Family support for stroke: one year follow up of a randomised controlled trial.

BACKGROUND: There is evidence that family support can benefit carers of stroke patients, but not the patients themselves. OBJECTIVE: To extend the follow up of a single blind randomised controlled trial of family support for stroke patients and carers to one year to ascertain whether there were any late effects of the intervention. METHODS: The study was a randomised controlled trial. Patients admitted to hospital with acute stroke who had a close carer were assigned to receive family support or normal care. Families were visited at home by a researcher 12 months after the stroke, and a series of questionnaires was administered to patient and carer. RESULTS: The benefits to carers mostly persisted, though they were no longer statistically significant because some patients were lost to follow up. There was no evidence of any effects on patients. CONCLUSION: Family support is effective for carers, but different approaches need to be considered to alleviate the psychosocial problems of stroke patients.

Family support for stroke: a randomised controlled trial.

BACKGROUND: Attention is currently focused on family care of stroke survivors, but the effectiveness of support services is unclear. We did a single-blind, randomised, controlled trial to assess the impact of family support on stroke patients and their carers. METHODS: Patients with acute stroke admitted to hospitals in Oxford, UK, were assigned family support or normal care within 6 weeks of stroke. After 6 months, we assessed, for carers, knowledge about stroke, Frenchay activities index, general health questionnaire-28 scores, caregiver strain index, Dartmouth co-op charts, short form 36 (SF-36), and satisfaction scores, and, for patients, knowledge about stroke and use of services, Barthel index, Rivermead mobility index, Frenchay activities index, London handicap scale, hospital anxiety and depression scales, Dartmouth co-op charts, and satisfaction. FINDINGS: 323 patients and 267 carers were followed up. Carers in the intervention group had significantly better Frenchay activities indices (p=0.03), SF-36 scores (energy p=0.02, mental health p=0.004, pain p=0.03, physical function p=0.025, and general health perception p=0.02), quality of life on the Dartmouth co-op chart (p=0.01), and satisfaction with understanding of stroke (82 vs 71%, p=0.04) than those in the control group. Patients' knowledge about stroke, disability, handicap, quality of life, and satisfaction with services and understanding of stroke did not differ between groups. Fewer patients in the intervention group than in the control group saw a physiotherapist after discharge (44 vs 56%, p=0.04), but use of other services was similar. INTERPRETATION: Family support significantly increased social activities and improved quality of life for carers, with no significant effects on patients.

The London handicap scale: a re-evaluation of its validity using standard scoring and simple summation.

OBJECTIVE: To assess the validity of the London handicap scale (LHS) using a simple unweighted scoring system compared with traditional weighted scoring METHODS: 323 patients admitted to hospital with acute stroke were followed up by interview 6 months after their stroke as part of a trial looking at the impact of a family support organiser. Outcome measures included the six item LHS, the Dartmouth COOP charts, the Frenchay activities index, the Barthel index, and the hospital anxiety and depression scale. Patients' handicap score was calculated both using the standard procedure (with weighting) for the LHS, and using a simple summation procedure without weighting (U-LHS). Construct validity of both LHS and U-LHS was assessed by testing their correlations with the other outcome measures. RESULTS: Cronbach's alpha for the LHS was 0.83. The U-LHS was highly correlated with the LHS (r=0.98). Correlation of U-LHS with the other outcome measures gave very similar results to correlation of LHS with these measures. CONCLUSION: Simple summation scoring of the LHS does not lead to any change in the measurement properties of the instrument compared with standard weighted scoring. Unweighted scores are easier to calculate and interpret, so it is recommended that these are used.

The impact of an information pack on patients with stroke and their carers: a randomized controlled trial.

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). CONCLUSIONS: 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.

Delay in presentation of patients with acute stroke to hospital in Oxford.

We identified prospectively all patients (181 patients, 183 episodes) admitted to hospital in Oxford with acute stroke from 1 January to 30 June 1997. Data were inadequate in 30, leaving 153 episodes in 151 patients (63 men, 90 women). Structured interviews were used to investigate the timing of events preceding admission. Most strokes (91%) occurred at home, and 36% of patients were alone. After a median delay of 15 min, 56% called a GP (median 30 min response), 41% an ambulance (median 48 min to admission), and 3% went directly to A&E. Median time from hospital admission to doctor assessment was 69 min. Factors reducing delay were: initially calling an ambulance rather than a GP (p < 0.0001); onset not at home (p < 0.001); symptoms improving between onset and admission (p < 0.002); and altered consciousness (p < 0.002). The stroke was not recognized by 44% of patients, but no significant delay resulted. Overall, 31% were admitted within 3 h of onset, 46% within 6 h. Initial contact with the GP is a major determinant of delay. If acute therapies for stroke become available, GPs should be the primary targets for an educational initiative.

Comparison of postal version of the Frenchay Activities Index with interviewer-administered version for use in people with stroke.

OBJECTIVE: To assess the agreement between postal and interviewer-administered versions of the Frenchay Activities Index (FAI) and to assess the criterion validity of the postal version, using interviewer administration as a gold standard. DESIGN: Comparison of responses to FAI administered by post and then by interview (median delay 10 days). SUBJECTS: Forty-eight Oxfordshire residents admitted to hospital with acute stroke between 1 August 1994 and 31 January 1995 and discharged alive within six months of their stroke. RESULTS: The limits of agreement of the total FAI score are from -5.4 to 7.2. The kappa statistic for each of the 15 individual items that make up the FAI ranged from 0.35 to 1. For nine items, agreement was moderate or fair, and for six items, agreement was good or very good. The mean difference between the overall scores was 0.9 (95% confidence interval: -0.1 to 1.9). The correlation between the overall scores was 0.94 (Spearman's rank correlation coefficient). CONCLUSION: The postal version of the FAI is a satisfactory alternative to direct administration, but poor agreement in scores for individual patients emphasizes that the two approaches should not be used sequentially to monitor individual patients.

Guillain-Barré syndrome in Oxfordshire: clinical features in relation to age.

We have examined the clinical features of Guillain-Barré syndrome (GBS) in a UK series with a valid epidemiological base, studying cases from a geographically-defined population using enhanced data from the Oxford record linkage study and applying standard diagnostic criteria. Clinical features in patients aged > or = 60 years were compared with those aged 20-59 years. Cranial nerve involvement was found less often in old than in young adults (6/21 vs 27/41, chi 2 p < 0.02). Old patients more frequently had other diagnoses accompanying GBS (10/21 vs 3/41, p < 0.001). There were no significant differences between old and young in: occurrence or type of preceding illness; site of symptoms at onset; severity of maximal neurological impairment; sphincter dysfunction or any autonomic involvement; requirement for artificial ventilation; case fatality rate; proportion of patients with no residual disability at or before 12 months from onset; mean duration from onset to maximal neurological impairment, from onset to first signs of recovery, and from maximal neurological impairment to recovery ('plateau time'). The variety and severity of clinical features of Guillain-Barré syndrome are similar in old and young adults.

Age-specific incidence of Guillain-Barré syndrome in Oxfordshire.

The epidemiology of Guillain-Barré syndrome was examined in a population-based retrospective study using defined diagnostic criteria and linked hospital records. Between 1974 and 1986 there were 72 incident cases, giving a crude annual incidence rate (95 per cent confidence interval) of 1.1 per 100,000 persons per year (0.8-1.4). Age-adjusted incidence rates were insignificantly higher for women, 1.23 (0.8-1.6), than for men, 1.0 (0.6-1.3). After infancy, rates increased with age, and remained high in the over-75 age group. These variations in incidence were not explained by variations in severity. There was evidence of an increase in rates over the period surveyed. Rates tended to be higher in the winter and early spring. The incidence of Guillain-Barré syndrome in the elderly has been underestimated in the past, and this study shows no evidence of a previously reported bimodal distribution of age-specific incidence in adult life.

Perimenopausal risk of falling and incidence of distal forearm fracture.

A postal survey of 2000 women and 2000 men sampled from the electoral roll in Oxford was undertaken to ascertain whether changes with age in the risk of falling might explain the stepwise increases in age specific incidence rates of distal forearm fracture which occur in women at around the age of 50. Corrected response rates were 83% for women and 72% for men. In women, but not in men, there was a rise in the risk of falling from 45 years, peaking in the 55-59 year age group, and sinking to a nadir at ages 70-74. In both sexes rates rose in extreme old age. These variations were not attributable to preferential response from people who had suffered a fracture. It is concluded that changes in the risk of falling interact with osteoporosis to produce a perimenopausal rise in the incidence of forearm fractures and contribute to the fluctuations in incidence of these fractures in old age.

Transvenous pacemaker electrodes placed unintentionally in the left ventricle: three cases.

Three patients are described in whom pacemaker electrodes were unintentionally placed within the left ventricle, followed by considerable delay before the error was recognized. In two cases temporary pacemaker wires were inserted into the subclavian artery and passed along a retrograde course. One patient required urgent surgery for acute arterial obstruction on removal of the wire. In the third case, a permanent wire was inserted correctly into a vein but traversed the atrial septum, probably via a patent foramen ovale, to enter the left ventricle. Twelve lead electrocardiograms in all three patients showed paced complexes with right bundle branch block configuration. This appearance should raise suspicion that the pacemaker electrode might be in the left ventricle, in which case its position should be defined by chest radiographs (including a lateral view) and echocardiography.

A comparison of the long-term effects of sotalol and atenolol on QT interval and arrhythmias after myocardial infarction.

In order to dissociate the Class III effects of sotalol on QT interval and arrhythmias from those of chronic beta-receptor blockade, we compared the effects of sotalol 160 mg b.d. and atenolol 50 mg b.d. in a double-blind crossover study of 103 patients followed for one year after discharge following acute myocardial infarction. Sotalol caused a highly significant lengthening of the absolute and corrected QT (QTc) interval over atenolol which was apparent by day 6 and persisted unchanged throughout the follow-up period. The increase in QT interval averaged 43 ms (9%). Sotalol blunted the increase in ventricular premature beat frequency on ambulatory monitoring which occurred with atenolol, although direct comparison of arrhythmia frequency between the groups receiving atenolol and sotalol revealed no significant difference. Marked lengthening of QTc interval (greater than 500 ms) was observed on 29 occasions in patients receiving sotalol, most commonly at day 6, but no episodes of polymorphic ventricular tachycardia were recorded. The Class III action of sotalol persists over and above any response to beta-blockade during a one-year follow-up period. In a population with a low incidence of spontaneous arrhythmias, however, there was only a modest difference in antiarrhythmic efficacy between atenolol and sotalol. Episodes of marked lengthening of QT interval induced by sotalol in the absence of other adverse factors need not be arrhythmogenic.

An outbreak of Q fever affecting postal workers in Oxfordshire.

Twenty-five people in Oxfordshire were found to have had clinical illness due to Q fever in the 3 months from April to June 1983. Twelve cases were diagnosed through the routine laboratory diagnostic service. Five of these were postmen, four of whom worked in a sorting office where an outbreak of illness similar to influenza had been noted by the Occupational Health Nurse. Thirteen cases were diagnosed by active case-finding in this sorting office but investigation failed to define the source of the outbreak. Nine of the 18 postal workers were found to have antibodies to phase I Coxiella burnetii antigen. The significance of these antibodies is discussed. Surveillance for over 2 years has not revealed anyone with symptoms or signs suggestive of chronic Q fever. An outbreak of Q fever among postal workers has not previously been described. We recommend continued surveillance for this enigmatic condition.

Comparison of inhaled and intravenous terbutaline in acute severe asthma.

In patients with acute severe asthma, 5 mg of terbutaline by inhalation and 500 microgram intravenously in divided doses both produced equally effective but not maximal bronchodilatation. There was no difference in the production of side-effects. These results support the view that inhaled therapy can be as effective in patients with acute severe asthma as injected treatment. In view of the risks of intravenous treatment, especially using high doses, inhaled bronchodilator therapy would seem advisable as initial treatment.

Pulmonary and pleural involvement in angio-immunoblastic lymphadenopathy.

A patient with angio-immunoblastic lymphadenopathy is described in whom involvement of the lungs and pleura by characteristic immunoblasts was demonstrated. The literature on pleural and pulmonary involvement in this rare and only recently recognized condition is reviewed.