As knowledge of pathophysiology grows, so does the refinement of diagnoses. Sometimes increased knowledge permits consolidation and unification. Unfortunately, at our present level of understanding, it usually demands proliferation of diagnostic categories. As tedious as this diagnostic splintering may seem, such is the price currently exacted of both the investigator and the clinician who seek to optimise management. Increased diagnostic refinement often requires inquiry into matters outside the bounds of one's specialty. Most often we turn to the radiologist or to the laboratory to narrow the differential diagnosis generated from the history and neurological examination. As we have shown, a useful intermediate step is extension of the physical examination to organs such as the skin, which are not the traditional preserve of the neurologist. That any text could confer the sophistication required for expert dermatological diagnosis is an unrealistic expectation. However, we hope that this review will encourage careful examination of the skin, hair, and nails by the neurological practitioner, with consideration of referral to a dermatologist when greater expertise is required. (+info)
Measuring change in disability after inpatient rehabilitation: comparison of the responsiveness of the Barthel index and the Functional Independence Measure.
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BACKGROUND: The importance of evaluating disability outcome measures is well recognised. The Functional Independence Measure (FIM) was developed to be a more comprehensive and "sensitive" measure of disability than the Barthel Index (BI). Although the FIM is widely used and has been shown to be reliable and valid, there is limited information about its responsiveness, particularly in comparison with the BI. This study compares the appropriateness and responsiveness of these two disability measures in patients with multiple sclerosis and stroke. METHODS: Patients with multiple sclerosis (n=201) and poststroke (n=82) patients undergoing inpatient neurorehabilitation were studied. Admission and discharge scores were generated for the BI and the three scales of the FIM (total, motor, and cognitive). Appropriateness of the measures to the study samples was determined by examining score distributions, floor and ceiling effects. Responsiveness was determined using an effect size calculation. RESULTS: The BI, FIM total, and FIM motor scales show good variability and have small floor and ceiling effects in the study samples. The FIM cognitive scale showed a notable ceiling effect in patients with multiple sclerosis. Comparable effect sizes were found for the BI, and two FIM scales (total and motor) in both patients with multiple sclerosis and stroke patients. CONCLUSION: All measures were appropriate to the study sample. The FIM cognitive scale, however, has limited usefulness as an outcome measure in progressive multiple sclerosis. The BI, FIM total, and FIM motor scales show similar responsiveness, suggesting that both the FIM total and FIM motor scales have no advantage over the BI in evaluating change. (+info)
Prevention of poststroke depression: 1 year randomised placebo controlled double blind trial of mianserin with 6 month follow up after therapy.
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OBJECTIVES: (1) To test whether early prophylactic antidepressive treatment by mianserin is able to prevent poststroke depression, and (2) to discover whether mianserin as an antidepressant has any beneficial influence on the outcome of ischaemic stroke. METHODS: A randomised, double blind, placebo controlled study involved 100 consecutive patients under 71 years old admitted to hospital for an acute ischaemic stroke; they were enrolled to receive 60 mg/day mianserin or placebo for 1 year. They were examined on admission, and at 2, 6, 12, and 18 months with depression, stroke, and functional outcome scales. RESULTS: According to DSM-III-R, the prevalence of major depression was 6% at the initial stage, 11% at 1 year, and 16% at 18 months. At no time point did prevalences differ between the treatment groups, nor were differences found in depression scales, although at 2 months a greater improvement from initial assessment on the Hamilton depression scale was evident in patients on mianserin (p=0.05). Some beneficial changes on the Hamilton depression scale and Beck depression inventory were found in patients older than 56 (median age) and in men treated with mianserin, but not in other subgroups. Mianserin treatment did not affect stroke outcome as measured by neurological status, nor did it have any influence on functional outcome as measured by Rankin scale or Barthel index. CONCLUSION: It was not possible to show that early initiation of antidepressant therapy can prevent poststroke depression, because the prevalence of poststroke depression remained low even in patients on placebo. In this stroke population with a low rate of depressive patients, antidepressive medical treatment failed to affect stroke outcome. (+info)
Intermittent compression for the treatment of the oedematous hand in hemiplegic stroke: a randomized controlled trial.
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OBJECTIVE: To evaluate the efficacy of intermittent pneumatic compression in treating oedema in the hemiplegic hand of stroke patients. DESIGN: Single-blind randomized control trial. SETTING: acute and rehabilitation elderly care wards in a teaching district. SUBJECTS: 37 Subjects with a first ever hemisphere stroke were randomized to treatment with standard physiotherapy either alone or combined with intermittent pneumatic compression. MAIN OUTCOME MEASURES: The effect of treatment on oedema was assessed using measures of the hand volume of the hemiplegic hand. The impact on function was assessed using the motricity index. RESULTS: The treated group showed no change in the mean stroke hand volume. In the control group the mean stroke hand volume decreased by 3.2 ml. There was no statistically significant difference between the groups. The median scores for the motricity index increased for both groups but there was no significant difference between the groups and any improvement in motor function was independent of any treatment effects. CONCLUSION: Intermittent pneumatic compression at the prescribed pressure and duration of this study is not an effective treatment for the oedematous stroke hand. (+info)
Predicting sudden death in the population: the Paris Prospective Study I.
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BACKGROUND: Sudden death was found to share the same set of usual risk factors as coronary events and therefore could not be specifically predicted in the population. It appears, however, that parental history of sudden death has not been investigated yet as a risk factor for sudden death. Therefore, we assessed risk factors, including parental sudden death, associated with the occurrence of sudden death in a long-term cohort study. METHODS AND RESULTS: We included 7746 men employed by the city of Paris who were 43 to 52 years of age in 1967 to 1972 in the Paris Prospective Study I. Each subject underwent a physical examination and an ECG, provided blood for laboratory tests, and answered questionnaires administered by trained interviewers who paid particular attention to family medical history. Men with known ischemic cardiac disease were further excluded from analysis. For 95.5% of the men, vital status was obtained from specific inquiries until retirement, then by death certificates. Resting heart rate, systolic or diastolic blood pressure, tobacco consumption, body mass index, diabetes status, serum cholesterol, and parental history of sudden death were independent factors associated with sudden death during follow-up (23 years on average). When adjusted for confounding variables, including parental history of myocardial infarction, relative risk of sudden death associated with parental sudden death was 1.80 (95% CI, 1.11 to 2.88). CONCLUSIONS: Parental sudden death is an independent risk factor for sudden death in middle-aged men. The existence of familial risk factors for sudden death may help provide better identification of subjects at high risk of and early prevention of sudden death. (+info)
Microangiopathy of the brain and retina with hearing loss in a 50 year old woman: extending the spectrum of Susac's syndrome.
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A 50 year old woman presented with a subacute onset of vertigo and diplopia followed by an encephalopathy with confusion, spasticity, ataxia, myoclonus, and multiple branch retinal arteriolar occlusions and unilateral sensorineural deafness. Brain biopsy confirmed multiple microinfarcts with no vasculitis. After the procedure she had a right iliofemoral deep vein thrombosis and was found to be heterozygous for the factor V Leiden mutation. She was treated with anticoagulants and made a marked recovery with no relapses 6 months after presentation. This case extends the age range at which Susac's syndrome can present, and raises the possibility that the condition may be associated with abnormalities of coagulation. (+info)
Transcranial Doppler: preventing stroke during carotid endarterectomy.
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Carotid endarterectomy (CEA) is more effective at preventing strokes than medical therapy alone in those patients with severe symptomatic stenosis of the internal carotid artery and this benefit persists despite a perioperative stroke/death rate of approximately 5%. Thromboembolism has been established as the underlying cause of the majority of perioperative strokes, but this could not be detected using the existing methods of monitoring or quality control. Early studies demonstrated that transcranial Doppler monitoring (TCD) could detect intraoperative embolism, but the clinical significance of this finding was questioned as the incidence of these emboli far exceeded the incidence of perioperative strokes. This study aimed to establish the clinical relevance of TCD-detected emboli during CEA by differentiating emboli into two broad categories; air and particulate, and comparing the quantity of each with a variety of clinical outcomes including neurological and cognitive function, retinal fundoscopy, automated visual fields and CT/MRI brain scans. This prospective study was performed on 100 consecutive patients undergoing CEA with all assessments performed pre- and postoperatively by independent specialists in the relevant fields. Embolisation was detected in 92% of successfully monitored operations. Most emboli were characteristic of air microbubbles and not associated with the development of adverse clinical events. However, emboli characteristic of particulate material were detected during the initial dissection phase and in the recovery phase after final restoration of flow. These particulate emboli were associated with the development of both neurological and cognitive deficits. In particular, persistent embolisation after final restoration of flow heralded incipient carotid artery thrombosis and the development of stroke. Early intervention based on the TCD evidence of continuing embolisation can prevent the stroke from occurring. (+info)
Audit of cardiac catheterisation in a district general hospital: implications for training.
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OBJECTIVE: To assess complications of diagnostic cardiac catheterisation in a non-surgical centre by review of the first three years' experience and audit of 2804 diagnostic left heart procedures. DESIGN: Analysis of a prospective database of cardiac catheter procedures. SETTING: District general hospital without available on site cardiac surgery. RESULTS: The rate of major complications of cardiac catheterisation was 0.07%. Mortality was 0. 07%, and the rate of arterial complications (requiring surgical repair) was 0.24% for brachial arteries and 0.17% for femoral. These results are comparable to those reported from national and international surgical centres. CONCLUSION: A diagnostic cardiac catheterisation service can be offered in non-surgical hospitals without an increased risk to patients. It highlights the relevance of training in angioplasty and questions the appropriateness of starting preliminary invasive cardiology training of specialist registrars in district general hospitals. (+info)