt, R., Stronegger, W.J., Fazekas, F. and Reinhart, B. (1996),

Sociodemographic predictors and concurrent validity of The Mini Mental State

Examination and The Mattis Dementia Rating Scale. European Archives of

Psychiatry and Clinical Neuroscience, 246 (6), 317-319.

Abstract: The Mini Mental State Examination (MMSE) and the Mattis Dementia Rating

Scale (MDRS) are among the most commonly used screening tests for dementia. The

goals of our study were, firstly, to identify sociodemographic factors which may

explain the variance of test results in a community sample and, secondly, to

investigate the interrelationship of these two dementia screening tests in order to

evaluate the concurrent validity. A total of 1947 subjects were investigated in the

setting of the Austrian Stroke Prevention Study (ASPS). Our study confirms most

previous results demonstrating a relationship of higher dementia test scores with both

younger age and higher educational level. Interestingly, the results we obtained

suggest only a weak relationship and poor concurrent validity of the two tests. The

total scores of the two tests show poor joint variance. This could lead to the

conclusion that these tests evaluate different cognitive domains

Keywords: AGE/community/concurrent validity/dementia/dementia

screening/EDUCATION/MMSE/POPULATION/predictors/sociodemographic

Gofin, J., Kark, J.D., Abramson, J.H. and Epstein, L. (1995), Trends in blood pressure

levels over time in middle-aged and elderly Jerusalem residents. European Heart

Journal, 16 (12), 1988-1994.

Abstract: Change in blood pressure levels over time was investigated in Jerusalem, in

two cross-sectional surveys in 1970 and in 1986 among residents of a neighbourhood

aged 50 years and more. The study population comprised 1397 individuals in 1970

and 1858 in the 1986. Age-adjusted mean systolic and diastolic blood pressure levels

were lower in 1986 than in 1970 by 6.9 mmHg and 4.7 mmHg, respectively. The

prevalence of blood pressure levels above 160 and/or 95 mmHg in 1986 was lower

by 50% and there was a twofold increase in current treatment for hypertension. The

reduction in blood pressure in both sexes remained evident upon control for

confounding effects of age, ethnic group, education, body mass index and reported

treatment for hypertension. The proportion of people who had blood pressure levels

below 140/90 and did not report being under treatment, increased. The possibility of

methodological problems inherent in this type of study were considered. More

effective antihypertensive treatment in 1986 can explain only part of the reduction.

The decrease in levels of blood pressure as revealed by this study may reflect a real

reduction in the population that could explain part of the striking decline in

cardiovascular mortality in Israel

Keywords: age/aged/blood pressure/changes over time/community

survey/CORONARY

HEART-DISEASE/education/elderly/epidemiology/EPIDEMIOLOGY/hypertension

/HYPERTENSION/ISRAEL/mortality/POPULATION/prevalence/RISK-FACTORS

/STROKE/treatment/women's health

Vitullo, F., Marchioli, R., DiMascio, R., Cavasinni, L., DiPasquale, A. and Tognoni, G.

(1996), Family history and socioeconomic factors as predictors of myocardial

infarction, unstable angina and stroke in an Italian population. European Journal of

Epidemiology, 12 (2), 177-185.

Abstract: A comprehensive case-control study was conducted in an Italian region in

order to compare the influence of family history of cardiovascular events,

socioeconomic factors, social networks, and their joint associations with major risk

factors, on the risk, of myocardial infarction (MI), unstable angina (UA) and

ischemic stroke (IS). A total of 513 patients with MI, 178 with UA, 237 with IS, and

928 hospitalised controls were recruited. The odds ratio (OR) of MI for two or more

relatives with a positive history of MI was 3.6 (95% CI: 1.8-7.3). Family history of

MI was predictive for UA (OR = 5.8; 95% CI: 1.2- 28.7), but not for IS. A family

history of stroke was more associated with the risk of MI than of IS. After

adjustment for known risk factors, the OR of MI for more educated people was 2.1

(1.3-3.6) compared with less-educated people. Large family size seemed to be

protective for MI. The effect of major risk factors on MI ranged from additive

(diabetes) to multiplicative jointly with high education and family history of MI. A

family history of stroke increased IS risk threefold jointly with smoking and

hyperlipidemia, and eightfold with diabetes. Besides a family history of MI and IS,

in this community a higher educational status seems to better identify groups at

increased risk of MI. The joint associations have important preventive implications

since by identifying high-risk individuals (for MI and IS) a more careful assessment

and control of risk factors amenable to intervention may be performed

Keywords: ARTERY DISEASE/cardiovascular

events/CARDIOVASCULAR-DISEASE/case-control

studies/community/CORONARY HEART-DISEASE/diabetes/education/family

history/INDEPENDENT PREDICTOR/ischemic/MEN/MORTALITY/myocardial

infarction/NETHERLANDS/PARENTAL HISTORY/predictors/risk factors/RISK-

FACTORS/smoking/SOCIAL SUPPORT/socioeconomic/socioeconomic

factors/stroke/TRANSIENT ISCHEMIC ATTACKS/unstable angina

Brainin, M. (1997), Neurological acute stroke care: the role of European neurology -

European Federation of Neurological Societies task force. European Journal of

Neurology, 4 (5), 435-441.

Abstract: In 1995 the EFNS has made stroke treatment and prevention a major policy

issue and established a Task Force to develop guidelines for acute neurological

stroke care for use by neurologists throughout Europe and to be modified according

to local and national requirements. This Task Force report supplements

recommendations and treatment guidelines previously published. It focuses on the

need of adapting neurological hospital services to immediate stroke care and sets up

lines of argumentation and organisational recommendations compiled on various

levels of evidence. Due to the increase of aging populations across Europe the

socioeconomic and health burden of stroke will increase in many countries within the

next decades. In addition, acute stroke mortality differs greatly among European

countries being the highest in many countries of Eastern Europe and lowest in many

of the Western nations. This implies that management of acute stroke varies in

intensity and quality and a uniform improvement of care can be achieved in many

countries by involving more neurologists. The viability of ischemic brain tissue may

extend up to 18 or even 24 hours but experimental and human stroke research shows

that the earlier the intervention takes place the more likely the outcome is favourable.

Thrombolysis has been recommended for use within a therapeutic time window of up

to 3 hours following the onset of stroke, a time window of up to 6 hours is currently

being tested. Neuroprotection drugs are being tested for time windows up to 12 hours.

Factors delaying early hospital referral as well as factors delaying in-hospital

management can be overcome if neurologists participate in public education

programmes that propagate early recognition of symptoms and advocate emergency

hospitalization. Training programmes for medical and paramedical staff can improve

initial diagnosis of stroke. Organizational structures within the hospital are

recommended that allow neurologists to react quickly and have access to all

investigations on an emergency basis. It is important to have an early accurate

diagnosis of the stroke as various subtypes have different frequencies with which

complications and associated comorbidities occur, have varying rates and patterns of

worsening and recurrence. It is essential to establish neurological stroke units for

acute care wherever possible. Such units have been shown to be effective but their

elements and components making them most efficacious are still not well known.

Neurological acute stroke units have the primary aim of initiating stroke treatment on

an emergency basis and of clarifying the stroke cause. Ready availability of CT,

neurosonological investigations, ECG, echocardiography, and laboratory tests

including coagulation is mandatory. Cardiac monitoring as well as monitoring of

blood pressure, blood gases, body temperature and blood glucose should be

performed immediately upon hospital arrival. When available, arteriography, MRI,

EEG monitoring, and new brain imaging techniques should be used. An acute stroke

unit should consist of 6 (4-8) beds. Depending on the severity of stroke, case-mix

and complication rates such a unit can serve a population between 200,000 and

400,000 inhabitants and treat 350 to 800 strokes per year. After stabilisation, referral

to a non- intensive stroke rehabilitation unit is recommended. In larger hospitals

where a stroke unit cannot be installed easily it is recommended to set up a mobile

neurological acute stroke team that is available at emergency departments.

Neurologists should be able to take up the history of the patient from the paramedics

immediately upon arrival, make the first assessment and follow the patient to other

departments. Seamless management includes early neurorehabilitation, the use of a

stroke pathway and access to all investigations in order to perform therapies on an

emergency basis

Keywords: ACCURACY/ACUTE ISCHEMIC STROKE/aging/blood

pressure/burden/COMPLICATIONS/COSTS/DELAYING HOSPITAL

ADMISSION/DIAGNOSIS/education/EEG/guidelines/hospitalization/ischemic/MA

NAGEMENT/MORTALITY/MRI/paramedics/rehabilitation/severity/socioeconomic

/stroke/stroke rehabilitation/stroke treatment/stroke units/symptoms/UNIT

Ranstam, J., Merlo, J., Blennow, G., Hanson, B.S., Ostergren, P.O. and Melander, A.

(1997), Impaired cognitive function in elderly men exposed to benzodiazepines or

other anxiolytics. European Journal of Public Health, 7 (2), 149-152.

Abstract: A representative sample of 68 year old men living in Malmo, Sweden, was

investigated concerning use of anxiolytic-hypnotic drugs. The subjects were

psychometrically tested using the synonyms, Koh's block design, paired associates,

visual retention, and digit symbol tests. Subjects with continuous use of anxiolytics,

the vast majority of which consisted of benzodiazepines, had an increased risk of

impaired cognitive function (RR=3.2 and p=0.008). Multivariate adjustments for

differences in education, alcohol habits, exposure to organic solvents and stroke

between users and non-users of anxiolytics did not reduce the estimate of risk

(RRadj=3.4; 95% confidence interval: 1.3-8.9). Adjusting for differences in the

number of subjects with a history of depression reduced the risk estimate slightly

(RRadj=2.7; 95% confidence interval: 1.0-7.7) but adjustments for differences in

anti-hypertensive and anti- diabetic medication had no influence. Subjects with

occasional use of anxiolytics and subjects with occasional or continuous use of

hypnotics showed no risk increase. Neither selection bias nor information bias

appeared to explain the findings. Accordingly, increased caution is warranted when

prescribing benzodiazepines for regular anxiolytic use

Keywords: anxiolytics/benzodiazepines/cognitive

function/COMMUNITIES/COMMUNITY/depression/education/elderly/HEALTH/st

roke/Sweden/USERS

Tormo, M.J., Navarro, C., Chirlaque, M.D. and PerezFlores, D. (1997), Prevalence and

control of arterial hypertension in the south- east of Spain: A radical but still

insufficient improvement. European Journal of Epidemiology, 13 (3), 301-308.

Abstract: Stroke mortality rates in Spain are one of the highest in all of Europe. At the

same time, the Murcia region (south-east Spain) shows, for both genders, the highest

age-adjusted stroke mortality rates in all of Spain. The earliest available hypertension

figure estimations for this area go back to 1981, when a high prevalence combined

with an almost nonexistent control was detected. One decade later, updated

prevalence estimations of hypertension are presented jointly with their degree of

control and their association with other risk factors based on the results of a

prevalence survey in a random population sample (n = 3,091). Arterial, blood

pressure was measured following the MONICA protocol, maintaining a tight quality

control on between and within-observer variability. As hypertensive was considered

any person with systolic blood pressure (SEP) greater than or equal to 140 mmHg or

with diastolic blood pressure (DBP) greater than or equal to 90 mmHg or with

antihypertensive pharmacological treatment. Detected prevalence rises to 32.3% (CI

95%: 29.1%-35.5%) among males and to 23.7% (CI 95%: 21.4%-26%) among

females, maintaining its level regarding figures observed back in 1981. However, its

control has been increased, especially among hypertensive women [from less than

5% in 1981 to 35% (95% CI: 32%-37.8%) at present]. Hypertension is strongly

associated to hiperchoIesterolemia, overweight, obesity and diabetes (p 0.05) in tests that evaluate language, verbal intelligence and

visuospatial functions, while the patients with LA showed poorer performance

(p6.21mmol/l,

hypertension, diabetes, education, and being foreign born were computed by

gender-specific height categories separately for men (n = 2826) and women (n =

3741). Results A graded inverse association between stature and risk of CHD was

observed among men which persisted after adjustment for confounders. Men >69.75

inches had an 83% lower risk of CHD compared with men less than or equal to 65

inches. Zn addition, the tallest men had a 67% decreased risk of stroke compared

with the shortest men. No significant relation between stature and CHD or stroke was

observed among women. Conclusions These data support the hypothesis that stature

is inversely related to both risk of CHD and stroke at least among men. Factors

which might explain this association remain to be determined

Keywords: ACUTE MYOCARDIAL-INFARCTION/age/coronary heart

disease/education/FOLLOW/HEALTH-

PROGRAM/HEIGHT/hypertension/ISCHEMIC-HEART-DISEASE/LUNG-FUNCT

ION/MORTALITY/relative

risk/RISK-FACTORS/smoking/SOCIAL-FACTORS/stature/stroke/SURVEILLANC

E/women

Cairney, J. and Wade, T.J. (1998), Correlates of body weight in the 1994 National

Population Health Survey. International Journal of Obesity, 22 (6), 584-591.

Abstract: OBJECTIVE: This study examines three specific questions about obesity and

overweight, using a nationally representative sample of Canadians. Are

sociodemographic and lifestyle behaviors associated with body weight? is body

weight correlated with specific health outcomes? Has the prevalence of obesity in

Canada changed since 1978? METHODS: Secondary data analysis of a

cross-sectional survey. SAMPLE: This study uses the 1994 National Population

Health Survey (NPHS) by Statistics Canada. It is a stratified random sample of

19600 Canadians across ail provinces. RESULTS: The results show that age, gender,

education, birth place and region, are significantly associated with obesity. When a

lower criterion is used for overweight and obesity (body mass index, BMI greater

than or equal to 25), dummy variables for marital status and occupation are also

significant. Second, obesity is associated with poorer self-rated health, high blood

pressure, heart disease, diabetes, arthritis, respiratory and stomach problems. For

those respondents who have a BMI score of 25 or greater, there is also an association

with stroke. Finally, it is unclear whether the prevalence of obesity has changed.

However, there appears to be a systematic difference between studies using actual

height and weight measurements (anthropometric) vs self- reported measurements.

CONCLUSIONS: Weight can be considered a modifiable risk factor and reductions

in the prevalence of obesity should reduce the risk of specific chronic conditions.

Provincial variations in the prevalence of obesity (BMI greater than or equal to 27)

and overweight and obesity (BMI greater than or equal to 25) suggest that collapsing

provinces into regions may obscure important interprovincial differences in body

weight. More research is required to assess whether or not obesity is decreasing in

Canada. Some of the limitations of self-reported data are discussed

Keywords: ADULTS/age/blood pressure/BMI/BREAST-CANCER/chronic illness and

disease/education/FAT DISTRIBUTION/gender/health outcomes/lifestyle

factors/MASS

INDEX/MEN/obesity/OBESITY/OVERWEIGHT/PREVALENCE/SAMPLE/self-ra

ted health/sociodemographic/stroke/TRENDS

Lieberman, D., Galinsky, D., Fried, V., Grinshpun, Y., Mytlis, N., Tylis, R. and

Lieberman, D. (1999), Factors affecting the results of the Clock Drawing Test in

elderly patients hospitalized for physical rehabilitation. International Journal of

Geriatric Psychiatry, 14 (5), 325-330.

Abstract: The Clock Drawing Test (CDT) is a recognized and accepted instrument for

the early diagnosis of dementia in the elderly. In a prospective study we evaluated

the association between the results of this test and a broad range of clinical,

functional and sociodemographic variables. The study was conducted on elderly

patients hospitalized for rehabilitation following stroke or hip fracture (HF) in the

geriatric ward of a university hospital in southern Israel. The administration df the

CDT and its scoring system were adapted from Sunderland et al. and Wolfe-Klein et

al. The study was conducted on all 425 elderly patients who were hospitalized during

the study period and who were capable of completing the test. Stepwise multiple

regression was used to evaluate the association between the results of the CDT and

the other variables. The mean CDT score (+/- SD) for the entire study population was

7.8 +/- 2.5 and 145 patients (34%) had scores of 6 or below. Of the 41 variables that

were tested, significant associations with the CDT were found for the following four

variables only: the Folstein minimental test (beta = 0.447, p 2.0 mg/dL), or active liver disease; or patients who quit

smoking prior to surgery were excluded from the study. Both groups received similar

anesthetic and surgical management. All patients received a battery of

neurocognitive tests both preoperatively and 6 weeks after CABG surgery.

Neurocognitive test scores were separated into 4 cognitive domains, with a

composite cognitive index (the mean of the four domain scores) determined for each

patient at every testing period. Measurements and Main Results: The overall rate of

cognitive decline at 6 weeks after surgery in smokers was 36.2%, whereas

nonsmokers showed a deficit rate of 36.6%. Nonsmokers were significantly older

and presented for surgery on average 6 years later than the smokers. Female sex

represented a considerably larger proportion of patients in the nonsmoker group.

Smokers had a higher prevalence of myocardial infarction. The univariate analysis of

cognitive change at 6 weeks adjusted for age, baseline cognitive index, and education

years showed no difference between the 2 groups. Sex, history of myocardial

infarction, hypertension, stroke, transient ischemic attack, and duration of

cardiopulmonary bypass did not contribute to the multivariate logistic regression

model and were dropped from the final analysis. Significant multivariate predictors

of neurocognitive dysfunction included age, left ventricular ejection fraction,

baseline education level, and baseline cognitive index. Conclusions: This study

confirmed previous findings that age, baseline cognitive function, years of education,

and impaired left ventricular function are independent predictors of neurocognitive

decline at 6 weeks after CABG surgery. Smoking is neither preventive nor causative

of cognitive decline after CABG surgery. (C) 2003 Elsevier Inc. All rights reserved

Keywords: age/BYPASS GRAFT-SURGERY/COGNITIVE DECLINE/cognitive

dysfunction/cognitive function/coronary/coronary artery bypass graft

surgery/education/function/HUMANS/hypertension/ischemic/myocardial

infarction/NEVER-SMOKERS/PREDICTORS/prevalence/renal

disease/RISK/smoking/STROKE/SUBCUTANEOUS

NICOTINE/surgery/TERM/TOLERANCE/transient

Gordon, A.L., Ganesan, V., Towell, A. and Kirkham, F.J. (2002), Functional outcome

following stroke in children. Journal of Child Neurology, 17 (6), 429-434.

Abstract: The aim of this study was to describe the functional consequences of

childhood stroke in terms of activity limitation and to explore the relationship

between extent of brain damage, impairment, and functional sequelae. A further aim

was to describe the health of the parents of these children. Seventeen children and

adolescents with cerebral infarction in the territory of the middle cerebral artery were

enrolled in the study. A new activity limitation measure with a 4-point Likert scale

(the Paediatric Stroke Activity Limitation Measure) was designed to examine the

degree of difficulty experienced by the children in daily activities. The relationship

between activity limitation scores, standardized health-related quality of life

assessment (Child Health Questionnaire), extent of brain damage, and results of a

comprehensive neurologic examination (Pediatric Stroke Outcome Measure) were

investigated. Parent health was assessed using the Short-Form 36 General Health

Survey. Activity limitation was evident in the domains of education, self-care, and

motor skills. There was very good interobserver agreement using the new activity

limitation scale between the occupational therapist and pediatric neurologist (Cohen's

kappa = 0.88). In comparison with population norms, the subjects scored below

average in both physical and psychologic health. There was a clear relationship

between radiologically apparent extent of brain damage, degree of impairment, and

functional outcome. Parental health also rated generally lower than expected. This

exploratory study suggests that both children who have had a stroke and their parents

have significant and wide-ranging health needs

Keywords: ADULTS/AGE/assessment/CANADA/cerebral

infarction/CHILDHOOD/education/functional outcome/health/HEALTH

SURVEY/HEMIPLEGIA/ISCHEMIC

STROKE/LIFE/occupational/outcome/population/quality of

life/QUESTIONNAIRE/self care/stroke

Shah, S., Vanclay, F. and Cooper, B. (1991), Stroke Rehabilitation - Australian Patient

Profile and Functional Outcome. Journal of Clinical Epidemiology, 44 (1), 21-28.

Abstract: A prospective, multi-institutional, population based study identified 1274

non-surgical stroke admissions to all hospitals in a major Australian city during 1984.

The demographic and diagnostic profile and the nature of functional recovery of all

258 first stroke survivors who were referred for inpatient rehabilitation and presented.

The median duration of rehabilitation stay was 49 days. The mean functional

independence score, as measured on a modified Barthel Index at admission was 44,

compared with 78 to discharge, a mean improvement of 34. Stair climbing had the

lowest mean value on admission (12), while bowel control had the lowest residual

deficit on discharge (95). The stroke study group was representative of the

unimpaired aged population in all respects except ethnicity, where differences are

attributed to age. The variables identified as significant are; side and severity of

paralysis, age and sex, marital status and ethnicity. Stroke rehabilitation outcome was

not influenced by etiology, site of lesion, arterial distribution, occupation or

education

Keywords: ADL/age/aged/AUSTRALIA/BARTHEL INDEX/CEREBROVASCULAR

ACCIDENT/education/ethnicity/etiology/FUNCTIONAL

RECOVERY/outcome/OUTCOME

MEASURE/PATTERNS/PREDICTION/rehabilitation/severity/stroke/STROKE

REHABILITATION

White, L., Katzman, R., Losonczy, K., Salive, M., Wallace, R., Berkman, L., Taylor, J.,

Fillenbaum, G. and Havlik, R. (1994), Association of Education with Incidence of

Cognitive Impairment in 3 Established Populations for Epidemiologic Studies of the

Elderly. Journal of Clinical Epidemiology, 47 (4), 363-374.

Abstract: We analyzed the association of education, occupation, and sex with incidence

of cognitive impairment using data from three communities in the Established

Populations for Epidemiologic Studies of the Elderly (EPESE) projects (New Haven,

East Boston, and Iowa). Participants were initially interviewed in 1981-1983, with

follow-up 3 and 6 years later. Incident cognitive impairment was defined on the basis

of either: (1) increase in the number of errors in Short Portable Mental Status

Questionnaire (SPMSQ) (i.e. from a baseline level below the cutoff value to a score

above the cutoff), or (2) inability to respond to interview questions at a follow-up

contact (requiring a proxy informant), or (3) death with a recorded diagnosis of a

dementing illness. In multiple logistic regression models, the major factors predicting

the development of cognitive impairment were advanced age, any errors on baseline

SPMSQ, 8 or fewer years of education, and occupation. Education and occupation

remained significant predictors after controlling for age, site, sex, stroke, and

baseline SPMSQ score

Keywords: age/AGING/ALZHEIMERS-DISEASE/COGNITIVE

IMPAIRMENT/COMMUNITY

POPULATION/DEMENTIA/diagnosis/DISORDERS/EDUCATION/FRAMINGHA

M/INCIDENCE/MENTAL STATE

EXAMINATION/OCCUPATION/PERFORMANCE/predictors/PREVALENCE/RE

SIDENTS/stroke/SYNAPSE LOSS

Dodson, D.J., Hooton, T.M. and Buchwald, D. (1995), Prevalence of

Hypercholesterolemia and Coronary Heart-Disease Risk-Factors Among

Southeast-Asian Refugees in A Primary-Care Clinic. Journal of Clinical Pharmacy

and Therapeutics, 20 (2), 83-89.

Abstract: The National Cholesterol Education Program's guidelines for the detection,

evaluation, and treatment of high serum cholesterol in adults were employed in

screening 155 Southeast Asian refugees in a primary care clinic in Seattle,

Washington. In order to determine the need for a therapeutic intervention,

information also was collected on the presence of other coronary heart disease (CHD)

risk factors. Male gender (39%), cigarette smoking (27%) and hypertension (26%)

were the most common CHD risk factors; diabetes mellitus, obesity, a family or prior

history of CHD or eerebral/peripheral vascular disease were each noted in less than

10%. The mean serum total cholesterol was 194 mg/dl. Thirty-seven (24%) patients

required further lipoprotein analysis based on cholesterol level, history of CHD and

risk factors for CHD. Twenty-one (66%) of 32 patients who underwent lipoprotein

analysis (14% of all patients) were candidates for a therapeutic intervention for

hypercholesterolaemia. Additionally, 14 (44%) patients undergoing lipoprotein

analysis had depressed high-density lipoprotein levels ( 7.6 were at increased risk of death from CHD (relative

risk = 1.4, 95% confidence interval = 1.1-1.8) after adjustment for smoking status

and other CVD risk factors. Similar results were observed among nonsmokers (RR =

1.4, 95% CI = 0.9-2.0). These results suggest that higher WBC counts are a predictor

of CHD mortality independent of the effects of smoking and other traditional CVD

risk factors, which may indicate a role for inflammation in the pathogenesis of CHD.

Additional studies are needed to determine whether interventions to decrease

inflammation can reduce the risk for CHD associated with elevated WBC. (C) 2001

Elsevier Science Inc. All rights reserved

Keywords: ACUTE MYOCARDIAL-INFARCTION/age/aged/ALL-CAUSE

MORTALITY/ARTERY DISEASE/ATHEROSCLEROSIS/cardiovascular

disease/cholesterol/cigarette smoking/coronary/coronary heart disease/DEATH

INDEX/diabetes/diseases/education/ENGLAND/epidemiology/FOLLOW-UP/INFL

AMMATION/LEUKOCYTE COUNT/mortality/physical activity/PLAQUE

RUPTURE/race/relative risk/risk/risk

factors/RISK-FACTORS/smoking/stroke/survival analysis/white blood cell count

Cheung, R.T.F. (2001), Hong Kong patients' knowledge of stroke does not influence

time-to-hospital presentation. Journal of Clinical Neuroscience, 8 (4), 311-314.

Abstract: A prospective interview of consecutive patients admitted with acute stroke

was conducted over an 8-week period to study the influence of patients' knowledge

of stroke on time to presentation in Hong Kong. Early arrival was defined as within 6

h of symptom onset. The patients' general knowledge of stroke was fair, and early

arrival was seen in 40 (56.3%) of 71 patients. Early presentation was associated with

male sex (P = 0.028) and a lower initial Glasgow coma scale score (P = 0.072), but

not with age, a better general knowledge of stroke, a previous history of stroke or

transient ischaemic attack, Rankin score upon discharge, and level of education. On

the other hand, late presentation was associated with a belief in permanent disability

(P = 0.056). Thus, improving the general knowledge of stroke among Hong Kong

people may not reduce delay in hospital presentation of stroke patients. (C) 2001

Harcourt Publishers Ltd

Keywords: acute/ACUTE ISCHEMIC STROKE/acute

stroke/age/China/Chinese/disability/education/EMERGENCY/health

education/Hong

Kong/hospital/knowledge/male/RISK-FACTORS/SIGNS/stroke/stroke onset/stroke

patients/survey/THROMBOLYTIC THERAPY/transient

Chang, C.L., Marmot, M.G., Farley, T.M.M. and Poulter, N.R. (2002), The influence of

economic development on the association between education and the risk of acute

myocardial infarction and stroke. Journal of Clinical Epidemiology, 55 (8), 741-747.

Abstract: Rates of myocardial infarction and stroke increase as countries "develop."

These disorders emerge among higher socio-economic groups, but once "developed,"

most events occur in lower socio- economic groups. We evaluated the association

between education as a measure of socio-economic status and risk of acute

myocardial infarction (AMI) and stroke in regions at various stages of development

and between stroke risk and life expectancy. The study comprised 2,478 cases of

AMI or woke and 6,819 controls among women aged 19-49, from Africa, Asia, Latin

America, and Eastern Europe. Compared to those with high educational attainment,

stroke risk was reduced among less educated women in Africa, but was significantly

higher in the other three regions. Low education was associated with increased risk

of AMI in Eastern Europe but not in the other three regions combined. Educationally

related stroke risk was positively correlated with national life expectancy. (C)

Elsevier Science Inc. All rights reserved

Keywords: acute/acute myocardial infarction/aged/economic/economic

development/education/educational

attainment/ENGLAND/HEART-DISEASE/INEQUALITIES/MORTALITY/myocar

dial infarction/risk/socioeconomic/socioeconomic status/stroke/women/young

women

Buhlin, K., Gustafsson, A., Hakansson, J. and Klinge, B. (2002), Oral health and

cardiovascular disease in Sweden - Results of a national questionnaire survey.

Journal of Clinical Periodontology, 29 (3), 254-259.

Abstract: Objective: The purpose of the present study was to assess the relation between

dental health and cardiovascular disease in an adult Swedish population. Material

and method: A questionnaire was sent to 4811 randomly selected Swedes. It

contained 52 questions about dental care habits, oral health, cardiovascular disease

and their socio-economic situation. Odd ratios for all cardiovascular diseases (CVD)

and the subgroup myocardial infarction, stroke and high blood pressure were

calculated with a logistic regression model adjusted for age, gender, smoking,

income, civil status and education. These ratios were calculated for subjects greater

than or equal to41 years since few people suffer from CVD before this. Results: The

national questionnaire was answered by 2839 (59%) people between 20-84 years of

age and, of them, 1577 were 41 years of age or more. We found a significant

association between self-reported bleeding gums (odds ratio 1.60, p= 0.0017),

presence of dentures (odds ratio 1.57, p=0.0076) and known CVD, which has also

been reported in international studies. However, no association between loose teeth,

deep pockets and known CVD was detected. Conclusion: The results indicate that

oral health and, especially gingival inflammation is associated with CVD

Keywords: adult/ADULT-POPULATION 1973/age/ASSOCIATION/blood

pressure/cardiovascular disease/cardiovascular

diseases/COPENHAGEN/CORONARY HEART-DISEASE/DENTAL

CONDITIONS/diseases/education/epidemiology/gender/health/myocardial

infarction/MYOCARDIAL-INFARCTION/odds ratio/periodontal

disease/PERIODONTAL- DISEASE/population/questionnaire/RISK/risk

factor/smoking/socioeconomic/stroke/survey/Sweden/SWEDISH

POPULATION/VALIDITY

Chang, C.L., Shipley, M.J., Marmot, M.G. and Poulter, N.R. (2002), Can cardiovascular

risk factors explain the association between education and cardiovascular disease in

young women? Journal of Clinical Epidemiology, 55 (8), 749-755.

Abstract: We sought to explain the observed variation in the relationship between

education and cardiovascular disease (CVD) among young women in countries at

different stages of economic development. Data comprised 2,478 cases of acute

myocardial infarction (AMI) or stroke and 6,819 age-matched controls from Africa,

Asia, Eastern Europe, and Latin America. The risks of AMI associated with lower

education observed in Eastern Europe and higher education in non-European

countries were reduced by 92% in Eastern Europe and totally abolished in

non-European countries by adjustment for standard cardiovascular risk factors. The

inverse associations between education and stroke risk in the three non-African

regions were attenuated by 22, 47, and 60% after adjustment. In Africa, the slight

inconsistent trend towards lower stroke risk in less well educated women was

unaffected by adjustment. These data suggest that standard risk factors explain a

substantial proportion if not all of the difference in AMI risk associated with

education but a lesser proportion of educationally linked stroke risk. (C) 2002

Elsevier Science Inc. All rights reserved

Keywords: acute/acute myocardial infarction/cardiovascular disease/cardiovascular risk

factors/CORONARY HEART-DISEASE/DEATH/developing

countries/economic/economic development/education/educational

attainment/ENGLAND/EXPLANATIONS/MEN/MORTALITY/myocardial

infarction/MYOCARDIAL-INFARCTION/POPULATION/risk/risk

factors/SOCIAL-CLASS/SOCIOECONOMIC- STATUS/stroke/women/young

women

Gillum, R.F. and Mussolino, M.E. (2003), Education, poverty, and stroke incidence in

whites and blacks: The NHANES I epidemiologic follow-up study. Journal of

Clinical Epidemiology, 56 (2), 188-195.

Abstract: The purpose of this study was to test the hypothesis that educational

attainment and poverty index are inversely associated with incidence of stroke in

blacks and in whites. The NUANES I Epiderniologic Follow-up Study data were

analyzed. We analyzed 2953 women and 2661 men with no history of stroke before

baseline (1971-1975), using the incidence of stroke through 1992, years of education,

and poverty index at baseline. In white men aged 45 to 74, Cox regression models

showed an inverse age-adjusted association with education that did not attain

statistical significance. In white women, those with 12 or more years of education

had significantly lower age- adjusted risk of stroke compared with those with less

than 8 years. A test for linear trend was significant when adjusting for age (P =

0.0005). In blacks, stroke risk was significantly lower in those with 8 or more years

of education than in those with 50 were more likely to have a high knowledge score (defined as 80% or more

correct, odds ratio [OR], 2.8; P=.04 and OR, 5.7; P4 h, 9.0%), but no additional relative benefit resulted

from earlier treatment with accelerated t-PA versus streptokinase (p = 0.38). Longer

presentation and treatment delays were both associated with increased mortality rate

(presentation delay 4 h, 8.6%; treatment delay 90

min, 8.1%). As time to treatment increased, the incidence of recurrent ischemia or

reinfarction decreased, but the rates of shock, heart failure and stroke increased.

Conclusions. Earlier treatment resulted in better outcomes, regardless of

thrombolytic strategy. Elderly, female and diabetic patients were treated later, adding

to their already substantial risk

Keywords: ACUTE MYOCARDIAL-INFARCTION/CAMPAIGN/CHEST

PAIN/DELAY/elderly/incidence/INTERVENTION/mortality/plasminogen

activator/PUBLIC-EDUCATION/SIZE/stroke/surgery/survival/thrombolytic

therapy/tissue-type/treatment/TRIAL

Mazur, D.J. (1997), How older patient preferences are influenced by consideration of

future health outcomes. Journal of the American Geriatrics Society, 45 (6), 725-728.

Abstract: OBJECTIVE: To determine patients' willingness to accept intubation and

ventilatory support (IVS) when the best outcome available is a state involving both

cognitive and physical/behavioral deficits. DESIGN: Structured interviews with

patients seen consecutively in a continuity Care general medicine clinic. SETTING:

A university-based Department of Veterans Affairs Medical Center. SUBJECTS: A

total of 113 patients (mean age = 67.3 years, age range 42-89; mean level of formal

education = 12.6 years, range 2-24). MEASUREMENTS: Patients were asked to

consider whether they would permit their physicians to intubate them and put them

on ventilatory support when the best outcome to be expected was one of three future

health care states, presented in the following order: State 1, where their mental and

physical state of recovery would be exactly like their current mental and physical

states at the time of their visit to the general medicine clinic (the patient's current

baseline mental and physical functioning); State 2, involving cognitive compromise;

State 3, involving both cognitive and physical/behavioral compromise. RESULTS:

One patient refused IVS on State 1; 20.4% (23/113) of patients refused IVS on State

2; 23.0% (26/113) refused IVS on State 3; and 49.6% (56/113) reported they would

accept IVS resulting in all three states. Six of 113 patients (5.3%) reported they

would leave the decision up to their physician beginning with State 1 and continuing

through State 3. One patient reported that he would leave the decision (State 1

through State 3) up to his wife. A reported history of stroke is related to patients'

expressed dislike of IVS that would leave them with residual deficits.

CONCLUSION: The results suggest that a substantial number of our older male

veteran population would prefer intubation and ventilatory support if presented with

a situation in which the best outcome that a physician could offer them was cognitive,

physical, and behavioral dysfunction. These results also indicate that those patients

who have had a stroke seem to be less inclined to accept IVS in more severe

outcomes states

Keywords: ADVANCE DIRECTIVES/age/DIALYSIS PATIENTS/education/health

outcomes/LIFE-SUSTAINING TREATMENTS/outcome/stroke

Schmidt, R., Hayn, M., Reinhart, B., Roob, G., Schmidt, H., Schumacher, M.,

Watzinger, N. and Launer, L.J. (1998), Plasma antioxidants and cognitive

performance in middle-aged and older adults: Results of the Austrian Stroke

Prevention Study. Journal of the American Geriatrics Society, 46 (11), 1407-1410.

Abstract: OBJECTIVES: To study the association between cognitive status and plasma

concentrations of various antioxidants in middle- aged and older individuals without

neuropsychiatric disease. DESIGN: Evaluation of cross-sectional data from a cohort

study. SETTING: The Austrian Stroke Prevention Study. PARTICIPANTS: A total

of 1769 subjects aged 50 to 75 years, with no history or signs of neuropsychiatric

disease, selected randomly from the community register. MEASUREMENTS: The

score on the Mattis Dementia Rating Scale (MDRS) was dichotomized according to

age- and education-specific lowest quartile cut-off points. Reversed-phase high

performance liquid chromatography measurements of the plasma concentrations of

lutein/zeaxanthin, cryptoxanthin, canthaxanthin, lycopene, alpha-carotene, beta-

carotene, retinol, gamma-tocopherol, alpha-tocopherol, and ascorbate wore measured.

RESULTS: Individuals with MDRS results below the lowest quartile cut-off point

had lower levels of beta-carotene and alpha-tocopherol than their counterparts with

test performance above this limit (0.44 +/- .33 mu mol/L vs 0.51 +/- .48 mu mo/L, P

160 (17% for whites and

18% for African Americans) and 16% had a diastolic blood pressure of >90 (14% for

whites and 20% for African Americans). During the 6 years of follow- up, 29% of

the sample died (with no difference in mortality rates between whites and African

Americans). PARTICIPANTS: 4,000 community-dwelling people age 65 years and

older; 1,846 were white and 2,154 were African American. MEASUREMENTS:

Systolic and diastolic blood pressure and all-cause mortality. RESULTS: Systolic

blood pressure positively related to mortality during the 6 years of follow-up

(relative risk = 1.05). Among whites the relationship of diastolic pressure to

mortality was nonlinear, with those at the upper and lower ends of the distribution at

increased risk. Among African Americans, diastolic pressure was unrelated to

mortality. The analyses were controlled for age; gender; education; body mass index

(BMI); smoking history; taking a medication to manage blood pressure; a history of

cancer, diabetes mellitus, heart attack, or stroke; poor subjective health; impaired

functional status; and cognitive impairment. CONCLUSIONS: The findings confirm

that among older adults there is a significant relationship overall between systolic

blood pressure and mortality over 6 years of follow-up in both whites and African

Americans. Diastolic pressure was a risk factor for whites only

Keywords: African/African American/African Americans/age/aging/blood

pressure/BMI/cognitive impairment/community/DESIGN/diabetes/diabetes

mellitus/education/functional status/gender/health/HEART-DISEASE

MORTALITY/hypertension/longitudinal

study/mortality/NORTH-CAROLINA/older adults/older

people/PARTICIPANTS/PREDICTORS/race/relative risk/risk/risk

factor/smoking/stroke/SYSTOLIC HYPERTENSION/whites

Blake, G.J., Ridker, P.M. and Kuntz, K.M. (2002), Projected life-expectancy gains with

statin therapy for individuals with elevated C-reactive protein levels. Journal of the

American College of Cardiology , 40 (1), 49-55.

Abstract: OBJECTIVES We sought to estimate the potential gains in life expectancy

achieved with statin therapy for individuals without overt hyperlipidemia but with

elevated C-reactive protein (CRP) levels. BACKGROUND Persons with low-density

lipoprotein (LDL) cholesterol levels below current treatment guidelines and elevated

CRP levels are at increased risk of cardiovascular disease and may benefit from

statin therapy. METHODS We constructed a decision-analytic model to estimate the

gains in life expectancy with statin therapy for individuals without overt

hyperlipidemia but with elevated CRP levels. The annual risks of myocardial

infarction (MI) and stroke, as well as the efficacy of statin therapy, were based on

evidence from randomized trials. Estimates of prognosis after MI or stroke were

derived from population-based studies. RESULTS We estimated that 58-year-old

men and women with CRP levels greater than or equal to0.16 mg/dl but LDL

cholesterol 600 mug/l) than whites

when high D-dimer (yes/no) was analyzed, and blacks had an average level that was

nearly 408 higher than whites in analyses of the continuous version of the outcome.

This racial effect was not substantively affected in multivariable analyses with

demographic and socioeconomic variables controlled. Race, age, functional status,

current smoking, high blood pressure, and weight loss were related to level of

D-dimer, and race, age, and functional status were related to the presence of a high

D-dimer level (in the top 10% of the sample). Conclusions. Black, older, and

functionally impaired persons had significantly higher levels of D-dimer in this

sample of community-dwelling elderly persons. The findings for race were

particularly striking and persisted even after controlling for smoking and other

factors known to be related to thrombosis and were not mediated by social factors.

This result may contribute to our understanding of the increased levels of thrombotic

events found in these groups

Keywords: activities of daily living/ACUTE STROKE/age/aging/blacks/blood

pressure/CORONARY-ARTERY DISEASE/DEGRADATION

PRODUCT-D/diabetes/disability/diseases/education/elderly/ENDOTHELIAL-CELL

S/FIBRINOGEN/function/functional status/gender/health/hypertension/INCIDENT

CARDIOVASCULAR-DISEASE/income/INTERLEUKIN-1/life

satisfaction/morbidity/morbidity and

mortality/mortality/MYOCARDIAL-INFARCTION/outcome/PLASMINOGEN-AC

TIVATOR INHIBITOR/population/race/racial differences/RISK-

FACTORS/self-rated health/smoking/social/socioeconomic/stroke/whites

Fillenbaum, G.G., Pieper, C.F., Cohen, H.J., Cornoni-Huntley, J.C. and Guralnik, J.M.

(2000), Comorbidity of five chronic health conditions in elderly community residents:

Determinants and impact on mortality. Journals of Gerontology Series A-Biological

Sciences and Medical Sciences, 55 (2), M84-M89.

Abstract: Background. Comorbidity is common in elderly persons. Its extent, correlates,

and life-threatening impact in representative community residents are unclear.

Methods. Self- reported information of physician-diagnosed coronary artery disease

(CAD), cerebrovascular disease (CVD, diabetes, and cancer was obtained annually

between 1986-87 and 1992-93, and hypertension was obtained triennially from the

participants of the Duke Established Populations for Epidemiologic Studies of the

Elderly, a stratified multistage sample of 4126 Black and White community residents

aged 65-100, living in a five-county area of North Carolina. Date of death was

obtained from death certificates identified through search of the National Death

Index. Statistical procedures included descriptive statistics, logistic regression, and

survival analysis. Results. Of this sample, 57% reported hypertension, 20% diabetes,

15% CAD, 9% cancer, and 9% CVD; 29% reported none of these conditions,

whereas 29% reported two or more. Demographic characteristics were not related to

comorbidity with CVD or cancer. Increased education tended to be protective. The

effect of age, gender, and race varied with condition. At baseline there was

substantial comorbidity among hypertension, CAD, CVD, and diabetes, but not with

cancer. Hypertension, CVD, and diabetes were risk factors for CAD, whereas

diabetes was a risk factor for CVD. After controlling for demographic characteristics,

all health conditions except hypertension were predictive of B-year mortality, as was

the presence of comorbidity. Conclusion. We found significant comorbidity in older

persons who have hypertension, CAD, CVD, or diabetes; particular risk of

developing comorbidity, particularly CAD, among those with hypertension, CVD,

and diabetes; and risk of CVD in those with diabetes. With the exception of

hypertension, these conditions, and comorbidity per se, are life-threatening

Keywords: age/aged/CARDIOVASCULAR-DISEASE/cerebrovascular

disease/common/community/coronary/CORONARY

HEART-DISEASE/correlates/death

certificates/diabetes/education/elderly/gender/GENERAL-

PRACTICE/health/HYPERTENSION/impact/LIFE/mortality/OLDER

ADULTS/PREVALENCE/race/RISK/risk factor/risk

factors/STROKE/survival/survival analysis/WOMEN

Brady, C.B., Spiro, A., McGlinchey-Berroth, R., Milberg, W. and Gaziano, J.M. (2001),

Stroke risk predicts verbal fluency decline in healthy older men: Evidence from the

normative aging study. Journals of Gerontology Series B-Psychological Sciences

and Social Sciences, 56 (6), 340-346.

Abstract: Risk factors for stroke cause ischemic changes in the cerebral white matter

that may affect frontal lobe functions more than other brain functions. Therefore,

stroke risk could specifically affect performance on behavioral indexes traditionally

associated with frontal lobe function such as verbal fluency. The authors examined

this hypothesis in 235 healthy older men (mean age = 66.41 years) who received

concurrent medical and neuropsychological examinations twice at a 3-year interval.

Relations between stroke risk and decline in verbal fluency, memory, and

visuospatial performance were analyzed through regression, controlling for age and

education. Age was associated with decline in all cognitive functions; stroke risk was

associated with decline only on verbal fluency. The relation between stroke risk and

fluency decline was 80% as large as that between age and fluency decline. These

results suggest that stroke risk rivals the effects of aging on verbal fluency

performance

Keywords: affect/age/aging/ALZHEIMERS-DISEASE/brain/COGNITIVE

PERFORMANCE/DYSFUNCTION/education/frontal

lobe/FRONTAL-LOBE/function/ischemic/LESIONS/medical/MEMORY/men/perfo

rmance/risk/stroke/VASCULAR DEMENTIA

Petitti, D.B., Buckwalter, G., Crooks, V.C. and Chiu, V. (2002), Prevalence of dementia

in users of hormone replacement therapy as defined by prescription data. Journals of

Gerontology Series A-Biological Sciences and Medical Sciences, 57 (8),

M532-M538.

Abstract: Background. Studies of hormone replacement therapy (HRT) and dementia

and cognitive impairment show mixed results. This study assessed the prevalence of

dementia and cognitive impairment in users and nonusers of RRT defined using

computer- stored prescription information. Methods. The study involved 3924

women 75 years of age and older who were members of the Southern California

Kaiser Permanente Medical Care Program in 1998. HRT use was determined based

on prescription data for 1992-1998. Cognitive function and dementia were assessed

using the Telephone Interview of Cognitive Status supplemented by the Telephone

Dementia Questionnaire and medical record review. Results. Odds ratios (ORs) for

cognitive impairment/dementia showed expected associations with age, education,

ethnicity, and a history of stroke or Parkinson's disease. After adjustment, the OR for

cognitive impairment or dementia in HRT users compared with HRT nonusers was

0.91 (95% confidence interval 0.75-1.10). The adjusted ORs for all dementia and

dementia without cause in HRT users compared with nonusers were 0.77 (95%

confidence interval 0.59-1.00) and 0.78 (0.58-1.05), respectively. Twenty percent of

women with cognitive impairment or dementia who had been classified as HRT

users by prescription (one prescription each year from 1992-1998) denied hormone

use compared with 8.8% of women without impairment. Medical record review

validated prescription information for the impaired women. Conclusions. The study

identified an important methodologic problem in studies of HRT and cognitive

impairment and dementia that depend on recalled information about drug exposure.

A protective effect of HRT for cognitive impairment and dementia was neither

established nor ruled out based on the prescription data

Keywords: age/ALZHEIMERS-DISEASE/COGNITIVE FUNCTION/cognitive

impairment/CONTROLLED

TRIAL/dementia/education/ESTROGEN-REPLACEMENT/ethnicity/function/GRO

WTH/HIPPOCAMPAL-NEURONS/MEMORY/OLDER

WOMEN/POPULATION/prevalence/RISK/stroke/women

Swan, G.E. and Carmelli, D. (2002), Evidence for genetic mediation of executive

control: A study of aging male twins. Journals of Gerontology Series

B-Psychological Sciences and Social Sciences, 57 (2), 133-143.

Abstract: The objective of this study was to investigate the genetic and environmental

influences on indexes of executive control in elderly male twins (members of the

National Heart, Lung, and Blood Institute Twin Study). Multivariate genetic

modeling was applied to performance on four tests: Digit Symbol Substitution,

color-word interference, Trail Making B, and verbal fluency. After exclusion of

individuals with a positive stroke history, data were available for 80 monozygotic

and 78 dizygotic twin pairs of ages 69-80 years. Performance on all measures was

adjusted for age and education. Significant genetic and environmental influences to

performance on each measure of executive control were identified (range of

heritability = 34%-68%). Multivariate analyses revealed that a model with a latent

executive control factor most adequately fit the observed covariances on test

performance, chi(2) (58, N = 316) = 69.7, p = .14. The shared executive control

factor had a heritability of 79% and accounted for 10%-56% of the genetic variance

in performance on each of the four tests. Of the 4 tests examined in this analysis,

Digit Symbol Substitution appeared to be the marker of executive control with the

largest genetic component, whereas verbal fluency stood out as displaying a pattern

of genetic and environmental influences distinct from the other 3 measures

Keywords: ADULT

AGE-DIFFERENCES/age/aging/ALZHEIMERS-DISEASE/COGNITIVE

DECLINE/education/elderly/executive

control/FRONTAL-LOBE/Lung/male/MIDLIFE BLOOD-PRESSURE/National

Heart/PERCEPTUAL

SPEED/performance/RISK-FACTORS/stroke/TEST-PERFORMANCE/WHITE-M

ATTER LESIONS/WORKING-MEMORY

Nguyen, H.T., Black, S.A., Ray, L.A., Espino, D.V. and Markides, K.S. (2002),

Predictors of decline in MMSE scores among older Mexican Americans. Journals of

Gerontology Series A-Biological Sciences and Medical Sciences, 57 (3),

M181-M185.

Abstract: Background. The purpose of this analysis was to examine the association of

sociodemographic variables and health-related conditions with 5-year declines in

cognitive function function among Mexican American elderly persons. Methods. The

cognitive function of 1759 participants was assessed by using the Mini- Mental State

Examination (MMSE) in 1993/1994 and again in 1998/1999. Cognitive decline was

defined by two sets of criteria: (1) a drop to 17 or below oil the MMSE at follow-up,

and (2) a decline of at least three points. the mean change in MMSE scores among

respondents who obtained scores at or abode the 5th percentile distribution at

baseline, Results. Cognitive decline was significantly associated with

sociodemographic variables including, age. education. marital status, and household

composition, In addition. respondents with reported vision impairment. stroke, and

diabetes were at increased risk for cognitive decline after controlling for multiple

potential confounders. Conclusion. Although age and education hake been reported

as the more salient predictors of cognitive deterioration, other sociodemographic and

several medical condition, including stroke and diabetes should be considered as part

of cognitive aging studies among Mexican American elders

Keywords: age/aging/ALZHEIMERS-DISEASE/ASSOCIATION/cognitive

decline/cognitive function/COGNITIVE

IMPAIRMENT/COMMUNITY/DEMENTIA/diabetes/DIABETES-MELLITUS/edu

cation/elderly/function/Mexican/Mexican American elders/Mexican

Americans/Mexican-Americans/MINI-MENTAL-STATE/MMSE/PERSPECTIVE/P

OPULATION/predictors/risk/SAMPLE/sociodemographic/stroke

Ostir, G.V., Raji, M.A., Ottenbacher, K.J., Markides, K.S. and Goodwin, J.S. (2003),

Cognitive function and incidence of stroke in older Mexican Americans. Journals of

Gerontology Series A-Biological Sciences and Medical Sciences, 58 (6), 531-535.

Abstract: Background. Given the high prevalence of cognitive impairment in older

Mexican Americans and limited longitudinal research examining cognitive function

in this ethnic group, we conducted a study examining whether cognitive impairment

is a risk factor for new onset of stroke among older Mexican Americans. Methods.

We performed a prospective cohort study of 2682 Mexican Americans aged 65 years

and older living in the southwestern United States. For subjects with no prior history

of stroke and who completed the Mini-Mental State Examination (MMSE) at

baseline, stroke incidence was assessed after 2, 5, and 7 years of follow-up. Results.

In Cox proportional regression models, MMSE score at baseline predicted risk of

incident stroke over a 7-year follow-up period. For the unadjusted model, subjects

with an MMSE score of 21 or higher were half as likely to report stroke at follow-up

(hazard ratio [HR], 0.49; 95% confidence interval [CI], 0.35-0.69: p 55

years), in poorer health (higher prevalence of cancer, stroke, hypertension), less

likely to smoke, and more likely to be single than the average patient visiting the

firms (P 0.05). In the traumatic group, depression was

associated with time since amputation but not with other variables. However, in the

surgical group, depression was associated with age, education level, marital status,

economic status, time since amputation, and whether the patient was treated with

prosthesis. Our data indicated that depression is a common clinical condition among

amputees. Clinicians may be advised to schedule periodic contacts with amputees

over long periods to identify those in need of psychiatric intervention

Keywords:

ADAPTATION/age/AMPUTEES/depression/diagnosis/DISABILITY/education/me

n/prevalence/STROKE

Launer, L.J., Jama, J.W., Ott, A., Breteler, M.M.B., Hoes, A.W. and Hofman, A. (1997),

Histamine H2 blocking drugs and the risk for Alzheimer's disease: The Rotterdam

study. Neurobiology of Aging, 18 (2), 257-259.

Abstract: We investigated the cross-sectional relation of the use of histamine H2

blocking drugs and the risk for AD in the population-based Rotterdam Study. AD

was clinically diagnosed according to DSM-IIIR and NINCDS-ADRDA criteria.

Data on medication used in the past week were obtained by having subjects show

vials of medications and were classified according to the Anatomical Therapeutic

Chemical (ATC) index. There were 7276 subjects with complete data, including 208

with AD and 378 H2 users (ATC code A0BA). Compared to the total cohort of

non-H2 users, the relative risk (estimated as the odds ratio) for AD among those

taking H2 blockers was 0.95 (95% confidence interval (CI) 0.52-1.75), after

controlling for age, education, sex, history of stroke, and use of benzodiazepines and

nonsteroidal antiinflammatory drugs. To address unmeasured confounding (by

(contra) indication), we compared the risk of AD in H2 users with a subset of

subjects using topical medications (ATC code D and S; n = 436). The adjusted OR in

this comparison was 1.24 (95% CI 0.52-2.98). These results do not support the

hypothesis that use of histamine H2 blocking drugs protect against AD. (C) 1997

Elsevier Science Inc

Keywords: AD/age/Alzheimer's

disease/DEMENTIA/DIAGNOSIS/education/epidemiology/histamine H2

blockers/inflammatory processes/MENTAL STATE/relative risk/stroke

Launer, L.J., Ross, G.W., Petrovitch, H., Masaki, K., Foley, D., White, L.R. and Havlik,

R.J. (2000), Midlife blood pressure and dementia: the Honolulu-Asia aging study.

Neurobiology of Aging, 21 (1), 49-55.

Abstract: We studied the association of mid-life blood pressure to late age dementia,

specifically Alzheimer's disease and vascular dementia. Data are from the cohort of

3703 Japanese-American men who were followed in the Honolulu Heart Program

(HHP,1965- l971), and subsequently re-examined in 1991 for dementia. We assessed

the risk (odds ratio (95% CI)) for dementia associated with categories of systolic

(SBP) and diastolic blood pressure (DBP), stratified by never/ever treatment with

anti- hypertensive medications, and adjusting for age, education, apolipoprotein

epsilon allele, smoking and alcohol intake. Among those never treated (57% sample),

the risk for dementia was OR 95%CI 3.8 (1.6-8.7) for DBP of 90-94 mmHg, and 4.3

(1.7- 10.8) for DBP of 95 mmHg and over compared to those with DBP of 80 to 89

mmHg. Compared to those with SEP of 110 to 139 mmHg, the risk for dementia was

4.8 (2.0-11.0) in those with SEP 160 mmHg and higher. Blood pressure was not

associated with the risk for dementia in treated men. These results were consistent

for Alzheimer's disease and vascular dementia. This study suggests elevated levels of

blood pressure in middle age can increase the risk for late age dementia in men never

treated with anti-hypertensive medication. (C) 2000 Published by Elsevier Science

Inc. All rights reserved

Keywords: age/aging/alcohol/Alzheimer's

disease/ALZHEIMERS-DISEASE/antihypertensive

medication/APOLIPOPROTEIN-E/ATHEROSCLEROSIS/blood

pressure/cardiovascular disease/COGNITIVE DECLINE/cohort/CORONARY

HEART-DISEASE/dementia/education/elderly/epidemiology/HYPERTENSION/JA

PANESE MEN/longitudinal study/men/middle age adults/odds ratio/risk/RISK-

FACTORS/smoking/STROKE/treatment/vascular/vascular dementia/VASCULAR

DEMENTIA

Lindenstrom, E., Boysen, G. and Nyboe, J. (1993), Risk-Factors for Stroke in

Copenhagen, Denmark .1. Basic Demographic and Social-Factors.

Neuroepidemiology, 12 (1), 37-42.

Abstract: The Copenhagen City Heart Study is a prospective study based on a randomly

selected sample of an urban population of, initially, 19,698 participants followed

since 1976. Risk factor analysis was based on the initial examination of 13,000

persons greater-than-or-equal-to 35 years old without previous stroke who responded

to the first invitation. In the period 1976-1988, 696 initial cases were identified: 584

strokes, 106 transient ischemic attacks and 6 retinal-artery occlusions. We used the

regression model of Cox based on a hierarchic system of risk factors that indicated

the way they influence each other. This method distinguishes independent risk

factors and estimates their causal influences on the risk of stroke. Among the basic

variables analyzed in this paper, significant effects were found for age, sex, length of

school education and income. There was a tendency for living alone to be a risk

factor as opposed to living with someone, while no influence could be demonstrated

for family history of stroke

Keywords: age/CEREBROVASCULAR

DISEASES/education/EPIDEMIOLOGY/family

history/GOTEBORG/ischemic/MEN/MYOCARDIAL-INFARCTION/RISK

FACTORS/school/stroke/SWEDEN/transient

Sitzer, M., Skutta, M., Siebler, M., Sitzer, G., Siegrist, J. and Steinmetz, H. (1998),

Modifiable stroke risk factors in volunteers willing to participate in a prevention

program. Neuroepidemiology, 17 (4), 179-187.

Abstract: The current trends in stroke incidence require continued efforts to improve

primary prevention. Compared to large-scale public health approaches, more limited

programs targeting volunteers may offer some advantages. We invited all 12,824

members of a health insurance company program who lived within 50 km from one

of two study sites to participate in a vascular screening program aimed at reducing

modifiable risk factors. 1,837 persons registered and participated(14.3%, mean age

53 +/- 12 years, 50% men). Using the Framingham stroke risk profile for persons

aged 55 years or above (n = 961, 52.3%), 97 stroke events can be predicted for this

age group within 10 years. The majority of these 97 events will occur in those with

mean resting blood pressure values greater than or equal to 140 mm Hg (systolic) or

greater than or equal to 90 mm Hg (diastolic; 420 persons, mean age 64 +/- 7 years,

60 expected events), or with a particularly high age- and sex-adjusted risk (288

persons, mean age 68 +/- 7 years, 60 expected events). Our pilot study provides an

estimate of the prevalence of modifiable vascular risk factors among volunteer

participants of a prevention program. Possible benefits of this approach will be

investigated in a second step using a randomized intervention

Keywords: age/atherosclerosis/blood pressure/cardiovascular diseases/cerebrovascular

diseases/CORONARY HEART-DISEASE/EDUCATION/health

education/HEALTH-PROGRAM/hypertension/HYPERTENSION/incidence/INTER

VENTION/MINNESOTA/NORTH-KARELIA PROJECT/PHYSICAL-

ACTIVITY/prevalence/primary prevention/PROBABILITY/program

evaluation/public health/risk factors/stroke/TRENDS

Casetta, I., Granieri, E., Gilli, G., Lauria, G., Tola, M.R. and Paolino, E. (1999),

Temporal trend and factors associated with delayed hospital admission of stroke

patients. Neuroepidemiology, 18 (5), 255-264.

Abstract: The effectiveness of stroke treatment depends on the time interval between

onset of symptoms and admission to hospital. The purpose of our investigation was

to assess, over a 10-year period, the mean delay in admission to hospital in stroke

patients to determine factors which might be associated with this delay, to define the

putative number of patients available for accrual in clinical trials, and to identify

strategies aimed at decreasing the time to admission. We collected data on all stroke

patients consecutively admitted to our clinic from 1986 to 1995. The following

variables were investigated: age, sex, educational and occupational level, home

accommodation, family and personal history of vascular disease or factors known to

affect the risk of vascular disease, and type and severity of stroke. The individual and

independent contribution of these variables was assessed by univariate and

multivariate analysis. The accurate time of stroke onset was established for 760

patients. Of these, 24.7% were admitted within 1 h from the onset of symptoms, 41%

within 2 h, 54% within 4 h and 72.5% within 12 h. The mean delay was 21 +/- 2 h

(SE) and the median was 3.5 h. Acute onset of neurological deficits, stroke severity

and family history of cerebrovascular disease were associated with earlier

presentation. According to the current guidelines for thrombolytic therapy, only 16%

of the patients could have been included in a clinical trial. This study suggests that

despite a relatively short time to hospital admission in most patients and an altered

help-seeking behavior over time, many stroke patients did not present early enough

to be recruited for clinical trials or to benefit from new treatments. The majority of

patients with timely presentation were not eligible for acute treatment, or were

subjects with severe stroke for whom caution is advised before initiating

thrombolytic therapy. It has been suggested that the patient's indecision to seek

medical help is the most important reason for a delayed hospital admission of stroke

patients. These results underscore the importance of interventions aimed at reducing

the delay in stroke treatment induced by patients who are unaware of the decisive

role of the time of treatment induction. The finding that earliest admissions for stroke

comprised patients with a previous history of cerebrovascular disease suggests that

an education campaign might highlight the importance of an early admission

Keywords: ACUTE MYOCARDIAL-INFARCTION/ARRIVAL TIME/clinical

trials/COMMUNITY/delay

admission/epidemiology/hospitalization/MULTICENTER/PROJECT/stroke/stroke

treatment/THERAPY

Abel, G.A., Chen, X., Boden-Albala, B. and Sacco, R.L. (1999), Social readjustment

and ischemic stroke: Lack of an association in a multiethnic population.

Neuroepidemiology, 18 (1), 22-31.

Abstract: Clinical experience has suggested that stressful life events and ongoing

stressful illness, collectively termed 'social readjustment', may precipitate stroke. We

investigated the association between a simple in-office evaluation of such stressors

and stroke in an urban, multiethnic study population. Cases were patients from the

Northern Manhattan Stroke Study with first ischemic stroke; controls were derived

through random digit dialing with n:m matching for age, gender, and race-ethnicity.

Social readjustment was measured through in- person interview using Amster and

Krauss' Geriatric Social Readjustment Rating Scale (GSRRS), a one-time, 35-item,

checklist type weighted questionnaire of stressful life events occurring in the

previous 6 months. Conditional logistic regression was used to analyze the GSRRS

and its quartiles as well as stressful events subgroups, adjusting for education,

hypertension, cardiac disease, diabetes, and number of weekly visits as a measure of

socialization. Six hundred and fifty- five cases of ischemic stroke and 1,087 controls

were utilized. The mean age of the cases was 69.8 years, with 55.4% women, 51.0%

Hispanics, 28.4% blacks, and 19.1% whites. GSRRS scores ranged from 0 to 812;

the mean score was 205.5 for the cases and 206.2 for the controls. The analysis

showed no association between stroke and a 20-point increase on the GSRRS (OR =

1.01,95% CI = 0.99-1.01). There was also no effect for the second, third or highest

versus lowest quartile. No association was found in age, gender or race-ethnic

subgroups, or when analyzing negative events, severely threatening events, or

ongoing stressful illnesses separately. While this study does not preclude social

readjustment as a stroke risk factor, it suggests that the one-time assessment often

done in the medical office setting has little relevance for stroke prevention planning

Keywords: age/blacks/CARDIOVASCULAR REACTIVITY/cerebrovascular

disease/CORONARY-ARTERY

DISEASE/education/epidemiology/gender/HEART-DISEASE/Hispanics/hypertensi

on/ischemic/life events/LIFE EVENTS/MIDDLE-AGED

MEN/MYOCARDIAL-INFARCTION/PSYCHOLOGICAL

STRESS/RISK-FACTORS/social readjustment/stress/stroke/stroke

prevention/SUSCEPTIBILITY/whites/women

Goldstein, L.B., Edwards, M.G. and Wood, D.P. (2001), Delay between stroke onset

and emergency department evaluation. Neuroepidemiology, 20 (3), 196-200.

Abstract: Background. Public educational programs have been developed to reduce

delays between the onset of ischemic stroke symptoms and emergency department

evaluation. An increase in the proportion of patients presenting soon after stroke

would reflect the effectiveness of these efforts. Methods. All patients (n = 506) with

ischemic stroke admitted to an academic medical center located within the 'Stroke

Belt' of the USA were prospectively identified over 2 years (1998-1999).

Demographics, stroke characteristics and time from symptom onset to arrival in the

emergency department were recorded. Results: A higher proportion of ischemic

stroke patients presented within 3 h of symptoms in 1998 than in 1999 (18% of 234

vs. 8% of 272, p = 0.0001). Those with less severe strokes (Canadian Neurological

Scale score; Spearman r = 0.18, p 160 mm Hg (RR = 1.80, CI = 9.94 to 3.44) and alcohol intake exceeding 160 grams

per week (RR = 1.86, CI = 0.79 to 4.38) were weakly related. Conclusions: Our

results suggest that dementia significantly increases the risk of long- term stroke

recurrence, with additional independent contributions by cardiac disease and sex.

Cognitive impairment may be a surrogate marker for multiple vascular risk factors

and larger infarct volume that may serve to increase the risk of recurrence.

Alternatively, less aggressive medical management of stroke patients with cognitive

impairment or noncompliance of such patients with medical therapy may be bases

for an increased rate of stroke recurrence

Keywords: acute/age/ALCOHOL-CONSUMPTION/blood

pressure/BLOOD-PRESSURE/CEREBRAL INFARCTION/cognitive

impairment/COMMUNITY/DATA-BANK/dementia/education/FOLLOW-UP/HOS

PITALIZED COHORT/ischemic/MORTALITY/risk factors/stroke/stroke

patients/SURVIVAL/TRANSIENT ISCHEMIC ATTACKS/women

Qureshi, A.I., Giles, W.H., Croft, J.B. and Bliwise, D.L. (1997), Habitual sleep patterns

and risk for stroke and coronary heart disease: A 10-year follow-up from NHANES I.

Neurology, 48 (4), 904-911.

Abstract: Background: Habitual sleep patterns may independently affect morbidity and

mortality. However, the effect of habitual sleep patterns on the risk for stroke and

coronary heart disease is unclear. Methods: We evaluated the association between

sleep duration and daytime somnolence (often or almost always taking daytime naps)

with the incidence of stroke and coronary heart disease in a national cohort of 7,844

adults who participated in the First National Health and Nutrition Examination

Survey Epidemiologic Follow-up Study. Cox proportional hazards analyses were

used to examine these relationships during the 10-year follow-up. Results: After

adjusting for differences in age, race, gender, education, cigarette smoking, body

mass index, serum cholesterol, systolic blood pressure, and diabetes mellitus, the risk

for stroke was increased in persons who reported sleeping greater than 8 hours at

night compared with persons who slept between 6 and 8 hours (relative risk [RR] =

1.5, 95% confidence interval [CI] = 1.1 to 2.0). Daytime somnolence was also

associated with stroke incidence (RR = 1.4; 95% CI = 1.1 to 1.8). Persons who

reported both greater than 8 hours of sleep and daytime somnolence were at the

greatest risk for stroke (RR = 1.9, 95% CI = 1.2 to 3.1). Similar results were also

found for coronary heart disease, although the results did not reach statistical

significance in the multivariate adjusted model. Conclusions: Habitual sleep patterns

have significant effects on the risk for stroke

Keywords: age/ALAMEDA COUNTY/APNEA SYNDROME/blood pressure/coronary

heart disease/DAYTIME SLEEPINESS/diabetes/diabetes

mellitus/DISORDERS/DISTURBANCES/education/gender/HYPERTENSION/incid

ence/INFARCTION/INTRACRANIAL

HEMODYNAMICS/morbidity/MORTALITY/POPULATION/race/relative

risk/smoking/stroke

Chandra, V., Ganguli, M., Pandav, R., Johnston, J., Belle, S. and DeKosky, S.T. (1998),

Prevalence of Alzheimer's disease and other dementias in rural India - The Indo-US

study. Neurology, 51 (4), 1000-1008.

Abstract: Objective: To determine the prevalence of AD and other dementias in a rural

elderly Hindi-speaking population in Ballabgarh in northern India. Design: The

authors performed a community survey of a cohort of 5,126 individuals aged 55

years and older, 73.3% of whom were illiterate. Hindi cognitive and functional

screening instruments, developed for and validated in this population, were used to

screen the cohort. A total of 536 subjects (10.5%) who met operational criteria for

cognitive and functional impairment and a random sample of 270 unimpaired control

subjects (5.3%) underwent standardized clinical assessment for dementia using the

Diagnostic and Statistical Manual of Mental Disorders-fourth edition diagnostic

criteria, the Clinical Dementia Rating Scale (CDR), and National Institute of

Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and

Related Disorders Association (NINCDSADRDA) criteria for probable and possible

AD. Results: We found an overall prevalence rate of 0.84% (95% CI, 0.61 to 1.13)

for all dementias with a CDR score of at least 0.5 in the population aged 55 years and

older, and an overall prevalence rate of 1.36% (95% CI, 0.96 to 1.88) in the

population aged 65 years and older. The overall prevalence rate for AD was 0.62%

(95% CI, 0.43 to 0.88) in the population aged 55+ and 1.07% (95% CI, 0.72 to 1.53)

in the population aged 65+. Greater age was associated significantly with higher

prevalence of both AD and all dementias, but neither gender nor Literacy was

associated with prevalence. Conclusions: In this population, the prevalence of AD

and other dementias was low, increased with age, and was not associated with gender

or literacy. Possible explanations include low overall life expectancy, short survival

with the disease, and low age-specific incidence potentially due to differences in the

underlying distribution of risk and protective factors compared with populations with

higher prevalence

Keywords: AD/AGE/Alzheimer's

disease/COMMUNITY/dementia/DIAGNOSIS/EDUCATION/elderly/ELDERLY

POPULATION/GENDER/incidence/literacy/MOVIES

PROJECT/prevalence/SENSITIVITY/SPECIFICITY

Liu, C.K., Lai, C.L., Tai, C.T., Lin, R.T., Yen, Y.Y. and Howng, S.L. (1998), Incidence

and subtypes of dementia in southern Taiwan - Impact of socio-demographic factors.

Neurology, 50 (6), 1572-1579.

Abstract: Objective: To determine the incidence rate (IR) and subtypes of dementia in

southern Taiwan. Methods: From a cohort of 2,915 community inhabitants aged 65

years and over, 2,507 and 2,175 subjects participated in the first-and second-year

follow-up surveys, respectively. A tare-phase study used the Mini-Mental State

Examination in phase I and the Consortium to Establish a Registry of Alzheimer's

Disease (CERAD) neuropsychological battery and the neurobehavioral examination

in phase II. We applied International Classification of Diseases (ICD)-10NA criteria

for dementia, National Institute of Neurological and Communication Disorders and

Stroke-Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA)

guidelines for Alzheimer's disease (AD), and National Institute of Neurological

Disorders and Stroke-Association Internationale pour la Recherche et l'Enseignement

en Neurosciences (NINDS- AIREN) criteria for vascular dementia (VaD). Results:

The annual IR for total dementia was 1.28%, which increased with age from 0.77%

for 65- to 74-year-olds to 6.19% for persons aged 85 years or older. AD (25 cases,

41.7%, IR = 0.54%) was the most common cause of dementia, followed by VaD (19

cases, 31.7%, IR = 0.41%) and mixed dementia (9 cases, 15.0%). After adjusting for

sex, increasing age was significantly associated with total dementia and AD (p 20

pg/mL, women with AD were four to six times more likely to have levels 2,500 adults, were asked to report up to three risk factors and warning

signs-for stroke. Predictors of inadequate knowledge (defined as not reporting any

correct responses) of stroke risk factors and warning signs were identified using

multiple logistic regression. Results: Eighty percent reported at least one correct risk

factor for stroke, and 28% reported three. The most frequently mentioned risk factors

were hypertension (32%), smoking (29%), and physical inactivity (26%). Sixty-nine

percent reported at least one correct warning sign of stroke, but only 14% reported

three. The most frequently mentioned warning signs were sudden weakness or

numbness (46%) and sudden slurred speech, disorientation, or difficulty

understanding (30%). Predictors for inadequate knowledge of both stroke risk factors

and warning signs were similar and included age, race, sex, education, hypertension,

and smoking. Conclusions: Knowledge of stroke risk factors and warning signs was

moderate at best. One in five respondents was not aware of any stroke risk factors,

and almost one in three was not aware of any stroke warning signs. Stroke

knowledge was poorest among groups that have the highest risk of stroke

Keywords: age/AWARENESS/EDUCATION/hypertension/ISCHEMIC

STROKE/knowledge/NEUROLOGY/PERCEPTIONS/POPULATION/PREVENTI

ON/race/risk/risk factors/smoking/stroke/survey/SYMPTOMS/warning signs

Hirono, N., Hashimoto, M., Yasuda, M., Ishii, K., Sakamoto, S., Kazui, H. and Mori, E.

(2002), The effect of APOE epsilon 4 allele on cerebral glucose metabolism in AD is

a function of age at onset. Neurology, 58 (5), 743-750.

Abstract: Background: Although the APOE epsilon4 allele is a well-known risk factor

for developing AD, the impact of the epsilon4 allele on clinical manifestations in

patients with AD is still controversial. One possible reason for this controversy is

that previous studies did not consider the effect of patient age at symptom onset.

Objective: To investigate the possible impact of patient age at onset of AD on the

effect of APOE genotype on regional cerebral glucose metabolism (rCMRglc).

Methods: The authors compared rCMRglc between probable AD patients (based on

criteria of the National Institute of Neurologic Disease and Stroke/AD and Related

Disorders Association) with APOE epsilon4/4 and APOE epsilon3/3 alleles in

early-onset (less than or equal to65 years old) and late-onset (>65 years old) groups.

In each group, the patients with APOE epsilon4/4 and APOE epsilon3/3 alleles were

comparable for age at onset, age at examination, sex, disease duration, education

level, and severity of dementia. Results: In the early-onset group, the patients with

the APOE epsilon4/4 genotype showed a significant decrease of rCMRglc in the

medial temporal lobe and a significant increase of rCMRglc in the inferior parietal

and posterior temporal cortices as compared with those patients with the APOE

epsilon3/3 genotype. In the late-onset group, there were no significant differences in

the rCMRglc pattern between the patients with APOE epsilon4/4 and APOE

epsilon3/3 alleles. Conclusions: The current findings indicate that the impact of the

APOE epsilon4 genotype on cerebral glucose metabolism of patients with AD may

be a function of age at symptom onset

Keywords: AD/age/ALZHEIMERS-DISEASE/APOE/APOLIPOPROTEIN-E

POLYMORPHISM/CLINICAL-DIAGNOSIS/COGNITIVE

DECLINE/DEMENTIA/E GENOTYPE/E TYPE-4

ALLELE/education/function/impact/LEWY

BODIES/NEUROLOGY/PATTERN/risk/risk factor/severity/TEMPORAL-LOBE

ATROPHY

Johnston, S.C., Fayad, P.B., Gorelick, P.B., Hanley, D.F., Shwayder, P., van Husen, D.

and Weiskopf, T. (2003), Prevalence and knowledge of transient ischemic attack

among US adults. Neurology, 60 (9), 1429-1434.

Abstract: Background: Little information is available about public knowledge of TIA

and prevalence of a TIA diagnosis. Methods: The National Stroke Association

sponsored a telephone survey by single-stage random-digit dialing of

noninstitutionalized US residents greater than or equal to18 years old, which was

conducted in 1999. Demographic characteristics of participants were compared to the

US population to produce weights for projections. Independent predictors of

knowledge and diagnosis of TIA were determined by including all demographic

characteristics in logistic regression models. Results: Among 10,112 participants,

2.3% reported having been told by a physician that they had a TIA. Older age, lower

income, and fewer years of education were independently associated with a diagnosis

of TIA. Of those with TIA, only 64% saw a physician within 24 hours of the event.

A physician diagnosis of stroke was reported by 2.3% of participants, of whom 19%

recalled having had a TIA before the stroke. An additional 3.2% of participants

recalled symptoms consistent with TIA but did not seek medical attention. Only

8.2% correctly related the definition of TIA and 8.6% could identify a typical

symptom. Men, nonwhites, and those with lower income and fewer years of

education were less likely to be knowledgeable about TIA. Conclusions: An

estimated 4.9 million people in the US report a diagnosis of TIA, and many more

recall symptoms consistent with TIA but do not seek medical attention. Reducing

stroke risk after TIA could have substantial impact on public health but will require

public education about the importance of having stroke symptoms evaluated, even if

they resolve

Keywords:

age/CEREBROVASCULAR-DISEASE/COMMUNITY/DIAGNOSIS/DISPARITIE

S/education/EMERGENCY/HEALTH/ischemic/knowledge/physician/POPULATIO

N/predictors/prevalence/PROGNOSIS/public

health/RISK-FACTORS/stroke/STROKE SYMPTOMS/survey/symptoms/transient

Kidwell, C.S., Shephard, T., Tonn, S., Lawyer, B., Murdock, M., Koroshetz, W.,

Alberts, M., Hademenos, G.J. and Saver, J.L. (2003), Establishment of primary

stroke centers - A survey of physician attitudes and hospital resources. Neurology, 60

(9), 1452-1456.

Abstract: Objectives: To survey US physicians involved in acute stroke care to

determine the proportion of hospitals that currently meet the recommended Brain

Attack Coalition (BAC) criteria for Primary Stroke Centers (PSC) and obtain

opinions regarding the value of stroke centers. Methods: A survey regarding the

BAC guidelines for the establishment of stroke centers was mailed to 3,245 US

neurologists, neurosurgeons, and emergency physicians. Results: A total of 1,032

responses were received. Seventy-nine percent (range by specialty 58 to 98%) of

respondents believed there was a need for stroke centers. If formal stroke center

designation were established, 81% (range 72 to 90%) would like their hospital to

become a PSC. Although 77% of respondents believed that their hospital currently

met recommended criteria for a PSC, only 7% actually meet all recommended

elements. However, 44% of hospitals already provide most acute stroke services. The

BAC criteria most frequently lacking were continuing medical education for

professional stroke center staff, stroke training for emergency department staff,

formal establishment of a stroke unit, and designation of a stroke center director.

Conclusions: The majority of emergency medicine and neuroscience physician

respondents involved in acute stroke care support the designation of primary stroke

centers. Although respondents globally overestimated the extent to which their

facilities currently meet BAC recommended criteria for PSC, detailed responses

suggested that over 40% of hospitals possess substantial existing acute stroke care

resources and are poised to function as PSC with modest additional administrative

and financial commitment

Keywords: acute/education/emergency medicine/function/guidelines/ISCHEMIC

STROKE/medical

education/medicine/physician/PLASMINOGEN-ACTIVATOR/stroke/stroke

unit/survey/training

Burridge, J.H. (2001), Does the drop-foot stimulator improve walking in hemiplegia?

Neuromodulation, 4 (2), 77-83.

Abstract: This article presents an overview of the research and clinical experience of the

use of Functional Electrical Stimulation (FES) for the treatment of drop-foot in

hemiplegia. The article reviews the evidence from the literature over the past 10

years to answer the question posed in the title. A description and explanation of

drop-foot stimulation is followed by a review and discussion of the literature based

on a search of the databases Medline, Cinhal, and Embase from 1990 to 2000, using

the key words: stimulation and hemiplegia and (common and peroneal) or (functional

and electrical) and (walking or gait) and drop* foot). Nine papers were reviewed,

only one of which was a randomized controlled trial. Quality of research is criticized

and the need for rigorous clinical studies, technological development, and

collaboration between clinicians and engineers is argued. The drop foot stimulator

does improve walking in hemiplegia, but factors such as patient and clinician

education, reliability of equipment, and selection of patients, are important

Keywords: drop-foot/education/functional electrical

stimulation/hemiplegia/PERONEAL NERVE/randomized controlled

trial/REFLEX/SPEED/STROKE/treatment

Sano, M., Haggerty, R., Kugler, S., Martin, B., Prohovnik, I., HurletJensen, A., Piomelli,

S. and DeVivo, D. (1996), Neuropsychological consequences of sickle cell disease.

Neuropsychiatry Neuropsychology and Behavioral Neurology, 9 (4), 242-247.

Abstract: In this study we assessed neuropsychological abilities in patients with sickle

cell disease (SCD) in the absence of clinically apparent stroke. Eighteen adult

patients with SCD with no history of stroke or chronic transfusion were compared

with a group of 18 unaffected ''nearest-relatives'' who were comparable in age,

education, and gender. Participants were assessed with a battery of tests measuring

memory, attention, language, motor speed, abstract reasoning, executive function,

and visuospatial abilities. Medical and neurological evaluations, magnetic resonance

(MR) imaging, and regional cerebral blood flow (rCBF) studies were conducted. The

SCD group demonstrated poorer performance on timed tests of attention and

construction. Five SCD cases and three of the comparison group had noncortical

abnormalities on MR imaging, and rCBF studies revealed hypofrontal flow patterns

in the SCD cases. However, cognitive deficits in the SCD group were evident even

among individuals without MR imaging or rCBF abnormalities, These results

suggest that subtle neuropsychological deficits can be associated with SCD in the

absence of stroke. Prospective studies are needed to assess etiologic factors

Keywords: age/ANEMIA/CEREBRAL

BLOOD-FLOW/CHILDREN/education/gender/magnetic resonance

imaging/memory/neuropsychological consequences/performance/regional cerebral

blood flow/sickle cell disease/STROKE

Ricker, J.H., Axelrod, B.N. and Houtler, B.D. (1996), Clinical validation of the oral trail

making test. Neuropsychiatry Neuropsychology and Behavioral Neurology, 9 (1),

50-53.

Abstract: The oral paradigm for the Trail Making Test (TMT)-which, unlike the

traditional written administration, has no visual or graphomotor component-was

investigated in 85 stroke patients with recent ( 75% of their patients, but the choice of such

routinely applied instruments varied between centres. The application of

measurement technology was restricted, with video and goniometry being used most

frequently. The main barriers to more frequent use of assessment toots were

perceived to be a lack of resources, information, and training. The (albeit limited)

results from this survey suggest that the assessment of motor deficits in neurological

rehabilitation is currently mostly qualitative and lacks standardisation. More

resources and education are required to support a more routine application of

assessment tools and to integrate measurement technology further in neurological

rehabilitation to assist in the process of quantification of outcomes

Keywords: ASHWORTH/assessment/barriers/education/measurement

technology/MEDICAL/motor deficits/neurological rehabilitation/outcome

assessment/questionnaires/rehabilitation/RELIABILITY/SCALE/SPASTICITY/stan

dardisation/STROKE/survey/training

[Anon]. (2000), Program requirements for residency/fellowship education in

neuroendovascular surgery/interventional neuroradiology: Special report on graduate

medical education. Neurosurgery, 46 (6), 1486-1493.

Abstract: Neuroendovascular surgery/interventional neuroradiology is a relatively new

subspecialty that has been evolving since the mid-1970s. During the last 2 decades,

significant advances have been made in this field of minimally invasive therapy for

the treatment of intracranial cerebral aneurysms; Acute stroke therapy intervention;

Cerebral arteriovenous malformations; Carotid-cavernous sinus fistulae; Head, neck,

and spinal cord vascular lesions; And other complex cerebrovascular diseases.

Advanced postresidency fellowship programs have now been established in north

america, europe, and japan, specifically for training in this new subspecialty. During

a period of 14 years, from 1986 to the present, an ad hoc committee comprising

senior executive committee members of the american society of interventional and

therapeutic neuroradiology, the joint section of cerebrovascular neurosurgery, and

the american society of neuroradiology met to establish general guidelines that were

mutually agreeable to both societies for training physicians in this field. These

training standard guidelines were unanimously endorsed by the executive committee

of the joint section of cerebrovascular neurosurgery in april 1999, by the executive

committee of the american society of interventional and therapeutic neuroradiology

and the american society of neuroradiology in may 1999, and by the executive

council of the american association of neurological surgeons and the congress of

neurological surgeons in june 1999. The guidelines for residency/fellowship

education have now been endorsed by the parent organizations of both the

interventional and diagnostic neuroradiology communities, as well as both senior

organizations representing neurosurgery in north america. These guidelines for

training should be used as a reference and guide by any institution establishing a

training program in neuroendovascular surgery/interventional neuroradiology

Keywords: aneurysms/CELLULOSE-ACETATE POLYMER/CEREBRAL

ARTERIOVENOUS-MALFORMATIONS/cerebrovascular diseases/DIRECT

THROMBOSIS/diseases/education/ENDOVASCULAR

TREATMENT/FIBRINOLYTIC THERAPY/guidelines/interventional

neuroradiology/medical/medical education/MICROBALLOON DEVICE/minimally

invasive therapy/neuroendovascular surgery/neurosurgery/OCCLUSIVE

DISEASE/organizations/PRELIMINARY CLINICAL- EXPERIENCE/residency

and fellowship education/stroke/THROMBOLYTIC THERAPY/training/training

standards and guidelines/TRANSLUMINAL ANGIOPLASTY/treatment/vascular

Wang, M.Y., Lavine, S.D., Soukiasian, H., Tabrizi, R., Levy, M.L. and Giannotta, S.L.

(2001), Treating stroke as a medical emergency: A survey of resident physicians'

attitudes toward "brain attack" and carotid endarterectomy. Neurosurgery, 48 (5),

1109-1115.

Abstract: OBJECTIVE: A major impetus of the "brain attack" campaign is the early

recognition and treatment of acute stroke. Critical to this goal is the education of

physicians during their residency training. METHODS: Resident physicians in Los

Angeles who were in family practice (18%), internal medicine (51%), emergency

medicine (20%), and neurology (11%) and had already completed their first year of

training responded to a questionnaire on stroke and the treatment of carotid stenosis.

RESULTS: Of the 266 respondents, 76% had heard of the "brain attack" campaign,

22% did not identify dysarthria as a symptom of stroke, and 21% did not identify

obtundation as a presentation of stroke. Twenty-eight percent chose not to use tissue

plasminogen activator for acute ischemic stroke, and 60% recognized the need to

begin treatment within 3 hours. More than 90% of respondents were able to identify

correct screening tests for patients with suspected carotid stenosis. However, 56%

responded that they would not advocate operating on patients with asymptomatic

severe stenosis (>70%) until stenosis reached a critical value (85%). Conversely,

45% would recommend operative treatment for symptomatic patients who had less

than 60% stenosis. Sixty-eight percent would refer patients to vascular surgeons,

14% to neurosurgeons, and 17% to both for carotid endarterectomy. CONCLUSION:

Recognition of stroke as a medical emergency is improving. However, significant

progress can still be made in the recognition of stroke symptoms. Primary care and

neurology residents remain skeptical about carotid endarterectomy for asymptomatic

patients, whereas there is enthusiasm for treating stroke survivors. Education by

members of the surgical community could promote the aggressive treatment of

asymptomatic patients to prevent stroke

Keywords: ACCURACY/acute/ACUTE ISCHEMIC STROKE/acute stroke/ARTERY

STENOSIS/brain attack/carotid/carotid endarterectomy/carotid

stenosis/community/DISEASE/EDUCATION/emergency

medicine/endarterectomy/family practice/ischemic/ischemic

stroke/medical/medicine/neurology/OUTCOMES/plasminogen

activator/PLASMINOGEN-ACTIVATOR/PROUROKINASE/questionnaire/RAND

OMIZED CONTROLLED

TRIAL/RATIONALE/screening/stroke/survey/symptoms/tissue plasminogen

activator/training/treatment/vascular

Chia, S.E. and Teo, K.J. (2001), Postural stability and neurobehavioural effects of heat

exhaustion among adult men. Neurotoxicology and Teratology, 23 (6), 659-664.

Abstract: The medical complications of heat disorders, including haematological,

cardiovascular and renal damage, have been well documented. However, very little

has been written on its neurological complications. The objective of this study was to

assess the effects of heat exhaustion on postural stability and neurobehavioral

functions of men. The study is prospective in design and spans a 3-year period. All

soldiers who were diagnosed to have heat exhaustion (cases) from I March 1998 to

31 August 1998 were included in the study. For each case, a healthy soldier (matched

for age, ethnicity, years of education and military vocation) was recruited to serve as

control. Each subject had a neurobehavioral assessment by using the Swedish

Performance Evaluation System (SPES), a computerized test battery. The postural

stability of the subjects was assessed using a computerized postural sway system.

Findings for 37 heat exhaustion cases and 37 controls revealed that cases had a

significantly higher prevalence of neurasthenia symptoms compared to the controls.

There were significant (small) differences between the cases and controls in the

neurobehavioral tests of choice reaction time, digit span and some parts of colour

word stress and logical series measures, Postural stability in the cases was

significantly poorer when in the "eyes-closed" condition, compared with the controls.

Men with heat exhaustion, studied 2 weeks after the acute episode, had significantly

more symptoms of neurasthenia, poorer performance in short-term memory and

slower reaction time. The cases (as a group) had significantly poorer postural

stability. (C) 2001 Elsevier Science Inc. All rights reserved

Keywords:

acute/adult/age/assessment/case-control/education/ENGLAND/ethnicity/heat

exhaustion/memory/men/neurobehavioral/NEUROPSYCHOLOGICAL

SEQUELAE/performance/postural

stability/prevalence/soldiers/stress/STROKE/symptoms/WORKERS

Shea, S., Misra, D., Ehrlich, M.H., Field, L. and Francis, C.K. (1992), Predisposing

Factors for Severe, Uncontrolled Hypertension in An Inner-City Minority Population.

New England Journal of Medicine, 327 (11), 776-781.

Abstract: Background. Hypertensive emergency and urgent hypertension are the most

severe forms of uncontrolled hypertension and are now seen predominantly in poor,

minority populations. We studied the characteristics of the medical care received by

patients with these conditions in order to identify risk factors for severe, uncontrolled

hypertension. Methods. Using a case- control study design, we interviewed 93

patients with severe, uncontrolled hypertension who presented in the hospital

emergency room and 114 control patients with hypertension; both groups were seen

at two New York City hospitals from 1989 through 1991. All the patients were black

or Hispanic. Multiple logistic-regression models were used to adjust for age, sex,

race or ethnic background, education, smoking status, alcohol- related problems, and

use of illicit drugs during the previous year. Results. After additional adjustment for

lack of health insurance, severe, uncontrolled hypertension was found to be more

common among patients who had no primary care physician (adjusted odds ratio, 3.5;

95 percent confidence interval, 1.6 to 7.7) and among those who did not comply with

treatment for their hypertension (adjusted odds ratio, 1.9; 95 percent confidence

interval, 1.4 to 2.5). Lack of health insurance was marginally associated with severe,

uncontrolled hypertension (adjusted odds ratio, 1.9; 95 percent confidence interval,

0.8 to 4.6) after adjustment for lack of a primary care physician and noncompliance

with antihypertensive treatment. Patients without a primary care physician and

without health insurance were more likely to have their blood pressure checked and

receive prescriptions for blood-pressure medications in emergency rooms than in

physicians' offices or clinics. Conclusions. Characteristics of both the health care

system and patients' behavior are associated with severe, uncontrolled hypertension.

Improving access to primary care physicians, through health insurance or other

means, may be an effective strategy for improving control of hypertension in

disadvantaged minority populations

Keywords: age/alcohol/blood

pressure/CARE/CONSEQUENCES/COST/education/EXPERIENCE/health/HEART

-DISEASE/hypertension/MEDICAL/ORAL CLONIDINE/PUBLIC HOSPITAL

EMERGENCY/race/risk factors/smoking/STROKE/treatment/URGENCIES

Ridker, P.M., Hennekens, C.H., Buring, J.E. and Rifai, N. (2000), C-reactive protein

and other markers of inflammation in the prediction of cardiovascular disease in

women. New England Journal of Medicine , 342 (12), 836-843.

Abstract: Background: Since inflammation is believed to have a role in the pathogenesis

of cardiovascular events, measurement of markers of inflammation has been

proposed as a method to improve the prediction of the risk of these events. Methods:

We conducted a prospective, nested case-control study among 28,263 apparently

healthy postmenopausal women over a mean follow-up period of three years to

assess the risk of cardiovascular events associated with base-line levels of markers of

inflammation. The markers included high-sensitivity C-reactive protein (hs-CRP),

serum amyloid A, interleukin-6, and soluble intercellular adhesion molecule type 1

(sICAM-1). We also studied homocysteine and several lipid and lipoprotein

measurements. Cardiovascular events were defined as death from coronary heart

disease, nonfatal myocardial infarction or stroke, or the need for

coronary-revascularization procedures. Results: Of the 12 markers measured,

hs-CRP was the strongest univariate predictor of the risk of cardiovascular events;

the relative risk of events for women in the highest as compared with the lowest

quartile for this marker was 4.4 (95 percent confidence interval, 2.2 to 8.9). Other

markers significantly associated with the risk of cardiovascular events were serum

amyloid A (relative risk for the highest as compared with the lowest quartile, 3.0),

sICAM-1 (2.6), interleukin-6 (2.2), homocysteine (2.0), total cholesterol (2.4),

low-density lipoprotein (LDL) cholesterol (2.4), apolipoprotein B-100 (3.4),

high-density lipoprotein (HDL) cholesterol (0.3), and the ratio of total cholesterol to

HDL cholesterol (3.4). Prediction models that incorporated markers of inflammation

in addition to lipids were significantly better at predicting risk than models based on

lipid levels alone (P= 160/95

mm Hg on >= 2 occasions within 3 months or received antihypertensives, High

proportions of cases (82%) and controls (85%) were on treatment. There was a

continuous relationship between the risk of stroke and levels of BP control. Of 73

cases and 135 controls who were hypertensive and responded to the postal

questionnaire, 56 and 83%, respectively, were aware of hypertension (P 65 yeats were less

likely to recognize symptoms (p = 0.001) and to consider stroke as an emergency.

Respondents with ai? affected relative (50.5%) tend to locate more exactly the

disease at the brain (p = 0.05) and to arrive earlier to the emergency, department (p =

0.045), than those with non-affected relatives. Conclusions. Less than a quarter of

our population have a good knowledge of the disease. Stroke is considered an

emergency unlike TIA. The information about stroke is theoretically associated with

early presentation to the emergency department. These results permit a redesign of

the questionnaire to conduct a second phase of the study and generalize them for the

Spanish population [REV NEUROL 1998; 27: 943-7]

Keywords: ACUTE ISCHEMIC STROKE/health

education/ischemic/KNOWLEDGE/RISK/risk factors/risk factors

knowledge/stroke/symptoms/warning signs

Egido, J.A. and Carneado, J. (1999), The stroke chain: From the onset of symptoms to

the emergency services. Revista de Neurologia, 29 (7), 617-622.

Abstract: Introduction. The treatment of stroke by thrombolysis or other methods

(neuroprotection, basic care, etc.) is more effective the sooner it is begun. The main

reasons for patients not receiving treatment during the acute phase of their illness are

slowness in reaching hospital and delay in emergency assessment once they arrive

there. It is necessary to identify the factors involved in these delays so as to modify

what can be improved and establish guidelines. Development. In the chain of events

leading to arrival in hospital there are independent factors related to the social and

health characteristics of the patients, their attitudes to illness, characteristics of the

stroke itself and of the health district. Analysis of the system for response to stroke

patients is extremely important before investing in measures to be applied during the

acute phase. This analysis should be based on the different stages at which delays

may occur. Outside the hospital, the systems to be recognized are those of the patient

and his family, contact with prehospital care teams and transport to the hospital of

reference. Hospital care involves making contact on arrival at the Emergency

Department, and the response of the neurologist or stroke team who give the initial

treatment. Conclusions. Programmes of education and improvement in the

organization of the different protagonists at the various stages reduce the time lost by

delay [REV NEUROL 1999; 29: 617-22]

Keywords: ACCESS/ACCURACY/ACUTE ISCHEMIC STROKE/DELAY/emergency

medical services/HOSPITAL

ADMISSION/IMPROVEMENT/MANAGEMENT/stroke/stroke chain/stroke

management/THERAPY/THROMBOLYSIS/TIME

Failde, I., Balkau, B., Costagliola, D., Moutet, J.P., Gabriel, J.M., Donnet, J.P. and

Eschwege, E. (1996), Arterial hypertension in the adult population of Guadeloupe,

and associated factors in subjects of African origin. Revue D Epidemiologie et de

Sante Publique, 44 (5), 417-426.

Abstract: This study was designed to estimate the prevalence of hypertension in

Guadeloupe, the French West Indies, and to evaluate the risk factors associated with

hypertension in the largest ethnic group, that of African origin. Households were

randomly selected using a two-stage systematic sample of districts and then of

houses; all adults aged 18 years in the household were included. In total, 1 043 men

and women were studied. Blood pressure, plasma glucose concentrations and

gamma-glutamyl transferase activity were measured, hypertensive treatment and

lifestyle factors recorded. The prevalence of hypertension, age-standardized to the

Guadeloupe population was 21 % and 26 % in men and women of African origin, 28

% and 22 % in those of Indian-origin and 18 % and 16 % for other origins. The vast

majority of subjects were unaware of their hypertension (90 % of men, 74 % of

women). After adjustment for age, factors associated with high blood pressure in the

826 adults of African origin were : obesity, hyperglycemia, low educational level and

family history of hypertension and of stroke. Additional factors in women were

alcohol consumption, gamma-glutamyl transferase activity, physical inactivity,

occupational category and a retired status, even after adjustment for age. Measures

must be taken to diagnose hypertension early, particularly in individuals of African

and Indian origin. An effective education program is needed, with an emphasis on

life-style factors associated with obesity : diet and physical activity

Keywords: African origin/AGE/aged/ALCOHOL-CONSUMPTION/arterial

hypertension/BLACKS/blood

pressure/BLOOD-PRESSURE/education/hypertension/INSULIN

RESISTANCE/life-style/lifestyle

factors/men/obesity/PREVALENCE/RACE/RACIAL-DIFFERENCES/RISK/risk

factors/stroke/treatment/WOMEN

Leys, D. and Pasquier, F. (1999), Arterial hypertension and cognitive decline. Revue

Neurologique, 155 (9), 743-748.

Abstract: Arterial hypertension is the leading risk factor for all stroke subtypes.

However, its relationship with cognitive decline and dementia is more complex than

a simple causal relationship. Cognitive functions are worse in patients with arterial

hypertension, especially when the level of education is lower, age higher and arterial

hypertension more severe. Arterial hypertension is an independent factor of cognitive

decline. It also leads to white matter changes which contribute to the cognitive

decline. Longitudinal studies have shown that a higher blood pressure at the age of

70 years is associated with an increased risk of dementia (vascular or Alzheimer) 10

to 15 years later, but blood pressure spontaneously decreases as dementia occurs.

Treatments of arterial hypertension decrease the incidence of stroke, but clinical

trials are still necessary to determine if they also decrease the incidence of dementia.

Preliminary results obtained in elderly subjects with systolic arterial hypertension,

support this hypothesis

Keywords: ALZHEIMERS-DISEASE/BLOOD-PRESSURE/clinical

trials/NEUROLOGIC FINDINGS/PREEXISTING

DEMENTIA/RESONANCE-IMAGING HYPERINTENSITIES/SCAN

LEUKO-ARAIOSIS/stroke/STROKE PATIENTS/SYSTOLIC

HYPERTENSION/VASCULAR RISK-FACTORS/WHITE-MATTER LESIONS

Ossemann, M., Mormont, E., Marin, V., Jamart, J. and Laloux, P. (2001), Identification

of variables associated with time of hospital presentation after ischemic stroke: study

of a rural population. Revue Neurologique, 157 (12), 1525-1529.

Abstract: We studied the time of arrival of 235 consecutive patients admitted to the

emergency department of a University Hospital located in a rural area after the first

symptoms of ischemic stroke or TIA. Among the following factors, we determined

those that might be involved in delayed admission: place of symptom onset, time and

place of onset of the first symptoms, contact with a general practitioner before

admission time, mode of transportation, clinical score, impairment of consciousness,

presence of seizures, heart complaints or headache, age and past medical history of

cerebrovascular, cardiovascular and hypertension diseases. Half of the patients

arrived within 4 h 10 of symptom discovery and 55 p. cent arrived within 6 hours.

The percentage of patients arriving within 3h (p=0.001) and 6 h (p=0.001) was

higher for those who had a stroke during the day (8 a.m.-8 p.m) than during the

evening and night. The other characteristics associated with a shorter delay included

a low neurological score on the Mathew's Stroke Scale (p 160/95 mmHg on triple therapy), hypertension in diabetes mellitus. Validation.

The guideline was developed by the Executive Committee of the Southern African

Hypertension Society with consensus meeting endorsement, and is endorsed by the

South African Medical Association Guideline Committee

Keywords: African/blood pressure/BLOOD-PRESSURE/cardiovascular

disease/cardiovascular risk factors/control/coronary/diabetes/diabetes

mellitus/DISEASE/DRUG/education/elderly/hypertension/patient

education/RANDOMIZED TRIAL/risk/risk factors/stroke

Havas, S. (1992), Heart-Disease, Cancer, and Stroke in Maryland. Southern Medical

Journal, 85 (6), 599-607.

Abstract: Maryland has higher mortality rates from heart disease, cancer, and stroke

(HCS) than the United States as a whole. More than 50% of deaths from HCS are

premature, occurring before age 75. The health care and indirect costs from these

three diseases total approximately $4.4 billion annually, placing a major economic

burden on the state. A large body of scientific literature has shown the potential for

the prevention of HCS. Currently, Maryland, like virtually all states, lacks the type of

systematic, well-coordinated, comprehensive intervention campaign needed to lower

morbidity, mortality, and health care costs from these three diseases. Such a

campaign has now been planned by the University of Maryland at Baltimore. Similar

campaigns are needed throughout much of the United States

Keywords:

age/burden/costs/diseases/EDUCATION/EXERCISE/HEALTH/MEDICAL/morbidi

ty/mortality/PHYSICAL-FITNESS/PREVENTION/PROJECT/RISK-FACTORS/str

oke/TRIAL

Helmert, U., Maschewskyschneider, U., Mielck, A. and Greiser, E. (1993), Social

Inequalities for Myocardial-Infarction and Stroke in West-Germany. Sozial-und

Praventivmedizin, 38 (3), 123-132.

Abstract: it is examined to which extent social inequalities exist in West-Germany (old

federal states) regarding myocardial infarction and stroke in the general population.

Databases were the regional and national health surveys which were conducted in the

framework of the German Cardiovascular Prevention Study (GCP) from 1984 to

1991. 12 445 males and 13 335 females aged 40-69 years were included in this

analysis. The assessment of myocardial infarction and stroke was done by a self

administered questionnaire. 648 (5.2 %) males and 252 (1.9 %) females reported a

myocardial infarction. 209 (1.7 %) males and 143 (1.1 %) females reported a stroke.

Social class was measured using an additive index comprising the dimensions

income, occupational status and education. For both genders it was found that the

prevalence of myocardial infarction and stroke increased significantly with

decreasing social class. This association remained significant also under control for

age and the cardiovascular disease risk factors cigarette smoking, hypertension,

hypercholesterolemia and overweight. The results clearly demonstrate that in

West-Germany - as was shown already for many other western industrialized nations

- social factors independently from the classical risk factors have a significant effect

on the incidence of myocardial infarction and stroke

Keywords: age/aged/assessment/cardiovascular

disease/education/health/hypertension/incidence/myocardial

infarction/prevalence/risk factors/smoking/stroke

Endo, K., Ichimaru, K., Shimura, H. and Imakiire, A. (2000), Cervical vertigo after hair

shampoo treatment at a hairdressing salon - A case report. Spine, 25 (5), 632-634.

Abstract: Study Design. A case report of cervical vertigo that occurred after shampoo

treatment in a hairdressing salon. Abnormalities were detected on magnetic

resonance images and magnetic resonance angiography scans. Objectives. To

describe the diagnosis of cervical vertigo caused by neck hyperextension. Summary

of Background Data. Neck hyperextension may induce vertigo and dizziness; the

pathophysiology remains unclear, however, because subjective findings are usually

difficult to document. Methods. The diagnosis, treatment, and outcome of a patient

with cervical vertigo that occurred after hair shampoo treatment in a hair dressing

salon were assessed, Results. Magnetic resonance angiography demonstrated

narrowing of the left vertebral artery, whereas magnetic resonance imaging showed

cerebellar infarction. Treatment included rest and drugs that activate cerebral

circulation and prevent platelet aggregation. Improvement was noted within few days.

Conclusions. The authors suggest that the hyperextended neck position during hair

shampoo treatment in a beauty parlor may be a risk factor for back lifting or

cerebellum vascular insufficiency. Public education should lead to avoidance of this

position during hair shampoo treatment at hair dressing salons

Keywords: beauty parlor stroke/cervical vertigo/diagnosis/education/Japan/magnetic

resonance imaging/neck extension injury/outcome/risk/risk

factor/STROKE/treatment/vascular/VISIT

Evans, R.L., Matlock, A.L., Bishop, D.S., Stranahan, S. and Pederson, C. (1988),

Family Intervention After Stroke - Does Counseling Or Education Help. Stroke, 19

(10), 1243-1249

Keywords: STROKE

Gorelick, P.B., Chatterjee, A., Patel, D., Flowerdew, G., Dollear, W., Taber, J. and

Harris, Y. (1992), Cranial Computed Tomographic Observations in Multiinfarct

Dementia - A Controlled-Study. Stroke, 23 (6), 804-811.

Abstract: Background and Purpose: We compared cranial computed tomography

findings among 58 multi-infarct dementia index cases and 74 multi-infarct control

subjects without cognitive impairment to identify potential determinants of

multi-infarct dementia. Methods: The cranial computed tomography records of acute

ischemic stroke patients with a history of multiple cerebral infarcts were compared to

determine the number, location, and size of cerebral infarcts; the pattern of infarction;

brain volume loss; and the degree of white matter lucency, sulcal enlargement, and

ventricular enlargement. Multi-infarct patients were divided into two groups: 1)

index cases were defined as those with multi-infarct dementia as defined by the

Diagnostic and Statistical Manual of Mental Disorders, edition 3 (DSM-III) criteria;

and 2) control subjects were defined as those multi-infarct patients without dementia

or multi-infarct dementia according to DSM-III criteria. Results: Overall,

multi-infarct index cases had more cerebral infarcts, more cortical and subcortical

left hemisphere infarcts, higher mean ventricular volume to brain volume ratio, more

extensive enlargement of the body of the lateral ventricles and cortical sulci, and a

higher prevalence of white matter lucencies. Among multi-infarct cases and control

subjects the most frequent site of infarction was the subcortical region, and the most

frequent pattern of infarction was lacunar. Stepwise logistic regression analysis

examined cranial computed tomography as well as other factors and showed that

level of education, stroke severity, left cortical infarction, and diffuse enlargement of

the left lateral ventricle were the best overall predictors of multi- infarct dementia.

Conclusions: Level of education, stroke severity, and left hemisphere infarction may

be predictors of multi-infarct dementia

Keywords: acute/ALZHEIMERS-DISEASE/BINSWANGER DISEASE/CEREBRAL

BLOOD-FLOW/CEREBRAL INFARCTION/CEREBROVASCULAR

RISK-FACTORS/cognitive impairment/CORTICAL ARTERIOSCLEROTIC

ENCEPHALOPATHY/DEMENTIA/education/ischemic/MAGNETIC-RESONANC

E/PATHOLOGIC CORRELATION/predictors/prevalence/severity/STROKE/stroke

patients/STROKE- DATA-BANK/TOMOGRAPHY/VASCULAR

DEMENTIA/WHITE-MATTER LESIONS/X-RAY COMPUTED

Alberts, M.J., Perry, A., Dawson, D.V. and Bertels, C. (1992), Effects of Public and

Professional-Education on Reducing the Delay in Presentation and Referral of Stroke

Patients. Stroke, 23 (3), 352-356.

Abstract: Background and Purpose: Several emerging stroke therapies require patients

to be treated within several hours of symptom onset. Past studies have documented a

significant delay between symptom onset and hospital presentation. As part of an

experimental treatment study using tissue-type plasminogen activator, we began a

multifaceted program of public and professional education to reduce the delay in

presentation and referral of acute stroke patients. Methods: The educational efforts

focused on improving the recognition of stroke symptoms, the study enrollment

criteria, and the need for rapid treatment of stroke patients. This program included 1)

interviews on television and radio, 2) newspaper articles, 3) lectures to local and

regional primary care and emergency department physicians, 4) mailings to several

thousand local physicians, 5) having neurologists on-call for referrals 24 hrs/day, and

6) use of the Duke Life-Flight helicopter. Results: Since starting our program, 139 of

159 (86%) patients with cerebral infarction presented primarily to or were referred to

our facility within 24 hours of symptom onset, compared with 70 of 187 (37%)

before our educational efforts (p 60% of the total time delay for patients not on

a neurology service. Conclusions: A substantial number of in-hospital stroke patients

experience a long delay between symptom recognition and a neurological evaluation.

While medical personnel are usually notified very soon after an in-hospital stroke is

recognized, such patients often do not receive a rapid neurological evaluation.

Additional education of hospital staff may reduce these time delays

Keywords: assessment/CARE/CEREBRAL-ISCHEMIA/CEREBROVASCULAR

DISEASE/CEREBROVASCULAR

DISORDERS/education/EPIDEMIOLOGY/HOSPITALIZATION/neurology/STRO

KE/STROKE MANAGEMENT/stroke patients/surgery/treatment/UNIT

Albanese, M.A., Clarke, W.R., Adams, H.P., Woolson, R.F., Bendixen, B.H., Davis,

P.H., Jacoby, M.R., Gomez, F.J., Dyken, M.E., Uc, E.Y., Wojcieszek, J.M., Kappelle,

L.J., Tanna, A.B., Mitchell, V.L., Gomez, C.R., Malkoff, M.D., Tulyapronchote, R.,

Sauer, C.M., Riaz, G., Schmidt, J.G., Malik, M.M., Banet, G.A., Karanjia, P.N.,

Madden, K.P., Ruggles, K.H., Mickel, S.F., Gottschalk, P.G., Hansotia, P.L.,

Sorenson, R.W., Jacobson, D.M., Hiner, B.C., Mancl, K., Lukasik, E., Bruno, A.,

Lakind, E.D., Jeffrey, D.R., Mladinich, E.K., Iqbal, J., Reiners, M., Barrett, D.W.,

Shibuya, D., Williams, J.K., Russell, P., King, M.K., Chapin, J.E., Carter, S., Jeffries,

L., Hier, D.B., Shapiro, R.A., Brint, S.U., Hoff, J., Oconnell, D., Fisher, M.J.,

Ameriso, S.F., Garabedian, M.H., Macko, R.F., Hanna, M., Yegyan, G.A., Martin,

A., Scicli, A., Jackson, C.M., Rothrock, J.F., Lyden, P.D., Brody, M.L., Zweifler,

R.M., Kelly, N.M., Gordon, D.L., Thiel, A.A., Fredericks, R.K., Singh, R.,

Dendinger, J., Gorelick, P.B., Riskin, B.J., Mirza, D.B., Kelly, M.A., Bijari, A.,

Murray, J.C., Curtin, J., Bozzola, F.G., Kofman, J.C., Brown, N., Dollear, W.C.,

Weinberger, J.M., Tuhrim, S., Rudolph, S.H., Horowitz, D.R., Sheinart, K.F.,

Gondolo, T.M., Ali, J., Bitton, A., Biller, J., Saver, J.L., Frank, J.I., Patrick, J.T.,

Fernandezbeer, E., Chadwick, L., Feldmann, E., Wilterdink, J.L., Ricks, L., Mohr,

J.P., Sacco, R.L., Clavijo, M., Rosenbaum, D.M., Sparr, S.A., Katz, P.M., Klonowski,

E., Byer, J.A., White, H.H., Sundrani, S., Zafar, M.J., Arora, R., Gamboa, E.C.,

Stacy, M., Bonnett, A., Kelley, C., Culebras, A., Carey, G.C., Martir, N.M., Kent,

P.F., Rabiee, H., Guevara, R.A., Bangco, M.S., Pastor, D., Ficarra, C., Coull, B.M.,

Briley, D.P., Clark, W.M., Kenny, C., Austin, T., Degarmo, P.L., Anderson, D.C.,

Tarrel, R.M., Nance, M.A., Bundlie, S.R., Doyle, J.J., Dierich, M., Love, B.B.,

Struck, L.K., Mueller, C., Hogan, E.L., Carter, T.D., Gurecki, P., Plyer, J.W.,

Muntzpope, B.K., Libman, R.B., Kwiatkowski, T.G., Kanner, R.M., Donnaruma, R.,

Cullen, V., Fayad, P.B., Brass, L.M., Pavalkis, F.J., Wrobel, C.J., Leramo, O.B.,

Buxton, S., Hollander, J., Honch, G.W., Weber, C., Mayman, C.I., Warach, S.J.,

Tijerina, M.L., Mandelbaum, M.A., Hassan, R.U., Abbas, D.H., Olmstead, C.G.,

Sedlacek, L., Miller, A.E., Keilson, M.J., Bruining, K.M., Drexler, E.E., Morgante,

L., Ramirezlassepas, M., Tulloch, J.W., Quinones, M.R., Clavel, A., Mendez, M.F.,

Zhang, S., Ala, T.A., Espinosa, C., Johnston, K.L., Kase, C.S., Wolf, P.A., Babikian,

V.L., Licatagehr, E.E., Allen, N.C., Homer, D., Neely, S., Carpenter, J., Horowitz,

S.H., Lava, N.S., Manning, M., Grimsman, K.J., Olson, J.D., Pennell, B.J., Johnson,

K., Cornell, S.H., Crosby, D.L., Simpson, T.M., Krumbholz, V., Zalesky, C.R.,

Wasek, P.A., Dieleman, J.A., Paulsen, J.M., Boreen, J.P., Jones, M.F., Robb, B.M.,

Oberbroeckling, L.A., Hansen, M.D., Hicklin, K.M., Dyken, M.L., Frankowski, R.F.,

Greenberg, C.S., Harker, L.A., Whisnant, J.P., Fincham, R.W., Kisker, T.C., Wallace,

R.B., Day, H.J., Detre, K.M., Grotta, J.C., Haley, E.C., Longstreth, W.T. and Marler,

J.R. (1994), Ensuring Reliability of Outcome Measures in Multicenter Clinical-Trials

of Treatments for Acute Ischemic Stroke - the Program Developed for the Trial of

Org-10172 in Acute Stroke Treatment (Toast). Stroke, 25 (9), 1746-1751.

Abstract: Background and Purpose Ensuring the reliability and validity of outcome

measures used in clinical trials is essential to the success of the trial. The Trial of Org

10172 in Acute Stroke Treatment (TOAST) is a multicenter clinical trial that is

recruiting patients with acute ischemic stroke seen at medical centers across the

United States. Methods This paper describes an approach to train physicians to use

three clinical measures: the National Institutes of Health (NIH) Stroke Scale, a

supplemental motor examination, and the Glasgow Outcome Scale. The program

included education, certification, remediation when needed, monitoring, and

reliability assessment. The goal was to ensure that interrater assessments were as

equivalent to one another as possible. Results Of the first 95 clinicians who began the

certification process, 75 passed during the first evaluation. Eighteen of the other

physicians were able to complete the process after remediation. The intraclass

correlations of both the NIH Stroke Scale and supplemental motor examination

exceeded 0.95. The kappa values for the Glasgow Outcome Scale were 0.61 and 0.62

for the first and second ratings of the videotape, respectively. Conclusions Our

experience suggests that a program that includes educational and certification

processes can be performed as part of the design of a multicenter clinical trial. The

method of providing educational and testing videotapes to each site so that

physicians can be trained and certified is an effective, inexpensive, and practical

approach for enhancing and certifying the expertise of the large number of

physicians involved in a multicenter study

Keywords: acute/assessment/CLINICAL

TRIALS/education/ischemic/monitoring/outcome/SCALE/STROKE/STROKE

ASSESSMENT/STROKE OUTCOME

Barsan, W.G., Brott, T.G., Broderick, J.P., Haley, E.C., Levy, D.E. and Marler, J.R.

(1994), Urgent Therapy for Acute Stroke - Effects of A Stroke Trial on Untreated

Patients. Stroke, 25 (11), 2132-2137.

Abstract: Background and Purpose As part of the recruitment efforts for the National

Institutes of Health Tissue Plasminogen Activator Pilot Study, public education and

awareness campaigns were conducted to encourage early hospital arrival. We

evaluated the change in arrival times during the course of the study for all stroke

patients, including those who were not entered into study. Methods Data were

gathered on all patients presenting within 24 hours of stroke onset to all of the study

hospitals. Coincident with the start of the study, educational and promotional

programs, which stressed signs and symptoms of stroke and the need to call 911,

were presented to physicians, paramedical personnel, and the public. The study was

divided into four quartiles to analyze differences in time to hospital arrival and use of

911. Results Of 2099 patients screened, time data were available on 1116. During the

course of the study, the mean time from symptom onset to hospital arrival declined

significantly (3.2 hours versus 1.5 hours). Patients arrived for treatment sooner at

community hospitals than at university/teaching hospitals. The use of 911 increased

from 39% in the first quartile of the study to 60% in the fourth quartile. This was a

consistent finding in all study sites. Increased use of 911 was seen almost exclusively

in patients with nonhemorrhagic stroke. Conclusions Times from stroke onset to

hospital arrival decreased significantly during the course of the National Institutes of

Health Tissue Plasminogen Activator Pilot Study. Significantly increased use of 911

was the likely major explanation for the shortened arrival times. The decrease in

arrival times may be a consequence of the public and professional education

programs conducted at all study sites

Keywords: ACUTE MYOCARDIAL-INFARCTION/CLINICAL

TRIALS/community/DELAY/education/EMERGENCY MEDICAL

SERVICES/FOCAL CEREBRAL-ISCHEMIA/HEALTH EDUCATION/PUBLIC-

EDUCATION/STROKE/stroke onset/stroke patients/symptoms/TIME/treatment

Sacco, R.L., Kargman, D.E., Gu, Q. and Zamanillo, M.C. (1995), Race Ethnicity and

Determinants of Intracranial Atherosclerotic Cerebral Infarction - the Northern

Manhattan Stroke Study. Stroke, 26 (1), 14-20.

Abstract: Background and Purpose The aim of this investigation was to determine the

importance of race as a determinant of intracranial atherosclerotic stroke in a

community-based stroke sample. Methods Residents from northern Manhattan over

age 39 years hospitalized for acute ischemic stroke (n=438, black 35%, Hispanic

46%, white 19%) were prospectively evaluated. Index ischemic strokes were

classified as atherosclerotic (17%), lacunar (30%), cardioembolic (21%), cryptogenic

(31%), and other (1%). Atherosclerotic infarcts were subdivided into extracranial

(9%) and intracranial (8%) atherosclerosis. Results The proportion of extracranial

atherosclerotic stroke was similar among the three race-ethnic groups, while

intracranial atherosclerosis was more frequent in blacks and Hispanics. The

unadjusted odds ratio for nonwhites (blacks and Hispanics combined) was 0.8

(confidence interval [CI], 0.4 to 1.8) for extracranial and 7.8 (CI, 1.04 to 57.7) for

intracranial atherosclerosis. Patients with intracranial disease were significantly

younger and had an increased frequency of hypercholesterolemia and

insulin-dependent diabetes compared with those with nonatherosclerotic disease. The

odds ratio for the association of nonwhite race-ethnicity and intracranial

atherosclerosis was reduced to 5.2 (CI, 0.7 to 40) after controlling for age and to 4.4

(CI, 0.6 to 35) after controlling for age, education, insulin-dependent diabetes, and

hypercholesterolemia. Conclusions The greater prevalence of diabetes and

hypercholesterolemia among blacks and Hispanics from northern Manhattan

accounted for much of the increased frequency of intracranial atherosclerotic stroke.

Further control of these risk factors could reduce the frequency of this stroke subtype

and minimize the disparities among different race-ethnic groups

Keywords: acute/age/ANTERIOR

CIRCULATION/ATHEROSCLEROSIS/BLACKS/DATA-BANK/diabetes/educatio

n/EPIDEMIOLOGY/Hispanics/ischemic/MORTALITY/OCCLUSIVE

CEREBROVASCULAR-DISEASE/prevalence/race/RACIAL

DIFFERENCES/RACIAL-DIFFERENCES/RISK

FACTORS/RISK-FACTORS/SEX/STROKE/TRANSIENT ISCHEMIC

ATTACKS/UNITED- STATES

Giles, W.H., Kittner, S.J., Anda, R.F., Croft, J.B. and Casper, M.L. (1995), Serum

Folate and Risk for Ischemic Stroke - First National- Health and Nutrition

Examination Survey Epidemiologic Follow- Up-Study. Stroke, 26 (7), 1166-1170.

Abstract: Background and Purpose A serum folate concentration less than or equal to

9.2 nmol/L has been associated with elevated levels of plasma homocyst(e)ine.

Elevated homocyst(e)ine levels have been associated with ischemic stroke in

case-control studies; however, the results from prospective studies have been

equivocal. We investigated whether a folate concentration less than or equal to 9.2

nmol/L was associated with ischemic stroke in a national cohort. Methods We used

data from the First National Health and Nutrition Examination Survey Epidemiologic

Follow-up Study (n=2006). Cox proportional hazards analyses were used to adjust

for differences in follow-up time and covariates. During the PS-year follow-up, 98

ischemic strokes occurred. Results After adjusting for age, race, sex, education,

diabetes, history of heart disease, systolic blood pressure, body mass index,

hemoglobin level, cigarette smoking, and alcohol intake, participants with a folate

concentration less than or equal to 9.2 nmol/L were at slightly increased risk for

ischemic stroke (relative risk [RR], 1.37; 95% confidence interval [CI], 0.82 to 2.29).

There was a folate- race interaction (P=.11 for interaction term). Whites with a folate

concentration less than or equal to 9.2 nmol/L had a relative risk of 1.18 (95% CI,

0.67 to 2.08), whereas blacks had a relative risk of 3.60 (95% CI, 1.02 to 12.71).

Conclusions These findings suggest that a folate concentration less than or equal to

9.2 nmol/L may be a risk factor for ischemic stroke, especially in blacks. However,

given the small number of stroke events, additional studies are needed to assess the

role of folate in the epidemiology of ischemic stroke

Keywords: age/alcohol/ATHEROSCLEROSIS/blacks/blood pressure/CONTAINING

AMINO-ACIDS/diabetes/education/ELEVATED PLASMA

HOMOCYST(E)INE/EPIDEMIOLOGY/FOLIC

ACID/homocyst(e)ine/HOMOCYSTEINE/HYPERHOMOCYST(E)INEMIA/HYPE

RHOMOCYSTEINEMIA/INFARCTION/ischemic/LOW-DENSITY

LIPOPROTEIN/OCCLUSIVE ARTERIAL-DISEASE/prospective

studies/race/RACIAL DIFFERENCES/relative risk/RISK

FACTORS/smoking/STROKE/VASCULAR- DISEASE

Addingtonhall, J., Lay, M., Altmann, D. and Mccarthy, M. (1995), Symptom Control,

Communication with Health-Professionals, and Hospital-Care of Stroke Patients in

the Last Year of Life As Reported by Surviving Family, Friends, and Officials.

Stroke, 26 (12), 2242-2248.

Abstract: Background and Purpose The needs of and appropriate service provision for

patients dying from stroke have received little attention. The quality of care in the

last year of life received by a population-based sample of stroke patients is described

here, focusing on symptom control, communication with health professionals, and

hospital care. Methods Secondary analysis was made of data from the Regional

Study of Care for the Dying, a retrospective interview survey in 20 nationally

representative English health districts. Subjects were 237 persons who died from

stroke in 1990. Of informants, 20% were spouses, 48% relatives, 11% friends or

neighbors, and 20% officials. Results More than half the patients were reported to

have experienced pain (65%), mental confusion (51%), low mood (57%), and urinary

incontinence (56%) in the last year of life. Pain control was inadequate: 51% of those

treated for pain by hospital doctors and 45% of those treated by general practitioners

were reported to have received treatment that relieved pain partially if at all. One

third of respondents thought that hospital doctors had been too rushed (37%), and

25% thought that the patient had had insufficient choice about treatment. Two fifths

had been unable to get all the information they had wanted about the patient's

condition. Conclusions Improvements in symptom control and psychosocial support

for patients who die from stroke are needed, as is better communication between

health professionals and patients and their families. Education of doctors and nurses

working with stroke patients in the principles of palliative care may help ensure that

all dying stroke patients receive high-quality care

Keywords: health/HOSPITALIZATION/QUALITY OF HEALTH

CARE/STROKE/stroke patients/survey/TERMINAL CARE/treatment

Howard, G., Russell, G.B., Anderson, R., Evans, G.W., Morgan, T., Howard, V.J. and

Burke, G.L. (1995), Role of Social-Class in Excess Black Stroke Mortality. Stroke,

26 (10), 1759-1763.

Abstract: Background and Purpose It has been suggested that a substantial proportion of

the excess stroke mortality among black Americans may be attributable to relatively

lower socioeconomic status (SES) in this group. In this report we provide the first

quantitative estimates of the proportion of excess black stroke mortality attributable

to SES for a large population-based cohort. Methods We used data from the National

Longitudinal Mortality Study for persons 45 years and older (73 400 white men, 87

528 while women, 6522 black men, and 8816 black women). Sex-specific

proportional hazards model were used to estimate excess black stroke mortality with

and without adjustment for education and income (measures of SES). The

contribution of SES to the excess black stroke risk was estimated from the difference

in regression coefficients for race in these models. Results In men, low SES was

associated with increased stroke mortality (P less than or equal to.0001) and

accounted for 14% to 46% of the excess black stroke risk (P less than or equal to.05).

However, we could find no association between SES and stroke mortality in women,

and SES did not account for a significant proportion of the excess stroke mortality in

black women. Conclusions Although SES proved to account for a statistically

significant proportion of excess male black stroke mortality, overall SES explained

less than one quarter of the observed excess between ages 45 and 65. In women, SES

did not significantly reduce the estimated excess black stroke mortality. Although

SES may be playing a role in excess black stroke mortality, a substantial proportion

of the excess appears attributable to other sources, including cerebrovascular risk

factors that are unrelated to SES, unmeasured lifestyle influences, social resources,

and genetic factors

Keywords: BLACKS/CARDIOVASCULAR-DISEASES/CORONARY

HEART-DISEASE/DEATH/EDUCATION/ETHNICITY/GENDER/HEALTH/LIFE

-STYLE/lifestyle/men/MORTALITY/race/RACIAL DIFFERENCES/RISK

FACTORS/RISK-FACTORS/socioeconomic/socioeconomic

status/SOCIOECONOMIC-STATUS/STROKE/women

Goldstein, L.B., Bonito, A.J., Matchar, D.B., Duncan, P.W., Defriese, G.H., Oddone,

E.Z., Paul, J.E., Akin, D.R. and Samsa, G.P. (1995), Us National Survey of Physician

Practices for the Secondary and Tertiary Prevention of Ischemic Stroke - Design,

Service Availability, and Common Practices. Stroke, 26 (9), 1607-1615.

Abstract: Background and Purpose Stroke is largely a preventable disease. However,

there are little data available concerning the use of stroke prevention diagnostic and

treatment modalities by practicing physicians. These data are critical for the rational

allocation of resources and targeting of educational efforts. The purposes of this

national survey were to gather information about physicians' stroke prevention

practice patterns and their attitudes and beliefs regarding secondary and tertiary

stroke prevention strategies. Methods We conducted a national survey of stroke

prevention practices among a stratified random sample of 2000 physicians drawn

from the American Medical Association's Physician Masterfile. The survey focused

on the availability of services and the use of diagnostic and preventive strategies for

patients at elevated risk of stroke. Besults Sixty-seven percent (n=1006) of eligible

physicians completed the survey. Diagnostic studies considered readily available by

at least 90% of physicians included carotid ultrasonography, transthoracic

echocardiography, Holter monitoring, and brain CT and MRI scans. MR angiography

was perceived as being readily available by 68% and transesophageal

echocardiography by 74% of respondents. Twelve percent of physicians reported

cerebral arteriography and 10% reported carotid endarterectomy as not being readily

available. Multiple logistic regression analyses showed that the availability of

services varied with physician specialty (noninternist primary care, internal medicine,

neurology, surgery), practice setting (nonmetropolitan versus small metropolitan or

large metropolitan areas), and for carotid endarterectomy, region of the country

(South, Central, Northeast, and West). The odds of carotid endarterectomy being

reported as readily available were approximately 2.5 to 3.5 times greater for

physicians practicing in the central, northeastern, and western regions compared with

those practicing in the South, independent of practice setting and specialty. With

regard to stroke prevention practices, 61% of physicians reported prescribing 325 mg

of aspirin for stroke prevention, while 33% recommend less than 325 mg and 4% use

doses of 650 mg or more. Seventy- one percent of physicians using warfarin reported

monitoring anticoagulation with international normalized ratios. and 78% reported

monitoring anticoagulated patients at least once a month. Fewer than 20% of

physicians reported knowing the perioperative carotid endarterectomy complication

rates at the hospital where they perform the operation themselves or refer patients to

have the procedure done. Conclusions Although all routine and most specialized

services for secondary and tertiary stroke prevention are readily available to most

physicians, variation in availability exists. The use of international normalized ratios

for monitoring warfarin therapy has not yet become universal. Physician knowledge

of carotid endarterectomy complication rates is generally lacking. Depending on their

causes, these problems may be addressed through targeted physician education

efforts and systematic changes in the way in which services are provided

Keywords: ANTICOAGULANTS/ASPIRIN/CAROTID

ENDARTERECTOMY/CEREBRAL-ISCHEMIA/DIAGNOSIS/DISEASE/educatio

n/LOW-DOSE

ASPIRIN/medicine/monitoring/MRI/neurology/prevention/STENOSIS/STROKE/ST

ROKE PREVENTION/surgery/survey/treatment/ultrasonography/WARFARIN

Alberts, M.J. (1995), Undergraduate and Postgraduate Medical-Education for

Cerebrovascular-Disease. Stroke, 26 (10), 1849-1851.

Abstract: Background and Purpose There is a perception among some physicians that

medical students and house officers receive little or no training in the diagnosis and

treatment of patients with cerebrovascular disease. However, there is a paucity of

data addressing the issue of medical education in this area. This study was performed

to determine the quantity and type of undergraduate and postgraduate medical

education on cerebrovascular disease that is presented to medical students and house

officers. Methods This was a prospective questionnaire study sent to 40 mainly

academic medical centers in the United States and Canada. Data were collected on

the percentage of programs offering stroke education, percentage of medical students

and house officers taking such courses, and the duration of reaching programs.

Results Sixty-one percent of the programs had dedicated stroke teaching efforts

during clinical rotations, averaging a total of 13.1 hours of didactic and clinical

teaching. Medical students received approximately 5 hours of preclinical stroke

instruction. Only 35% of the programs offered stroke training for house officers in

their internal medicine program. Most programs (81%) offered stroke conferences

and computer-based instruction. Conclusions At some institutions, medical students

received a modest amount of stroke education during their clinical rotations.

However, almost 40% of programs did not have required stroke education programs

for medical students. Most internal medicine programs that we surveyed did not have

specific stroke education efforts for house officers. Increased educational efforts in

this area may be indicated

Keywords: CARE/cerebrovascular disease/CEREBROVASCULAR

DISORDERS/diagnosis/EDUCATION/MEDICAL/medical

education/medicine/STROKE/STROKE ASSESSMENT/STROKE

MANAGEMENT/training/treatment

Alberts, M.J., Bennett, C.A. and Rutledge, V.R. (1996), Hospital charges for stroke

patients. Stroke, 27 (10), 1825-1828.

Abstract: Background and Purpose Stroke is a common disease with a yearly cost in the

United States of approximately $30 billion. The increasing prevalence of managed

care and cost-containment measures may affect the delivery of stroke care now and

in the future. This study was performed to determine (1) hospital charges and test

utilization for stroke patients and (2) the effectiveness of educational efforts in

modifying test utilization and related hospital charges. Methods Patients with a

diagnosis of stroke who were discharged from either the neurology service or another

service of the Department of Medicine (DOM) were identified. Data on test

utilization and hospital charges were collected and analyzed. Following this analysis,

educational sessions were held in an effort to reduce the use of specific diagnostic

tests. The effectiveness of these methods was studied in a second group of stroke

patients. Results In the baseline period there were 303 stroke patients, of which 262

(86%) were discharged from the neurology service and 41 (14%) were discharged

from other services of the DOM. Patients on the neurology service had a lower mean

length of stay than patients on the other services of the DOM (9.2 days versus 10.5

days) and lower mean total charges per case ($13 149 versus $15 727), although the

respective differences were not statistically significant. Patients on the neurology

service were more likely to have both brain CT and MRI performed (82 of 262

patients, 31.3%) than patients on the other services of the DOM (4 of 41, 9.8%,

P=.005). In addition, patients on the neurology service were more likely to undergo a

transthoracic echocardiogram than patients on the other services of the DOM (71.8%

versus 53.7%, P=.025). After educational sessions, the percent age of stroke patients

on the neurology service having both CT and MRI fell from 31.3% to 17.7%

(P=.005), and the number of stroke patients having a transthoracic echocardiogram

fell from 71.8% to 60.3% (P=.025). However, the overall charges for stroke patients

on the neurology service did not decrease. Conclusions Education can be successful

in reducing the utilization of and associated charges for specific diagnostic tests for

some stroke patients. A multidisciplinary approach to case management, using tools

such as care maps, may be necessary to realize significant cost savings in certain

groups of stroke patients

Keywords: age/cost/costs and cost analysis/diagnosis/diagnostic

tests/hospitalization/LENGTH/MRI/neurology/prevalence/quality of health

care/STAY/stroke/stroke management/stroke patients/UNIT/utilization

Fogelholm, R., Murros, K., Rissanen, A. and Ilmavirta, M. (1996), Factors delaying

hospital admission after acute stroke. Stroke, 27 (3), 398-400.

Abstract: Background and Purpose Clinical trials of new drugs that reverse neurological

deficits when used in the first hours of stroke onset suggest that early hospital

admission is important. We analyzed a database of patients with acute stroke to

determine the factors that delay hospital admission. Methods We analyzed all

patients with their first stroke during 1993 in the province of Central Finland

(population, 256 000). Patients referred to the Central Hospital, the only tertiary

referral hospital in the area, were included in the study. Results Of the patients with

first stroke, 363 (79%) were admitted to the Central Hospital. The stroke subtype was

confirmed in 356 (98%) patients with CT scan, and the patient population included

272 (75%) with brain infarction, 51 (14%) with intracerebral hemorrhage, and 40

(11%) with subarachnoid hemorrhage. The most important factor associated with a

delay in reaching the hospital was the referral pattern. The median delay was 2 hours

for patients brought directly to the Central Hospital, 8 hours if a physician at the

local health center was consulted, and 47 hours if the patient was first admitted to the

health center for observation. Other factors associated with a delay were ischemic

stroke and stroke onset in the evening or night or during the weekend. Conclusions

The majority of patients who are candidates for acute stroke trials arrive at the

hospital after prolonged delays for multiple reasons. Public and medical personnel

education could result in significant reduction in these delays

Keywords: acute/cerebral

infarction/education/epidemiology/Finland/health/hospitalization/intracerebral

hemorrhage/ischemic/stroke/stroke management/stroke onset/subarachnoid

hemorrhage/TIME

Desmond, D.W., Moroney, J.T., Sano, M. and Stern, Y. (1996), Recovery of cognitive

function after stroke. Stroke, 27 (10), 1798-1803.

Abstract: Background and Purpose Previous studies have suggested that recovery of

cognitive function after stroke is maximal within the first 3 months after onset. We

performed the present study to investigate the long-term course and clinical

correlates of improvement in generalized cognitive function after ischemic stroke.

Methods We administered a battery of neuropsychological tests to 151 patients (age,

70.4+/-7.7 years; education, 10.4+/-4.6 years) at 3 months and then annually after

stroke. We transformed their test results into z scores based on the performance of a

stroke-free normative group, averaged those scores to create a summary score, and

defined improvement in annual examinations as an increase in that summary score

greater than two standard deviations above the mean first annual change of the

normative group. We then used logistic regression to determine whether stroke

location, syndrome, or recurrence; vascular risk factors; dementia status; depression;

or demographic variables were associated with improvement. Results We found that

19 of the 151 patients exhibited improvement, which was evident only at the first

annual examination in most cases. Logistic regression determined that improvement

was significantly related to left hemisphere infarction relative to brain

stem/cerebellar infarction (odds ratio [OR], 5.57), while the presence of a major

hemispheral stroke syndrome showed a trend toward significance (OR, 3.32).

Diabetes mellitus was significantly associated with a failure to exhibit improvement

(OR, 0.12). Based on the logistic model, the probability of long-term improvement

would be 54.0% for a patient with a left hemisphere infarct and a major hemispheral

syndrome but only 11.9% if diabetes was also present. Conclusions Long-term

improvement in generalized cognitive function may be evident after stroke in

association with left hemisphere infarction and severe hemispheral syndromes, while

it may be compromised by diabetes, possibly because of an in creased burden of

cerebrovascular disease

Keywords: age/AUDITORY COMPREHENSION/burden/CEREBRAL

BLOOD-FLOW/cerebral infarction/cerebrovascular disease/cognition/cognitive

function/COMPUTED TOMOGRAPHIC

SCAN/correlates/DATA-BANK/DEMENTIA/depression/DEPRESSION

RATING-SCALE/diabetes/diabetes

mellitus/DIABETES-MELLITUS/education/GLOBAL APHASIA/HOSPITALIZED

COHORT/ischemic/neuropsychological tests/performance/risk

factors/RISK-FACTORS/stroke/stroke outcome

Brott, T., Broderick, J., Kothari, R., ODonoghue, M., Barsan, W., Tomsick, T., Spilker,

J., Miller, R., Sauerbeck, L., Farrell, J., Kelly, J., Perkins, T., McDonald, T., Rorick,

M., Hickey, C., Armitage, J., Perry, C., Thalinger, K., Rhude, R., Schill, J., Becker,

P.S., Heath, R.S., Adams, D., Reed, R., Klei, M., Hughes, A., Anthony, J.,

Baudendistel, D., Zadicoff, C., Rymer, M., Bettinger, I., Laubinger, P., Schmerler,

M., Meiros, G., Lyden, P., Dunford, J., Zivin, J., Rapp, K., Babcock, T., Daum, P.,

Persona, D., Brody, M., Jackson, C., Lewis, S., Liss, J., Mahdavi, Z., Rothrock, J.,

Tom, T., Zweifler, R., Kobayashi, J., Kunin, J., Licht, J., Rowen, R., Stein, D.,

Grisolia, J., Martin, F., Chaplin, R., Kaplitz, N., Nelson, J., Neuren, A., Silver, D.,

Chippendale, T., Diamond, E., Lobatz, M., Murphy, D., Rosenberg, D., Ruel, R.,

Sadoff, M., Schim, J., Schleimer, J., Atkinson, R., Wentworth, D., Cummings, R.,

Frink, R., Heublein, P., Grotta, J.C., DeGraba, T., Fisher, M., Ramirez, S., Hanson,

S., Morgenstern, L., Sills, C., Pasteur, W., Yatsu, F., Andrews, K., VillarCordova, C.,

Pepe, P., Bratina, P., Greenberg, L., Rozek, S., Simmons, K., Kwiatkowski, T.G.,

Horowitz, S.H., Libman, R., Kanner, R., Silverman, R., LaMantia, J., Mealie, C.,

Duarte, R., Donnarumma, R., Okola, M., Cullin, V., Mitchell, E., Levine, S.R.,

Lewandowski, C.A., Tokarski, G., Ramadan, N.M., Mitsias, P., Gorman, M.,

Zarowitz, B., Kokkinos, J., Dayno, J., Verro, P., Gymnopoulos, C., Dafer, R.,

DOlhaberriague, L., Sawaya, K., Daley, S., Mitchell, M., Frankel, M., Mackay, B.,

Weissman, J., Washington, J., Nguyen, B., Cook, A., Karp, H., Williams, M.,

Williamson, T., Barch, C., Braimah, J., Faherty, B., MacDonald, J., Sailor, S.,

Kozinn, M., Hellwick, L., Haley, E.C., Bleck, T.P., Cail, W.S., Lindbeck, G.H.,

Granner, M.A., Wolf, S.S., Gwynn, M.W., Mettetal, R.W., Chang, C.W.J., Solenski,

N.J., Brock, D.G., Ford, G.D., Kongable, G.L., Parks, K.N., Wilkinson, S.S., Davis,

M.K., Sheppard, G.L., Zontine, D.W., Gustin, K.H., Crowe, N.M., Massey, S.L.,

Meyer, M., Gaines, K., Payne, A., Bales, C., Malcolm, J., Barlow, R., Wilson, M.,

Cape, C., Bertorini, T., Misulis, K., Paulsen, W., Shepard, D., Tilley, B.C., Welch,

K.M.A., Fagan, S.C., Lu, M., Patel, S., Masha, E., Verter, J., Boura, J., Main, J.,

Gordon, L., Maddy, N., Chociemski, T., Windham, J., Zadeh, H.S., Alves, W., Keller,

M.F., Wenzel, J.R., Raman, N., Cantwell, L., Warren, A., Smith, K., Bailey, E.,

Marler, J.R., Easton, J.D., Hallenbeck, J.F., Lan, G., Marsh, J.D., Walker, M.D.,

Froehlich, J., Breed, J. and Fong, W.C. (1997), A systems approach to immediate

evaluation and management of hyperacute stroke - Experience at eight centers and

implications for community practice and patient care. Stroke, 28 (8), 1530-1540.

Abstract: Background and Purpose With the approval by the Food and Drug

Administration of recombinant tissue plasminogen activator (rt- PA) for acute

ischemic stroke within 180 minutes of symptom onset, patients and prehospital and

hospital systems will now have to treat stroke as a medical emergency. It is thus

critical to develop efficient hospital-based methods for hyperacute stroke patient

evaluation and intervention at both community-based and tertiary care academic

centers. Methods We describe how the eight centers in the National Institute of

Neurological Disorders and Stroke rt-PA Stroke Trial developed systems for

enrolling patients within 3 hours of symptom onset. The actual methodology and

practical sequence of events are detailed. Deming principles of system organization

were applied, and each center developed a flowchart of acute stroke patient screening,

assessment, and treatment. We divided the process into the following: clinical center

background and preparation, screening, stroke team response, data needed before

treatment, CT of the head, pharmacy, patient treatment, and monitored care. Critical

features, both unique to a given center and shared by several centers (common at four

or more centers), were summarized. Results Phase I of the trial included several

months of preparation with review of every detail involved in the process of acute

stroke care at each site, All centers worked closely with emergency medical sen ices.

Community stroke awareness and education programs were developed. A stroke

team was initiated and worked closely with the emergency department physicians

and nurses. Rapid and efficient communication systems and protocols were

established to reduce time to complete each task, Standardized stroke examinations

and protocols for blood pressure management and intracranial hemorrhage detection

as well as nursing flowcharts were used. Conclusions Hyperacute stroke treatment

can be initiated, often within 55 minutes of patient arrival at the hospital, in both

community and academic settings when all aspects of stroke carl processes are

identified, streamlined, and built into the day-to-day operations of the prehospital and

hospital healthcare delivery system

Keywords: acute/ADMISSION/blood pressure/cerebrovascular

disorders/community/DELAY/education/EMERGENCY/emergency medical

services/ischemic/MINUTES/plasminogen activator/protocols/stroke/stroke

treatment/thrombolytic therapy/TIME/tissue plasminogen

activator/tissue-type/URGENT THERAPY

Prencipe, M., Ferretti, C., Casini, A.R., Santini, M., Giubilei, F. and Culasso, F. (1997),

Stroke, disability, and dementia - Results of a population survey. Stroke, 28 (3),

531-536.

Abstract: Background and Purpose Stroke, disability, and dementia often coexist in

elderly people. We assessed the prevalence and mutual association of these disorders

in an elderly rural population. Methods We carried out a door-to-door survey on all

subjects aged 65 years or over (n=1032) living in a rural community. To evaluate the

associations between stroke and disability and between stroke and dementia, we

compared stroke patients with all stroke-free subjects by means of two multiple

logistic regression analyses. Subsequently, we performed a case-control analysis by

comparing each stroke patient with two age- and sex-matched population control

subjects. Results We identified 80 stroke patients. After the exclusion of five incident

cases, the prevalence of stroke was 7.3% (95% confidence interval [CI], 5.7 to 8.9).

Sixty-five percent of stroke survivors and 23% of stroke-free subjects were disabled

(age- and sex-adjusted odds ratio [OR], 6.3; 95% CI, 3.7 to 10.9). Thirty percent of

stroke survivors and 5.7% of stroke- free subjects were demented. The OR for

dementia (stroke patients versus all stroke-free subjects) was 5.8 (95% CI, 3.1 to 10.8)

and became 3.4 (95% CI, 1.5 to 8.0) in the case- control analysis. Conclusions In our

population, the prevalence of stroke was higher than in previous studies. Stroke

survivors were more disabled and more at risk for dementia than stroke- free subjects

Keywords:

age/aged/ALZHEIMERS-DISEASE/community/dementia/disability/disability

evaluation/EDUCATION/elderly/HOSPITALIZED

COHORT/PREVALENCE/stroke/stroke patients/survey/SURVIVAL/VASCULAR

DEMENTIA

Pohjasvaara, T., Erkinjuntti, T., Vataja, R. and Kaste, M. (1997), Comparison of stroke

features and disability in daily life in patients with ischemic stroke aged 55 to 70 and

71 to 85 years. Stroke, 28 (4), 729-735.

Abstract: Background and Purpose This study compared stroke features and poststroke

disability in two age groups of patients with ischemic stroke: younger (55 to 70 years)

and older (71 to 85 years). Stroke has an impact on daily living in many areas, but

whether risk factors, stroke features, and poststroke disability differ between young

and old patients with stroke is not so well established. Methods A cohort of 486

ischemic stroke patients aged 55 to 85 years admitted consecutively to the Helsinki

University Central Hospital (Finland) between December 1, 1993, and March 31,

1995, were examined 3 months after the index stroke. Structured medical,

neurological, and radiological (MRI or CT) examinations, mental status, and

emotional examination and interview of a close informant were done. Prestroke and

poststroke activities of daily living were assessed with five scales: the Index of ADL.

Instrumental Activities of Daily Living Scale, Functional Activities Questionnaire;

Blessed Functional Activities Scale, and Barthel Index. Results History of cardiac

failure (P 140 mg/dL, or a

plasma glucose level of >200 mg/dL 2 hours after administration of an oral glucose

load) with a self-reported physician diagnosis of stroke and myocardial infarction in

6547 adults aged 40 to 74 years participating in the Third National Health and

Nutrition Examination Survey. Multivariate logistic regression analyses were used to

investigate these relationships. Results-IGT and DM were observed in 1494 and

1532 adults, respectively. After adjustment for differences in age, gender,

race/ethnicity, education, hypertension, cholesterol, body mass index, and cigarette

smoking, IGT was not associated with stroke (odds ratio [OR], 0.9; 95% confidence

interval [CI], 0.5 to 1.6) or myocardial infarction (OR, 1.1; 95% CI, 0.7 to 1.6). DM

was associated with both stroke (OR, 1.6; 95% CI, 1.0 to 2.6) and myocardial

infarction (OR, 1.9; 95% CI, 1.3 to 2.8). Conclusions-In contrast to DM, IGT was not

associated with an increased likelihood of prevalent nonfatal stroke or myocardial

infarction

Keywords: age/CARDIOVASCULAR-DISEASE/CORONARY

HEART-DISEASE/DEPENDENT DIABETES-MELLITUS/diabetes

mellitus/diagnosis/education/FOLLOW-UP/gender/glucose

tolerance/hypertension/MEN/MORTALITY/myocardial

infarction/POPULATION/PREVALENCE/QUESTIONNAIRE/RISK-FACTORS/s

moking/stroke

Giles, W.H., Croft, J.B., Greenlund, K.J., Ford, E.S. and Kittner, S.J. (1998), Total

homocyst(e)ine concentration and the likelihood of nonfatal stroke - Results from the

Third National Health and Nutrition Examination Survey, 1988-1994. Stroke, 29 (12),

2473-2477.

Abstract: Background and Purpose-Elevated serum total homocyst(e)ine [H(e)] is an

independent risk factor for stroke. Few studies, however, have examined this

association in blacks. Methods-Data from the Third National Health and Nutrition

Examination Survey (n=4534), a nationally representative sample of US adults, were

used to examine the relationship between H(e) and a physician diagnosis of stroke

(n=185) in both black and white adults. Multivariate-adjusted logistic regression

analyses were used to examine this relationship. Results-Serum vitamin B-12 and

folate concentrations were significantly lower among participants in the highest H(e)

quartile (greater than or equal to 12.1 mu mol/L) than among participants in the

lowest quartile (less than or equal to 7.4 mu mol/L). Those in the highest quartile

were older, had higher mean cholesterol and blood pressure levels, and were more

likely to smoke and to have completed 50 years of age. Methods-Subjects were 657 adults living in the

community or in senior independent-living settings. The study examined the

effectiveness of the program when presented alone and when accompanied by

discussion (facilitation) led by a trained individual. Knowledge of stroke risk factors

and warning signs was assessed using parallel pretests and posttests developed and

validated specifically for the study. Results-ANCOVA indicated that neither

pretesting nor facilitation had a significant effect on posttest measures of knowledge.

Paired t tests of groups receiving both the pretest and posttest demonstrated

significant increase in knowledge (mean increase, 10.87%; P20 years, over a 6- to 9-month period. From the initially enrolled

138 volunteers, 60 subjects completed pretest and posttest carotid IMT data. The

assigned interventions were either the TM program or a health education group. By

use of B-mode ultrasound, mean maximum IMT from 6 carotid segments was used

to determine pretest and posttest IMT values. Regression analysis and ANCOVA

were performed. Results-Age and pretest IMT were found to be predictors of posttest

IMT values and were used as covariates. The TM group showed a significant

decrease of -0.098 mm (95% CI -0.198 to 0.003 mm) compared with an increase of

0.054 mm (95% CI -0.05 to 0.158 mm) in the control group (P=0.038, 2-tailed).

Conclusions-Stress reduction with the TM program is associated with reduced

carotid atherosclerosis compared with health education in hypertensive African

Americans, Further research with this stress-reduction technique is warranted to

confirm these preliminary findings

Keywords: African/African American/African Americans/aged/ARTERIAL- WALL

THICKNESS/atherosclerosis/blacks/BLOOD-PRESSURE/cardiovascular

disease/CARDIOVASCULAR REACTIVITY/carotid/carotid

arteries/COLESTIPOL-NIACIN THERAPY/control/coronary/coronary heart

disease/CORONARY HEART-DISEASE/education/ETHNIC-

DIFFERENCES/health/health education/INTIMA-MEDIA

THICKNESS/men/mortality/predictors/risk/risk

factors/RISK-FACTORS/stress/STROKE/TRANSCENDENTAL-MEDITATION/ul

trasonography/whites/women/WORKPLACE DEMANDS

Hebert, R., Lindsay, J., Verreault, R., Rockwood, K., Hill, G. and Dubois, M.F. (2000),

Vascular dementia - Incidence and risk factors in the Canadian Study of Health and

Aging. Stroke, 31 (7), 1487-1493.

Abstract: Background and Purpose-Very few population-based studies have

systematically examined incident vascular dementia (VaD). From the Canadian

Study of Health and Aging cohort, incidence rates of VaD were determined and risk

factors analyzed. Methods-This was a cohort incidence study that followed 8623

subjects presumed to be free of dementia over a 5-year period. The risk factors were

examined with a nested prospective case-control study. Exposure was determined by

means of a risk factor questionnaire administered to the subject or a proxy at the

beginning of the study. Results-On the basis of 38 476 person years at risk, the

annual incidence rate was estimated to be 2.52 per thousand undemented Canadians

(95% CI 2.02 to 3.02). Including an estimation of the probability of VaD among the

decedents, this figure rose to 3.79. For the risk factors study, 105 incident cases of

VaD according to the NINCDS-AIREN criteria were compared with 802 control

subjects. Significant risk factors were: age (OR=1.05), residing in a rural area (2.03),

living in an institution (2.33), diabetes (2.15), depression (2.41), apolipoprotein E

epsilon 4 (2.34), hypertension for women (2.05), heart problems for men (2.52),

taking aspirin (2.33), and occupational exposure to pesticides or fertilizers (2.05).

Protective factors were eating shellfish (0.46) and regular exercise for women (0.46).

There was no relation with sex, education, or alcohol. Conclusions-The study

confirmed some previously reported risk factors but also suggested new ones. It

raised concerns about the prescription of aspirin and perhaps other factors related to

rural life

Keywords: age/alcohol/ALLELE FREQUENCY/ALZHEIMERS-

DISEASE/apolipoprotein E/APOLIPOPROTEIN-E

EPSILON-4/aspirin/case-control/cerebrovascular

disorders/cohort/COMMUNITY/control/dementia/depression/diabetes/DIAGNOSIS/

education/ELDERLY

POPULATION/epidemiology/exercise/hypertension/incidence/men/MULTI-INFAR

CT DEMENTIA/occupational/PREVALENCE/PROJECT/questionnaire/risk/risk

factor/risk factors/STROKE/vascular/vascular dementia/women

Hart, C.L., Hole, D.J. and Smith, G.D. (2000), Influence of socioeconomic

circumstances in early and later life on stroke risk among men in a Scottish cohort

study. Stroke, 31 (9), 2093-2097.

Abstract: Background and Purpose-The purpose of the study was to investigate stroke

risk by socioeconomic measures. Methods-The analysis was based on a large cohort

study of 5765 working men, from 27 workplaces in Scotland, who were screened

between 1970 and 1973. Stroke was defined as having a hospital admission with a

main diagnosis of stroke or dying of stroke in the 25- year follow-up period.

Results-There were 416 men who had a stroke. Men with manual occupations when

screened, on first entering the workforce, men with manual occupations, and men

whose fathers had manual occupations had significantly higher rates of stroke than

men in the nonmanual categories. Men who left hull-time education at age 16 years

or under also had significantly higher rates of stroke. Men living in more deprived

areas had higher rates of stroke, but the rates were not statistically significant. The

most marked difference was in relation to father's social class, and although adjusting

for risk factors for stroke attenuated the relative rates, men whose fathers were in

manual social classes had higher relative rates of stroke than men whose fathers were

in nonmanual classes (adjusted relative rate for father's social class III manual was

1.37 [95% CI 1.03 to 1.81] and for father's social class IV or V was 1.46 [1.09 to

1.96]), Men who were upwardly mobile (father's social class manual, own social

class nonmanual) had a rate of stroke similar to that of stable manual men.

Conclusions-Poorer socioeconomic circumstance was associated with greater stroke

risk, with adverse early-life circumstances of particular importance

Keywords: ADULT MORTALITY/age/CARDIOVASCULAR-

DISEASE/cerebrovascular disorders/CHILDHOOD/cohort study/CORONARY

HEART-DISEASE/diagnosis/education/epidemiology/FOLLOW-UP/hospital/INEQ

UALITIES/men/MIDDLE-AGED MEN/prospective studies/risk/risk

factors/SCOTLAND/social/social

class/SOCIAL-CLASS/socioeconomic/stroke/WOMEN

Kernan, W.N., Viscoli, C.M., Brass, L.M., Makuch, R.W., Sarrel, P.M. and Horwitz,

R.I. (2000), Blood pressure exceeding national guidelines among women after stroke.

Stroke, 31 (2), 415-419.

Abstract: Background and Purpose-After a transient ischemic attack or stroke, the risk

for recurrence may be reduced by treatment of hypertension. The purpose of this

study was to determine how commonly blood pressure exceeds national guidelines

among patients who have had one of these events. Methods-Subjects were 644

women participating in a randomized trial of estrogen for secondary stroke

prevention. We measured blood pressure 1 month after the stroke or TIA while

patients were under the care of their personal physicians. Among 536 patients, a

second measure was made at an average of 2.9 years after the first. Results-The mean

age of participants was 71 years, and 73% reported a history of hypertension. At

baseline, only 44% (280/644) of the women had blood pressure values within

national guidelines (160/100 mmHg)

were history of hypertension, education less than college, and higher cognitive

functioning. Conclusions-Blood pressure values in excess of national guidelines are

common after stroke and TIA, especially among diabetic patients. Efforts to lower

blood pressure control may enhance secondary prevention

Keywords: ACUTE MYOCARDIAL-INFARCTION/adherence/age/blood

pressure/cerebrovascular disorders/cognitive

functioning/common/control/CT/education/estrogen/EVENTS/guidelines/HEALTH/

health services research/HEART-

DISEASE/HYPERTENSION/hypertension/ischemic/PREVENTION/prognosis/rand

omized clinical trials/RECURRENCE/RISK/stroke/stroke

prevention/TIA/transient/TRANSIENT ISCHEMIC

ATTACKS/treatment/TRIALS/women

Zhu, L., Fratiglioni, L., Guo, Z.C., Basun, H., Corder, E.H., Winblad, B. and Viitanen,

M. (2000), Incidence of dementia in relation to stroke and the apolipoprotein E

epsilon 4 allele in the very old - Findings from a population-based longitudinal study.

Stroke, 31 (1), 53-60.

Abstract: Background and Purpose-Both stroke and the apolipoprotein E (APOE)

epsilon 4 allele increase the risk of dementia. However, the interaction between

stroke and APOE on dementia is still unclear. We addressed this topic by using a

longitudinal design. Methods-We followed up a community cohort of 1301 subjects

aged greater than or equal to 75 years, who did not have dementia at baseline.

Among them, 92 subjects had a history of stroke (from 3 months to 16 years before

baseline interview). After the 3-year follow-up, 224 dementia cases had been

diagnosed. During the period of follow-up, 91 subjects had a first occurrence of

stroke (incident stroke). The APOE genotype was known for 985 subjects. Cox

proportional hazards regression models were constructed to estimate the risk for

dementia in terms of relative risks (RRs) for stroke and the APOE epsilon 4 allele,

with adjustment for age, sex, education, systolic blood pressure, antihypertensive

medication use, and heart disease. Results-In the entire study population, RRs for

dementia related to history of stroke and incident stroke were 1.7 (95% CI, 1.1 to 2.6)

and 2.4 (95% CI, 1.6 to 3.5), respectively, after adjustment for all potential

confounders. Subjects with stroke that occurred within 3 years before baseline had

RR of 2.4 (95% CI, 1.4 to 4.2), whereas those with stroke occurring >3 years before

baseline had RR of dementia of 1.1 (95% CI, 0.6 to 2.3). Among those with APOE

information, individuals with only history of stroke (that occurred within 3 years

before baseline) had RR of 3.1 (95% CI, 1.4 to 6.6), individuals with only the APOE

epsilon 4 allele had RR of 1.7 (95% CI, 1.1 to 2.5), and individuals with both factors

had RR of 5.3 (95% CI, 2.1 to 13.4). The corresponding figures when incident stroke

was examined instead of history of stroke were 2.3 (95% CI, 1.3 to 4.1), 1.7 (95% CI,

1.1 to 2.4), and 4.6 (95% CI, 2.0 to 10.6), respectively. The RR of interaction term

for history of stroke and APOE epsilon 4 was 1.1 (95% CI, 0.3 to 3.8; P=0.8). The

corresponding figure was 1.2 (95% CI, 0.4 to 3.4; P=0.7) for incident stroke and

APOE epsilon 4. Furthermore, the RRs of dementia without any stroke and dementia

with stroke in relation to APOE epsilon 4 were 1.6 (95% CI, 1.1 to 2.3) and 1.2 (95%

CI, 0.6 to 2.4), respectively. In addition, the APOE epsilon 4 allele was not

significantly related to the occurrence of stroke (RR=0.8; 95% CI, 0.5 to 1.5).

Conclusions-A relatively fresh stroke is a risk factor for dementia. APOE epsilon 4

increases the risk of dementia without stroke but not dementia with stroke. Our data

do not support a multiplicative effect of stroke and the APOE epsilon 4 allele on the

risk of dementia. However, both factors seem to have an additive effect on the risk of

dementia. The APOE epsilon 4 allele does not increase the risk of stroke in this

Swedish elderly population

Keywords: age/aged/ALZHEIMERS-DISEASE/antihypertensive

medication/APOE/apolipoprotein E/apolipoproteins/blood

pressure/CEREBROVASCULAR-DISEASE/cohort/community/dementia/E

GENOTYPE/E POLYMORPHISM/education/elderly/HOSPITALIZED

COHORT/ISCHEMIC STROKE/KUNGSHOLMEN- PROJECT/LINE

FREQUENCY/longitudinal/longitudinal

study/MINI-MENTAL-STATE/population/risk/risk

factor/sex/stroke/Sweden/VASCULAR DEMENTIA/very old

Dik, M.G., Deeg, D.J.H., Bouter, L.M., Corder, E.H., Kok, A. and Jonker, C. (2000),

Stroke and apolipoprotein E epsilon 4 are independent risk factors for cognitive

decline - A population-based study. Stroke, 31 (10), 2431-2436.

Abstract: Background and Purpose-Stroke and apolipoprotein E epsilon 4 (ApoE

epsilon 4) are individually important risk factors for cognitive decline, including

Alzheimer disease. It has been suggested that ApoE epsilon 4 multiplies the risk for

cognitive decline following stroke. In a population-based sample, using well-defined

sensitive cognitive measures, this study investigates whether cognitive decline

following stroke is worse for patients who carry the ApoE epsilon 4 allele.

Methods-Subjects were participants in the Longitudinal Aging Study Amsterdam

(LASA). The sample consisted of 1224 subjects, aged 62 to 85 years, who

participated in the 3-year follow-up examination and for whom ApoE and stroke data

were complete. We assessed cognitive decline using the Mini-Mental State

Examination, the Auditory Verbal Learning Test (memory: immediate and delayed

recall), and the Coding Task (information processing speed). The effects of stroke

and ApoE epsilon 4 on cognitive decline were evaluated with ANOVA and multiple

logistic regression analysis, adjusted for age, sex, education, and baseline cognition.

Results-A synergistic effect modification for stroke and ApoE epsilon 4 on cognitive

decline was not observed. Unexpectedly, instead, stroke patients canying the epsilon

4 allele demonstrated a nonsignificantly lowered risk for Mini-Mental State

Examination decline (R = 0.3; 95% CI 0.1 to 1.1). ApoE epsilon 4 was associated

with declines in information processing speed (OR=1,5; 95% CI 1.1 to 2.1) and small

declines for immediate and delayed recall. Conclusions-Stroke and ApoE epsilon 4

may impair cognition through distinct nonsynergistic mechanisms. The slowing of

information processing speed for ApoE epsilon 4 carriers was more evident than

impairment in memory

Keywords: ADULTS/age/aged/ALLELE/Alzheimer

disease/ALZHEIMERS-DISEASE/APOE EPSILON-4/apolipoprotein

E/apolipoproteins/CEREBROVASCULAR-DISEASE/cognition/cognitive

decline/DEMENTIA/DEPRESSION/education/longitudinal

studies/memory/population/population-based study/risk/risk

factors/ROTTERDAM/SAMPLE/stroke/stroke patients

Wein, T.H., Staub, L., Felberg, R., Hickenbottom, S.L., Chan, W.Y., Grotta, J.C.,

Demchuk, A.M., Groff, J., Bartholomew, L.K. and Morgenstern, L.B. (2000),

Activation of emergency medical services for acute stroke in a nonurban population -

The TLL Temple Foundation Stroke Project. Stroke, 31 (8), 1925-1928.

Abstract: Background and Purpose-Activating emergency medical services (EMS) is the

most important factor in reducing delay times to hospital arrival for stroke patients.

Determining who calls 911 for stroke would allow more efficient targeting of public

health initiatives. Methods-The T.L.L. Temple Foundation Stroke Project is an acute

stroke surveillance and intervention project in nonurban East Texas. Prospective case

ascertainment allowed chart abstraction and structured interviews for all hospitalized

stroke patients to determine if EMS was activated, and if so, by whom. Results-Of

429 validated strokes, 38.0% activated EMS by calling 911. Logistic regression

analysis comparing those who called 911 with those who did not activate EMS found

that individuals who were employed were 81% less likely to have EMS activated

(OR 0.19, 95% CI 0.04 to 0.63). Of the 163 cases in which 911 was called, the

person activating EMS was: self (patient), 4.3%; family member of significant other,

60.1%; paid caregiver, 18.4%; and coworker or other, 12.9%. Significant

associations between the variables age group (P=0.02), insurance status (P=0.007),

and living alone (P=0.05) with who called 911 was found on chi(2) analysis.

Conclusions- Educational efforts directed at patients themselves at risk for stroke

may be of low yield. To increase the use of time dependent acute stroke therapy,

interventions may wish to concentrate on family, caregivers, and coworkers of

high-risk patients. Large employers may be good targets to increase utilization of

EMS services for acute stroke

Keywords: acute/acute

stroke/age/ambulance/CARE/caregivers/DELAYS/education/emergency medical

services/EMS/health/hospital/KNOWLEDGE/medical/population/public

health/risk/RISK-FACTORS/SIGNS/stroke/stroke

patients/SYMPTOMS/TIME/utilization

Estrada, C.A., Hryniewicz, M.M., Higgs, V.B., Collins, C. and Byrd, J.C. (2000),

Anticoagulant patient information material is written at high readability levels.

Stroke, 31 (12), 2966-2970.

Abstract: Background-Warfarin therapy requires frequent monitoring and dose

adjustment. Elderly patients with atrial fibrillation, prior stroke, and lower literacy

skills may have difficulty reading brochures that explain dosing instructions,

procedures to follow, and the risks and benefits of anticoagulants. In general, it is

recommended that brochures be written at or below the 6th-grade level. We

determined the readability of patient information material being offered to patients

receiving anticoagulants. Methods and Results-We used the SMOG grade formula to

measure readability of written patient materials. We obtained 50 brochures

commonly used in anticoagulation management units from industry and health

advocacy groups. Patient information was related to atrial fibrillation (16%, n=8),

warfarin (44%, n=22), low-molecular- weight heparins (12%, n=6), or other related

topics (28%, n=14). The mean readability was found to be grade 10.7 (95% CI 10.1

to 11.2); none had a readability score at the 6th-grade level or below, 12% of the

brochures had readability scores at the 7th- to 8th-grade levels (n=6), 74% at the 9th-

to 12th- grade levels (n=37), and 14% at higher than 12th-grade level (n=7). The

readability grade level was similar for brochures produced by industry or health

advocacy groups (P=0.9) but higher for information obtained from the Internet

(12.2+/-1.3 grades) compared with other sources (10.3+/-2.1 grades; P=0.01).

Conclusions-Patient education materials related to the use of anticoagulants are

written at grade levels beyond the comprehension of most patients. Low-literacy

brochures are needed for patients on anticoagulants

Keywords: anticoagulants/anticoagulation/atrial fibrillation/deep vein

thrombosis/education/EDUCATION LITERATURE/FUNCTIONAL HEALTH

LITERACY/health/health education/literacy/monitoring/patient

compliance/STROKE/stroke prevention/warfarin

Billings-Gagliardi, S., Fontneau, N.M., Wolf, M.K., Barrett, S.V., Hademenos, G. and

Mazor, K.M. (2001), Educating the next generation of physicians about stroke -

Incorporating stroke prevention into the medical school curriculum. Stroke, 32 (12),

2854-2858.

Abstract: Background and Purpose-In response to the need to educate physicians about

stroke, we have implemented an educational program on stroke prevention for

undergraduate medical students within the first-year neuroscience course. This study

investigated whether first-year students learned and retained key information about

stroke, and used students' feedback both to identify effective curricular component,

and to explore their attitudes regarding stroke prevention. Methods-Stroke

knowledge and self-assessed confidence in that knowledge before, immediately after,

and 8 months after participation in the stroke curriculum were analyzed and

compared for 3 classes, using paired t tests and repeated-measures ANOVA. Student

feedback about the effectiveness of specific parts of the curriculum and about the

importance of stroke prevention was solicited and evaluated. Results-First-year

medical students in 3 classes more than doubled their overall stroke knowledge

scores (pretest total mean of 8.2: posttest mean 18.0). and retained significant

improvement 8 month,, later (mean 15.7). Subscores in all 4 areas of stroke

knowledge tested significantly increased (P 82) in never- treated subjects, was 1.3 (95%

CI 0.9 to 1.9) for the normal SBP/epsilon4 category, 2.6 (0.7 to 10.0) for the high

SBP/no epsilon4, and 13.0 (1.9 to 83.8) for the high SBP/epsilon4. Adjustment for

diabetes, prevalent stroke. coronary disease, and ankle-brachial index reduced the RR

of poor cognition by 25.5% (RR 13.0 to 10.8) in those with both risk factors. In the

treated group, the RR was 1.9 (0.7 to 4.5) for those with both risk factors.

Conclusions-The results suggest that midlife high SBP has a stronger adverse effect

oil cognitive function in persons with higher genetic susceptibility, but this effect

may be modified by antihypertensive treatment

Keywords:

age/aged/aging/alcohol/ALLELE/ALZHEIMERS-DISEASE/APOE/APOLIPOPRO

TEIN-E POLYMORPHISM/blood pressure/cognition/cognitive function/cognitive

impairment/coronary/coronary

disease/DECLINE/DEMENTIA/diabetes/education/function/genetics/HYPERTENSI

ON/IN- VITRO/ISOFORM-SPECIFIC DIFFERENCES/men/NEUROFIBRILLARY

TANGLES/relative risk/risk/risk

factors/RISK-FACTORS/smoking/STROKE/treatment

Everson, S.A., Lynch, J.W., Kaplan, G.A., Lakka, T.A., Sivenius, J. and Salonen, J.T.

(2001), Stress-induced blood pressure reactivity and incident stroke in middle-aged

men. Stroke, 32 (6), 1263-1269.

Abstract: Background and Purpose - Exaggerated blood pressure reactivity to stress is

associated with atherosclerosis and hypertension, which are known stroke risk factors,

but its relation to stroke is unknown. Previous work also indicates that the

association between reactivity and cardiovascular diseases may be influenced by

socioeconomic status. Methods - The impact of blood pressure reactivity and

socioeconomic status on incident stroke was examined in 2303 men (mean age, 52.8

+/-5.1 years) from a population-based, longitudinal study of risk factors for ischemic

heart disease in eastern Finland. Reactivity was calculated as the difference between

blood pressure measured during the anticipatory phase of an exercise tolerance test

(before exercise) and resting blood pressure, measured 1 week earlier. Mean systolic

reactivity was 20 mm Hg (+15.9), and mean diastolic reactivity was 8.6 mm Hg

(+8.5). Socioeconomic status was assessed as years of education. One hundred

thirteen incident strokes (90 ischemic) occurred in 11.2 (+1.6) years of follow-up.

Results - Men with exaggerated systolic reactivity (greater than or equal to 20 mm

Hg) had 72% greater risk of any stroke (relative hazard ratio [RH], 1.72; 95% CI,

1.17 to 2.54) and 87% greater risk of ischemic stroke (RH, 1.87; 95% CI, 1.20 to

2.89) relative to less reactive men. Moreover, men who were high reactors and

poorly educated were nearly 3 times more likely to suffer a stroke than better

educated, less reactive men (RH, 2.90; 95% CI, 1.66 to 5.08). Adjustment for stroke

risk factors had little impact on these associations. Diastolic reactivity was unrelated

to stroke risk. Conclusions - Excessive sympathetic reactivity to stress may be

etiologically important in stroke, especially ischemic strokes, and low socioeconomic

status confers added risk

Keywords: age/atherosclerosis/blood pressure/cardiovascular

diseases/CARDIOVASCULAR REACTIVITY/CAROTID

ATHEROSCLEROSIS/diseases/education/exercise/Finland/hypertension/impact/isc

hemia/ischemic/ischemic

stroke/ISCHEMIC-HEART-DISEASE/longitudinal/men/PROGRESSION/PSYCHO

LOGICAL STRESS/reactivity/RESPONSES/risk/risk

factors/RISK-FACTORS/social class/socioeconomic/socioeconomic

status/SOCIOECONOMIC-STATUS/stress/stress

stroke/stroke/WHITEHALL-II/YOUNG MEN

Malarcher, A.M., Giles, W.H., Croft, J.B., Wozniak, M.A., Wityk, R.J., Stolley, P.D.,

Stern, B.J., Sloan, M.A., Sherwin, R., Price, T.R., Macko, R.F., Johnson, C.J., Earley,

C.J., Buchholz, D.W. and Kittner, S.J. (2001), Alcohol intake, type of beverage, and

the risk of cerebral infarction in young women. Stroke, 32 (1), 77-83.

Abstract: Background and Purpose - The relationship between alcohol consumption and

cerebral infarction remains uncertain, and few studies have investigated whether the

relationship varies by alcohol type or is present in young adults. We examined the

relationship between alcohol consumption, beverage type, and ischemic stroke in the

Stroke Prevention in Young Women Study. Methods-All 59 hospitals in the greater

Baltimore-Washington area participated in a population-based case-control study of

stroke in young women. Case patients (n=224) were aged 15 to 44 years with a first

cerebral infarction, and control subjects (n=392), identified by random-digit dialing,

were frequency matched by age and region of residence. The interview assessed

lifetime alcohol consumption and consumption and beverage type in the previous

year, week, and day. ORs were obtained from logistic regression models controlling

for age, race, education, and smoking status, with never drinkers as the referent.

Results-Alcohol consumption, up to 24 g/d, in the past year was associated with

fewer ischemic strokes (24 g/d: OR 0.95, 95% CI 0.43 to 2.10) in comparison to

never drinking. Analyses of beverage type (beer, wine, liquor) indicated a protective

effect for wine consumption in the previous year (64).

Conclusions-Reduced preoperative endotoxin immunity is a predictor of increased

postoperative cognitive dysfunction in patients undergoing CABG, particularly in

those >60 years old. Interventions that increase IgM EndoCAb levels might improve

cognitive function after cardiac surgery

Keywords: ACUTE STROKE/ADHESION MOLECULES/age/ANTIENDOTOXIN

CORE ANTIBODIES/CARDIOPULMONARY BYPASS/cognition/cognitive

disorders/cognitive dysfunction/cognitive function/coronary/coronary artery bypass

graft surgery/coronary artery bypass surgery/CORONARY-BYPASS

SURGERY/education/elderly/endotoxemia/etiology/function/hypertension/incidence

/INTERLEUKIN-6/MORTALITY/NEUROCOGNITIVE FUNCTION/quality of

life/SEPTIC SHOCK/severity/STROKE/surgery/TUMOR- NECROSIS-FACTOR

Hsiang, J.N.K., Zhu, X.L., Wong, L.K.S., Kay, R. and Poon, W.S. (1996), Putaminal

and thalamic hemorrhage in ethnic Chinese living in Hong Kong. Surgical

Neurology, 46 (5), 441-445.

Abstract: BACKGROUND Hemorrhagic stroke is very common in the Chinese

population, and it is one of the leading causes of mortality in Chinese communities.

The risk factors to explain this high incidence are unknown, It is the purpose of this

study to look into the features of hemorrhagic stroke in the Hong Kong Chinese.

METHODS We conducted a prospective hospital-based study in which 60

consecutive Chinese patients with computed tomography diagnosis of putaminal or

thalamic hemorrhage were included, Their demographic and clinical data were

collected and analyzed. RESULTS Two major findings evolved from the present

study. (1) Unlike the Western studies, the majority of our patients were about a

decade younger; (2) 50% of the patients had previously diagnosed hypertension, but

only 20% of these patients were compliant with their antihypertensive medication,

Our results also suggested that low admission Glasgow Coma Scale scores, large

hematoma size, and the presence of intraventricular blood were associated with poor

outcomes. CONCLUSIONS This study concludes that hemorrhagic stroke is indeed

a serious health problem in Hong Kong. Simple measures, such as improvement of

health education and the primary care system in the management of hypertension,

would help to reduce the incidence of hemorrhagic stroke. (C) 1996 by Elsevier

Science Inc

Keywords: CEREBROVASCULAR-DISEASE/Chinese/diagnosis/education/ethnic

Chinese/health education/hemorrhagic

stroke/hypertension/incidence/MORTALITY/PREDICTION/primary intracerebral

hemorrhage/PROSPECTIVE RANDOMIZED TRIAL/putaminal hemorrhage/risk

factors/SPONTANEOUS INTRACEREBRAL HEMORRHAGE/stroke/STROKE

REGISTRY/thalamic hemorrhage/TRENDS

Ojo, A.O., Wolfe, R.A., Leichtman, A.B., Dickinson, D.M., Port, F.K. and Young, E.W.

(1999), A practical approach to evaluate the potential donor pool and trends in

cadaveric kidney donation. Transplantation, 67 (4), 548-556.

Abstract: Background. The potential supply of transplantable cadaver kidneys is often

expressed as donors per million population (pmp), which ignores some essential

factors governing organ donation. Methods. We performed a modeled analysis of

kidney donor extraction rates by age, gender, race, cause of death, geographic region,

and year in a cohort of evaluable deaths and actual cadaver donors between the ages

of 1 and 65 years (1988- 1993). Evaluable death was defined as an in-hospital death

in patients between the ages of 1 and 65 years whose ICD-9-CM cause of death was

not an obvious contraindication to kidney donation, The main outcome measures

were the crude donation rate and an adjusted donor extraction rate (DER) per 1000

evaluable deaths. Results. A total of 1.4x10(6) in-hospital deaths produced 300,502

evaluable deaths and 20,575 actual donors, Between 1989 and 1993, DER increased

from 61.1 to 75 per 1,000 evaluable deaths. DERs were highest among the youngest

age groups, declining significantly with age from 405.0 to 16.7/1,000 evaluable

deaths for age groups 1-10 and 56-65 years, respectively. There was a small

difference in donors pmp between blacks and whites (15 vs. 18), In contrast, DER

was seven times higher in whites compared with blacks (112.5 vs. 16.5/1,000

evaluable deaths; P<0.001), The crude donation rate (per 1,000 evaluable deaths)

was high for stroke (604.8) and trauma-related deaths (230.6), resulting in highly

efficient donor extraction from these deaths, Region-specific DERs ranged from 49.4

to 83/1,000 evaluable deaths and differed significantly from the corresponding

donors pmp, Conclusions. Estimating kidney donation relative to in-hospital

evaluable deaths is a meaningful measure of organ procurement efficiency. Efforts to

enhance cadaveric kidney donation should seek to understand and reduce the marked

demographic and regional disparity in donor extraction rates

Keywords: age/BLACKS/DEATHS/MINORITY ORGAN

TISSUE/PERFORMANCE/POPULATION/PROCUREMENT/race/SHORTAGE/str

oke/TRANSPLANT EDUCATION-PROGRAM/whites

Yang, H.Y., Li, X.H., Cao, W.H., Lu, J., Wang, T., Zhan, S.Y., Hu, Y.H. and Li, L.M.

(2002), Chinese national twin registry as a resource for genetic epidemiologic studies

of common and complex diseases in China. Twin Research, 5 (5), 347-351.

Abstract: Twins, due to their unique genetic and environmental relation ships, have

provided crucial insight in our understanding of genetic contributions to numerous

etiologically complex disorders in developed countries. As the leading cause of death

and adult disability, cardio- and cerebrovascular diseases are common in China,

followed by cancer. Obesity and psychological disorders are increasing. The overall

goal of this program is to develop a resource for genetic epidemiologic studies of

these and other common and complex diseases in China. Our initial focus is to

delineate the genetic and environmental determinants of vascular diseases in general,

coronary artery disease (CAD) and stroke in particular. To date, we have over 4500

twin pairs registered and about 700 twin pairs studied for various metabolic traits

(e.g., lipids, glucose, insulin, etc.). The long-term plan of this program is to (1)

establish a population-based twin registry from several selected regions in China for

future studies of specific common complex diseases; (2) conduct detailed

phenotyping for clinical and intermediate traits related to cardiovascular diseases; (3)

expand studies of twins to twin families by including their parents, siblings, and

offspring for genetic linkage and association studies; and (4) follow up twins in the

registry longitudinally. The goals of the program are health education and promotion

of healthy behavior, early identification of cases to provide timely medical attention,

and the evaluation of long-term effects of identified risk factors. We want to develop

collaborations with investigators who have expertise in cancer, psychological

disorders, and other disease areas

Keywords: adult/AUSTRALIA/cardiovascular diseases/cerebrovascular

diseases/China/Chinese/coronary/disability/diseases/education/health/health

education/lipids/registry/risk/risk factors/stroke/vascular diseases

Schneider, J.R., Droste, J.S. and Golan, J.F. (1997), Impact of carotid endarterectomy

critical pathway on surgical outcome and hospital stay. Vascular Surgery, 31 (6),

685-692.

Abstract: Carotid endarterectomy (CEA) is associated with substantial consumption of

hospital days and other resources, Although surgical outcomes in their practice

compared favorably with published benchmarks, the authors were concerned that

postoperative stays were unnecessarily long and that patients were receiving

unnecessary tests and pharmaceuticals. Recent studies suggest that within the bounds

oft safe practice, efforts to standardize care may increase quality and patient

satisfaction and reduce consumption of resources. They examined their practice of

CEA in an effort to discover the potential for quality improvement and decreased

utilization of resources. A CEA critical pathway (CP) was designed, the primary goal

of which was elimination of a possibly unnecessary second postoperative hospital

day for most patients and superfluous perioperative testing and medications. Data

were recorded prospectively both for Pre-CP patients during the year prior to CP

initiation and for subsequent CP patients during the subsequent 13-month period. CP

patients were interviewed and the pathway was described prior to surgery. Pre-CP

and CP patients were indistinguishable with respect to indications for CEA and

medical comorbidities. A single operative death occurred due to myocardial

infarction (Pre-CP). Perioperative stroke and other complications occurred in similar

numbers of Pre-CP and CP patients. CP resulted in a 0.5-day decrease in hospital

stay overall. CP was also associated with a 22% decrease in direct costs. One early

readmission for neck hematoma on postoperative day 2 (1 day postdischarge) might

have been preventable. A second readmission on postoperative day 2 was secondary

to a drug reaction and would likely have occurred prior to initiation of the CP as well,

CP resulted in significant decreases in resource utilization and with the possible

exception of a single readmission did not appear to adversely affect outcome,

Preoperative education and expectation that patients will be ready for discharge I day

after CEA are critical to patient acceptance and satisfaction. Further modification of

the CP may further decrease utilization of resources. CP is an excellent mechanism

to understand how surgeons practice and it facilitates quality improvement

Keywords: ANESTHESIA/ARTERIOGRAPHY/ARTERY/carotid

endarterectomy/costs/DISEASE/education/HYPERTENSION/INTENSIVE-CARE

UNIT/ISCHEMIA/myocardial infarction/SAFETY/SELECTIVE

USE/stroke/SUGGESTED STANDARDS/surgery/utilization

McKnight, R.H., Dawson, S.K., Westneat, S.C., Rodgers, G.C. and Ross, M.P. (1996),

Delay among the general public in telephoning a poison center. Veterinary and

Human Toxicology, 38 (2), 92-95.

Abstract: Delay in seeking treatment for poisonings can hinder patient recovery. Our

study examined delay in notifying a poison center about green tobacco sickness

(GTS), a form of nicotine poisoning resulting from dermal contact with tobacco

leaves. We conducted a follow-up survey of 55 cases of GTS reported by telephone

to the Kentucky Regional Poison Center in 1993. The ''delay'' group (38.2% of the

cases) was defined as those callers who stated in the follow-up report that they

should have phoned the poison center sooner than they did. Characteristics of the

callers who delayed and the GTS patients they reported were compared with

characteristics of the ''non- delay'' group. Delay was associated with callers'

awareness of the poison center's expertise in agricultural poisonings and with age and

sex of the patient. Our findings point to the need to target groups such as farmers

with an educational campaign to make them more aware of the extent of the poison

center's services and to encourage timely reporting of occupational poisonings

Keywords: age/CARE/CHEST

PAIN/EDUCATION/INJURY/MYOCARDIAL-INFARCTION/ONSET/PREHOSPI

TAL DELAY/SEEKING/STROKE/survey/SYMPTOMS/TIME/treatment

Scarlett, M. and Spencer, H. (2001), Severe neurological complications post-open heart

surgery - The Jamaican experience. West Indian Medical Journal, 50 (4), 297-303.

Abstract: During the period January 1994 to December 1999, a total of 395 patients -

adults and children - underwent various types of open heart surgical (OHS)

procedures. The age range of these patients was 10 days to 77 years. Most (43.5%) of

these patients underwent valve replacement - first time and 'redo' - as a result of

rheumatic heart disease of varying duration and severity. The other large group was

the complex congenital heart abnormalities (16%), followed by the group that

underwent repair of atrial septal defect (13%), coronary artery bypass graft (13%)

and repair of ventricular septal defect (12%). Open valve repair (2%) and excision of

atrial myxoma (0.5%) were uncommon OHS procedures. Nine patients (2.3%)

developed severe neurological complications (NCs) post-OHS. These included: a

short period (< 48 hours) of irritability and fluctuating consciousness level; seizure

activity associated with hemiparesis and/or blindness; severe encephalopathy and

vegetative state. Four patients showed complete recovery, but one died as a result of

complications of the anti-seizure medication. Of the other five, four died as a result

of the NCs, and one was discharged in a vegetative state. Such severe neurological

complications after an otherwise successful cardiac surgery represent a devastating

outcome for patients and their families, and the social and economic impacts are

enormous, Several risk factors were identified. The main ones being mitral valve

replacement (MVR), especially 'redo' surgery, female gender, age over 60 years, high

New York Heart Association functional class and post-operative hypotension.

However, the true incidence of NCs (gross and subtle) in the study group cannot be

ascertained. A detailed, structured neurological and neuropsychiatric assessment,

both pre- and post-operatively, is therefore needed to document the true incidence of

this complication. There is also the need for public education, especially for those

with valvular disease, in. order to encourage changes in attitude and behaviour

towards continued follow-up care and valve surgery, both first time and 'redo'

Keywords: age/ASCENDING

AORTA/assessment/CARDIAC-SURGERY/CARDIOPULMONARY

BYPASS/coronary/economic/education/gender/incidence/MANAGEMENT/MEDIC

AL/outcome/OUTCOMES/RISK/risk

factors/severity/social/STRATEGY/STROKE/surgery

Sargeant, L.A., Wilks, R.J. and Forrester, T.E. (2001), Chronic diseases - Facing a

public health challenge. West Indian Medical Journal, 50 27-31.

Abstract: Middle income countries like those in the Caribbean can feel proud of their

achievements in health care. There has been a dramatic fall-off in infant mortality

and crude mortality rates along with significant improvements in life expectancy at

birth. However, these countries now find themselves grappling with the burden of

chronic non-communicable diseases such as heart disease, stroke, hypertension,

diabetes mellitus and cancer, There are good data to support the view that some of

these diseases, in particular diabetes mellitus, have assumed epidemic proportions

and there is concern that this fact may have been missed by many because of the

surreptitious onset, as is the nature of the chronic diseases. The impact of this

epidemic may have suffered because of the higher profile of more topical issues like

HIV/AIDS even though the former makes a larger contribution to morbidity, and

mortality statistics. It is now obvious that despite the impact of other factors, lifestyle

changes are the major contributors to the epidemic. In populations of similar genetic

stock, living in significantly) different socio-economic circumstances, the impact of

increased dietary salt, increasing obesity and decreased physical activity on the

prevalence of hypertension, diabetes mellitus and livid disorders is unequivocal. Data

from the developed world, which has already been through this epidemic of chronic

diseases, have shown that increasing technological advances in medical care is an

inefficient way to respond to the situation. A multi-sectoral approach is required to

tackle this epidemic, including the provision of incentives for healthy eating and

widespread opportunities for increased exercise and other physical activities.

Continued research into the evolution of the epidemic, including reliable estimates

via surveillance methods is a necessary component of our response. The problems

and the solutions are not only the responsibilities of the health officials but must

involve education, agriculture and other sectors of the economy

Keywords: burden/diabetes/diabetes

mellitus/DIABETES-MELLITUS/diseases/education/EPIDEMIOLOGIC

TRANSITION/exercise/GLOBAL

BURDEN/health/hypertension/impact/lifestyle/MEDICAL/morbidity/MORTALITY

/NIDDM/obesity/physical activity/POPULATION/PREVALENCE/public

health/socioeconomic/stroke/WORLD

Ragland, D.R., Buffler, P.A., Reingold, A.L., Syme, S.L. and Buffler, M.L. (1998),

Disease and injury in California with projections to the year 2007 - Implications for

medical education. Western Journal of Medicine, 168 (5), 378-399.

Abstract: In this article, as part of an evaluation of the future of medical education in

California, we characterize the distribution of disease and injury in California;

identify major factors that affect the epidemiology of disease and injury in California,

and project the burden of disease and injury for California's population to the year

2007. Our goal is to elucidate the major causes of illness and disability at present and

in the near future in order to focus state resources on the interventions likely to have

the greatest impact. Data from various governmental agencies were utilized; the base

year, 1993, is the most recent year with sufficient information available when this

report was prepared. Several major risk factors have decreased, including smoking

(30% decline from 1984 to 1993) and drinking and driving. However, hypertension

prevalence has not changed, and overweight has increased dramatically. Poverty

continues to burden about 15% of Californians, with poverty highest among children.

During 1993, 220,271 Californians died, with 3 major causes accounting for 61% of

these deaths: coronary heart disease (31%), cancer (23%), and stroke (7%). In terms

of potential years of life lost (years lost before age 65), the most important causes of

death in 1993 were unintentional injury (756 years lost/100,000 population), cancer

(632 years), and the acquired immunodeficiency syndrome (AIDS; 491 years).

Mortality rates were highest among blacks and lowest among Asians. Overall

mortality in California has been declining for decades; ire just 1 decade, from 1980

to 1991, mortality declined from 780 to 680 deaths per 100,000 population. Several

major causes of death have declined, including coronary heart disease, stroke,

unintentional injury, cirrhosis, and suicide, while others have increased, for example,

chronic obstructive lung disease and diabetes mellitus. Death from AIDS increased

dramatically in the past decade, but is leveling off, and death from cancer is

beginning to decline. Rates for overall mortality and morbidity, and for most specific

conditions, should continue to decline. A projected 28% population increase by 2007

will yield a corresponding increase in the absolute level of disease cages and death; a

disproportionate increase in younger and older groups will yield increased conditions

affecting young (unintentional injury, AIDS) and older (heart disease, cancer, stroke,

diabetes mellitus) people. Californians should experience overall improved health in

coming years, reaping benefits of reduced environmental and behavioral risk factors

as well as improved medical treatment and rehabilitation. Coordinated strategies for

health promotion, disease prevention, delivery of medical treatment, and

rehabilitation are needed to maintain and improve present levels of health across the

life span

Keywords: age/blacks/burden/coronary heart disease/diabetes

mellitus/disability/education/epidemiology/HEALTH/hypertension/medical

education/morbidity/mortality/prevalence/rehabilitation/risk

factors/smoking/SOCIOECONOMIC-STATUS/stroke

Stahelin, H.B. (2000), Cognitive prerequisites of geriatric rehabilitation. Zeitschrift fur

Gerontologie und Geriatrie, 33 24-27.

Abstract: Rehabilitation aims at the restoration of maximal independence and autonomy

after functional loss due to illness or accident. In old age tosses of independence in

daily life and autonomy are accounted for up to 60 % by personal deficits in

cognitive abilities. Functional losses in cognitive abilities represent a higher risk of

having an accident or becoming ill. Cognitive performance proves to be predictive

for success of rehabilitation, independent of functional state. Using the example of a

fracture of the femur it can be shown that sensory and cognitive deficits increase the

risk of accidents and that executive abilities co-influence long-term results. Strokes

are more frequent if cognitive deficits have existed before and the resulting damages

are stronger Long-term results generally depend on complex abilities like everyday

competence, reasoning and memory. Experiences with patients with dementia

undergoing a memory training show that learning strategies are rarely generalized.

Therefore in rehabilitation specific disorders, as for example cortical or subcortical

patterns, have to be treated by different rehabilitation methods in the sense of

differential rehabilitation. For this an early neuro- psychological assessment of the

geriatric rehabilitation patient is needed. The cognitive-psychological findings only

scarcely and insufficiently enter diagnostics and therapy. The diverse cognitive

disorders have to be taken in account more frequently in education and differential

rehabilitation methods have to be developed for geriatric patients with cognitive

deficits

Keywords: age/assessment/cognitive abilities/cognitive

disorders/COMMUNITY/DEMENTIA/education/FUNCTIONAL STATUS/geriatric

rehabilitation/HEALTH/IMPAIRMENT/independence/INPATIENT

REHABILITATION/memory/methods/performance/PREDICTORS/rehabilitation/ri

sk/STROKE PATIENTS/success of rehabilitation/training

Nussel, E. (1991), Risk-Factors and Nutrition in the Elderly. Zentralblatt fur Hygiene

und Umweltmedizin, 191 (2-3), 333-346.

Abstract: In industrialized countries life expectancy in the elderly is decreased mainly

by degenerative cardiovascular diseases such as myocardial infarction and stroke.

Nutrition, especially excessive intake of calories, inbalanced diets as well as abuse of

alcohol and nicotin play an important role in cardiovascular mortality and morbidity

just as these factors do in the pathogenesis of certain types of cancer. The National

Health Survey 1984/86 in the FRG offers data on the prevalence of such risk factors

as elevated body weight, elevated blood pressure, hypercholesterolaemia, cigarette

smoking and alcohol consumption in different age groups. This knowledge provides

the basis of modern primary health care and health education in order to limit

diseases caused by unhealthy nutrition. In this respect the countrywide integrated

programme for action called "7 against 7" is not just an important part of primary

health care carried out by general practitioners but also an effective instrument in the

fight against civilizational diseases

Keywords: age/alcohol/blood pressure/BLOOD-PRESSURE/cardiovascular

diseases/diseases/education/elderly/health/health

education/morbidity/mortality/myocardial infarction/nutrition/prevalence/risk

factors/smoking/stroke

Shklovsky, V.M., Shipkova, K.M. and Lukashevich, I.P. (1999), Prognostic criteria of

restoration of speech in patients with sequelae of ischemic stroke. Zhurnal

Nevropatologii I Psikhiatrii Imeni S S Korsakova, 99 (11), 13-16.

Abstract: Structural analysis concerning a complex of both neuropsychologic and

clinical data of the patients with sequelae of ischemic stroke was performed. It was

revealed, that a character of the local alterations of electric activity (EA) on EEG,

testifying a functional state of cerebral structures, was an important prognostic

criterion of the efficiency of neurorehabilitation. The local EA changes in form of

groups of theta-waves and sharp waves of alpha- and theta- activites were

prognostically favourable signs; meanwhile polymorphic slow-wave was

unfavourable background for performing a restorative education. An analysis of the

speech disorders revealed that both semantic and dynamic aphasias occur more

frequently after ischemic stroke. A semantic aphasia was always accompanied by the

dynamic one and each form may be both leading and secondary. It may be dependent

on location of a focus (according to EEG) as well as on the character and

manifestation of the accompanying neuropsychologic symptomatology

Keywords: aphasia/education/EEG/ischemic/ischemic stroke/stroke