A private practice model for teaching and research activities.

The majority of neurologists in the United States are in fee for service patient management, dividing their time between hospital and office based practice. Many have had subspecialty training or have had research experience. It is our belief that research should be a component of a neurologist's practice. This is particularly true for an assessment of outcome. In order to accomplish this, we have developed a system which includes patient management, teaching, and clinical research, within our fee for service model.

Transient ischemic attacks: their frequency in the Lehigh Valley.

The incidence of transient ischemic attacks (TIAs) in the Lehigh Valley was analyzed using the Lehigh Valley Stroke Register based on data collected between July 1, 1982, and June 30, 1986. The overall average annual incidence rate was 22.9 per 100,000 population, and 23.2 and 22.5 per 100,000 population in men and women, respectively. Men had a statistically significant higher age-specific rate of TIAs than women. Our incidence appears to be lower than that reported in earlier studies but, because of methodologic differences, only continued observations in our population and in similar populations using a standardized methodology will resolve the question of whether TIA frequency is, in fact, declining.

Post traumatic extracranial vertebral artery dissection with locked-in syndrome: a case with MRI documentation and unusually favourable outcome.

A patient with a right vertebral artery dissection occurring after minor head trauma progressed to a massive pontine infarction. An unusually favourable outcome and MRI imaging are discussed.

Stroke in the Lehigh Valley: racial/ethnic differences.

We investigated black/white differences in stroke rate (standardized morbidity), severity, and subtype, and the relative frequencies of 5 primary risk factors (hypertension, diabetes, myocardial infarction, other heart diseases, and transient ischemic attack [TIA]) using the Lehigh Valley Stroke Register. Blacks had a statistically significant higher, age-adjusted rate of stroke than whites. We found no differences in stroke severity using our measures but blacks had a statistically higher proportion of lacunar stroke, while whites had a higher proportion of embolic stroke. There were no differences in proportions of thrombotic stroke or intracerebral hemorrhage. The relative frequencies of hypertension, myocardial infarction, other heart diseases, and diabetes were higher for blacks, while the relative frequency of TIA was higher for whites. These observations are consistent with other reports that blacks have a higher frequency of stroke and tend to have more small-vessel cerebrovascular pathology than whites.

Stroke in the Lehigh Valley: combined risk factors for recurrent ischemic stroke.

We used the Lehigh Valley Stroke Register and a logistic regression model for the odds ratio to study the relative contribution of several factors, considered jointly, to the risk of recurrent ischemic stroke. The factors were hypertension (HT), transient ischemic attack (TIA), myocardial infarction (MI), other heart diseases (OHD), diabetes mellitus (DM), age, and sex. Among these factors MI, OHD, and TIA constituted significantly greater risk than HTN, DM, age, or sex for ischemic stroke recurrence.

Stroke in the Lehigh Valley: risk factors for recurrent stroke.

Age-specific risk of recurrent stroke for various risk factors, calculated independently, was estimated using the first year of data from the Lehigh Valley Stroke Register. The register is based on a population of more than one-half million. Among the risk factors examined, the highest overall risk of recurrent stroke, 41.4, occurred with a history of at least one transient ischemic attack (TIA). After myocardial infarction (MI), the relative risk of a recurrent stroke was 8.0, while with all other heart diseases combined it was 8.4. With diabetes, the relative risk of a recurrent stroke was 5.6; with hypertension, it was 4.5. The relative risk increased with age after TIA and MI, but not for other heart disease, diabetes, and hypertension, except in the 85+-year-old age group.

The Lehigh Valley Stroke Program: establishing a communitywide, hospital-based stroke register.

A communitywide, hospital-based stroke register has been established in the Lehigh Valley of Pennsylvania and New Jersey. The Lehigh Valley has about 600,000 inhabitants and is geographically somewhat isolated. Ninety-five percent of the people are white, and the population has an age-sex distribution like that of the United States as a whole. All patients falling into any of nine diagnostic categories of stroke or transient ischemic attack are registered on admission to a hospital, and medical, social, and demographic data are abstracted onto precoded data forms. A single neurologist assigns definitive diagnoses according to standardized criteria after reviewing all of the medical data. The stroke register provides a new and powerful tool for collecting population-based data on a large number of cases in a short-time. After adjusting for demographic differences, epidemiologic studies can be carried out that may be generalizable to the entire United States. Several organizational aspects of the register and its operation are described in this report, and examples of the types of information and statistics readily calculable from the data in the register are given. The completeness of the stroke ascertainment and the large population registered also offer an excellent opportunity for any interested researcher to investigate the relationships between medical, social, and demographic conditions on the one hand and stroke risk on the other; to study the efficacy of prevention and treatment programs; and to determine health care provision requirements in a well-defined population.

Stroke in the Lehigh Valley: incidence based on a community-wide hospital register.

Since July 1982 a population-based study of stroke has been carried out in the Lehigh Valley, a region in Pennsylvania and New Jersey, USA, with 580,000 people. During the first year, the annual incidence rates of stroke and transient ischemic attack were 167 and 49 per 100,000 population, respectively. Cerebral thrombosis, embolus, cerebral hemorrhage and subarachnoid hemorrhage accounted for 76, 13, 8 and 3% of the strokes, respectively. The overall incidence rate and distribution of stroke by type agree well with other population-based studies. The large size of the population in the Lehigh Valley means that information on the epidemiology of stroke, as well as the effects of various therapies on stroke frequency and outcome, can be collected in a shorter period of time than in most other communities studied to date. Finally, an assessment of concordance in diagnosis between attending physicians and a neurologist using standardized criteria was possible for the entire community.

Neurological education of nonneurologists.

In 1975, the Joint Commission of Neurology, created by the American Academy of Neurology and the American Neurological Association, published its report including recommendations on neurological education. Commission data indicated that although neurologists constitute less than 1% of all physicians, at least 5% of all ambulatory patients and 13% of all hospitalized patients had primary or secondary neurologic diagnoses, or both. Thus, the commission recommended a major effort in the education of general physicians in neurology. That advice is apparently being ignored. This situation poses a serious health care problem and urgent steps are indicated to reverse this trend.

Pure motor hemiplegia secondary to brain-stem tumour.

'Pure motor hemiplegia' is a common stroke syndrome defined by Fisher as paralysis of face, arm, and leg on one side, unaccompanied by sensory signs, visual field defect, aphasia, or apractognosia. It occurs almost exclusively in hypertensive patients and carried a good prognosis. We report a case of a normotensive patient in whom pure motor hemiplegia was the presenting feature, not of a cerebrovascular syndrome, but of a pontine glioblastoma. We note that brain-stem tumours may masquerade as brain-stem strokes.

Mononeuropathy due to vincristine toxicity.

Vincristine sulfate is a known neurotoxin. Peripheral neuropathy is the most common toxic manifestation and is usually of the symmetrical, mixed, sensory-motor type. With this report we alert other physicians to another feature of vincristine neurotoxicity, namely, mononeuropathy.