Sex differences in trajectories of depression symptoms and associations with 10-year mortality in patients with stroke: the South London Stroke Register.

BACKGROUND AND PURPOSE: Depression is a common neuropsychiatric consequence of stroke. We identified trajectories of depression symptoms in men and women and examined their associations with 10-year all-cause mortality. METHODS: Data were obtained from the South London Stroke Register (1998-2016). Socio-demographic, stroke severity and clinical measures were collected during the acute phase. The Hospital Anxiety and Depression Scale was used to screen for depression at 3 months after stroke and then annually. We used group-based trajectory models to identify trajectories of depression and Cox proportional hazards models to study the risk of mortality in them. RESULTS: We studied 1275 men and 1038 women. Three trajectories of depression symptoms were identified in men: I-M (42.12%), low and stable symptoms; II-M (46.51%), moderate increasing symptoms; and III-M (11.37%), severe persistent symptoms. Four trajectories were identified in women; I-F (29.09%), low symptoms; II-F (49.81%), moderate symptoms; III-F (16.28%), severe symptoms; and IV-F (4.82%), very severe symptoms, all with stable symptoms. The 10-year adjusted mortality hazard ratios in men were: 1.68 [95% confidence interval (CI), 1.38-2.04] and 2.62 (95% CI, 1.97-3.48) for trajectories II-M and III-M, respectively, compared with I-M. In women these were: 1.38 (95% CI, 1.09-1.75), 1.65 (95% CI, 1.23-2.20) and 2.81 (95% CI, 1.90-4.16) for trajectories II-F, III-F and IV-F, respectively, compared with I-F. CONCLUSIONS: Depression trajectories varied independent of sex. Severe symptoms in women were double those in men. Moderate symptoms in men became worse over time. Increased symptoms of depression were associated with higher mortality rates. Data on symptom progression may help a better long-term management of patients with stroke.

The long-term outcomes of depression up to 10 years after stroke; the South London Stroke Register.

BACKGROUND: Post-stroke depression is a frequent chronic and recurrent problem that starts shortly after stroke and affects patients in the long term. The health outcomes of depression after stroke are unclear. AIMS: (1) To investigate the associations between depression at 3 months and mortality, stroke recurrence, disability, cognitive impairment, anxiety and quality of life (QoL), up to 5 years post-stroke. (2) To investigate these associations in patients recovering from depression by year 1. (3) To investigate associations between depression at 5 years and these outcomes up to 10 years. METHODS: Data from the South London Stroke Register (1997-2010) were used. Patients (n at registration=3240) were assessed at stroke onset, 3 months after stroke and annually thereafter. Baseline data included sociodemographics and stroke severity measures. Follow-up assessments included anxiety and depression (Hospital Anxiety and Depression scale), disability, QoL and stroke recurrence. Multivariable regression models adjusted for age, gender, ethnicity, stroke severity and disability were used to investigate the association between depression and outcomes at follow-up. RESULTS: Depression at 3 months was associated with: increased mortality (HR: 1.27 (1.04 to 1.55)), disability (RRs up to 4.71 (2.96 to 7.48)), anxiety (ORs up to 3.49 (1.71 to 7.12)) and lower QoL (coefficients up to -8.16 (-10.23-6.15)) up to year 5. Recovery from depression by 1 year did not alter these risks to 5 years. Depression in year 5 was associated with anxiety (ORs up to 4.06 (1.92 to 8.58)) and QoL (coefficients up to -11.36 (-14.86 to -7.85)) up to year 10. CONCLUSIONS: Depression is independently associated with poor health outcomes.

Stroke unit care in clinical practice: an observational study in the Florence center of the European Registers of Stroke (EROS) Project.

BACKGROUND: Randomized trials and meta-analyses indicate positive effects of stroke unit (SU) care on survival and dependency of patients with stroke. However, data on the advantages of SU in 'real-world' settings are limited. We prospectively assessed, in a large University Hospital, the effect of SU versus other conventional wards (OCW) care on all-cause mortality, death or dependency, death or institutionalization. METHODS: In a prospective observational study in the European Registers of Stroke Project, patients hospitalized for first-in-a-lifetime stroke were evaluated for demographics, risk factors, clinical presentation, resource use, 3-month and 1-year survival, and functional outcome. RESULTS: Overall, 355 patients (54.1% men, mean age 73.4 ± 14.5 years) were registered, 140 (39.4%) admitted to the SU, and 215 (60.6%) to OCW. OCW patients were older, whilst SU patients had more severe strokes according to NIHSS (P for trend = 0.025). SU patients were significantly more often treated by specialists in stroke medicine, stroke nurses, physiotherapists and speech therapists (all P < 0.001), psychologists (P = 0.025), dietitians (P < 0.001), and social workers (P = 0.003). MRI, carotid, and transcranial Doppler were significantly more often performed in SU patients (all P < 0.001). Intravenous fluids (P = 0.003) and intravenous anticoagulation (P < 0.001) were more often prescribed in SU. Controlling for case-mix, SU significantly reduced 1-year mortality (P = 0.020), death or dependency at 3 months (P = 0.006) and 1 year (P = 0.043), and death or institutionalization at 3 months (P = 0.001) and 1 year (P = 0.009). CONCLUSIONS: We confirmed the benefits of SU care in a clinical setting. Further analyses should define the contribution of individual components of care to stroke outcome.

Three-month stroke outcome: the European Registers of Stroke (EROS) investigators.

BACKGROUND: Contemporaneous data on variations in outcome after first-ever-lifetime stroke between European populations are lacking. We compared differences in case fatality rates, functional outcome, and living conditions 3 months after stroke within the European Registers of Stroke Collaboration. METHODS: Population-based stroke registers were established in France (Dijon), Italy (Sesto Fiorentino), Lithuania (Kaunas), the United Kingdom (London), Spain (Menorca), and Poland (Warsaw). All patients with first-ever-lifetime stroke of all age groups from the source population (1,087,048 inhabitants) were included. Data collection took part between 2004 and 2006. The study investigated population variations in outcome at 3 months (death, institutionalization due to stroke, or Barthel Index below 12 points) using multivariable logistic regression analyses adjusted for age, sex, stroke severity, stroke subtype, and comorbidities. RESULTS: A total of 2,034 patients with first-ever-lifetime stroke were included. Median age was 73 years, 52% were female. The mean weighted cumulative risk of death was 21.8% (95% confidence interval 20.0 to 23.6) with a 3-fold variation across populations. The weighted proportion of poor outcome was 41.3% (95% confidence interval 39.0 to 43.7) with a 2-fold variation across populations. CONCLUSION: More than 40% of patients had a poor outcome, defined as being dead, dependent, or institutionalized 3 months after stroke. Substantial outcome variations were found between populations that were explained by case mix variables in this analysis, yet a trend toward a higher risk of poor outcome was present in Kaunas.

Prior antiplatelet therapy and outcome following intracerebral hemorrhage: a systematic review.

OBJECTIVES: Antiplatelet therapy (APT) promotes bleeding; therefore, APT might worsen outcome in patients with intracerebral hemorrhage (ICH). We performed a systematic review and meta-analysis to address the hypothesis that pre-ICH APT use is associated with mortality and poor functional outcome following ICH. METHODS: The Medline and Embase databases were searched in February 2008 using relevant key words, limited to human studies in the English language. Cohort studies of consecutive patients with ICH reporting mortality or functional outcome according to pre-ICH APT use were identified. Of 2,873 studies screened, 10 were judged to meet inclusion criteria by consensus of 2 authors. Additionally, we solicited unpublished data from all authors of cohort studies with >100 patients published within the last 10 years, and received data from 15 more studies. Univariate and multivariable-adjusted odds ratios (ORs) for mortality and poor functional outcome were abstracted as available and pooled using a random effects model. RESULTS: We obtained mortality data from 25 cohorts (15 unpublished) and functional outcome data from 21 cohorts (14 unpublished). Pre-ICH APT users had increased mortality in both univariate (OR 1.41, 95% confidence interval [CI] 1.21 to 1.64) and multivariable-adjusted (OR 1.27, 95% CI 1.10 to 1.47) pooled analyses. By contrast, the pooled OR for poor functional outcome was no longer significant when using multivariable-adjusted estimates (univariate OR 1.29, 95% CI 1.09 to 1.53; multivariable-adjusted OR 1.10, 95% CI 0.93 to 1.29). CONCLUSIONS: In cohort studies, APT use at the time of ICH compared to no APT use was independently associated with increased mortality but not with poor functional outcome.

Patient-specific recovery patterns over time measured by dependence in activities of daily living after stroke and post-stroke care: the South London Stroke Register (SLSR).

BACKGROUND AND PURPOSE: Data on patient-specific recovery after stroke are lacking and the effects of complex healthcare interventions on the course of recovery were not reported. To quantify the recovery pattern up to 1 year post-stroke and assess effects of evidence-based treatments on the patient-specific course of recovery allowing its prediction. METHODS: A total of 355 patients after first-ever stroke from the population-based South London Stroke Register (source population >270,000) participated in a substudy between August 2002 and October 2004. At 1, 2, 3, 4, 6, 8, 12, 26, and 52 weeks post-stroke, Barthel Index (BI; ranging from 0 to 20) was documented. Multilevel growth models allowing predictions for patients with specific characteristics were calculated. RESULTS: Mean age was 70 years, 48% were male and 23% died within the first year. The age-, gender- and stroke subtype-adjusted BI curve sharply increased until week 8 to 24 depending on patient characteristics and subsequently plateaued. Multivariable analysis identified stroke unit care, appropriate secondary prevention and physiotherapy for those with disabilities as independent predictors of improved functional ability over time (P < 0.05). Patients receiving stroke unit care additionally gained 4 BI points within 6 months compared with their counterparts (P = 0.004). CONCLUSIONS: Functional outcome in the general population showed an increase followed by a plateau. Care parameters reflecting guideline treatment independently improved recovery illustrating the beneficial effects of evidence-based interventions on recovery in an unbiased population.

An observational study of acute stroke care in four countries: the European registers of stroke study.

BACKGROUND: The European Registers Of Stroke (EROS) project aimed to assess outcomes of stroke care across Europe, relating these to both case mix information from disease-specific population registers and the quality of stroke care provided at each centre. This included comparing information on quality of care with direct observation of the stroke care process in 4 centres. METHODS: Direct non-participant observational methods were used on a purposive sample of first-stroke patients admitted within the past 14 days to an acute-stroke unit or ward that admits stroke patients in 4 urban hospital sites in London, UK, Dijon, France, Kaunas, Lithuania, and St. Petersburg, Russia. We recorded patient characteristics with levels of contact with multi-disciplinary team (MDT) members and contact with families and mobilization to build a collection of 'snapshots' of stroke care throughout the patients' day. One independent observer undertook all observations over 1 day. RESULTS: We observed differences between centres in the proportion of observations where patients were alone (lowest proportion in London, highest proportion in St. Petersburg) (p > 0.001), where patients had contact with MDT members (p > 0.001) and family, and where patients were out of bed/mobile (p > 0.001) (both with highest proportion in London, lowest proportion in St. Petersburg). CONCLUSIONS: Higher levels of contact with the MDT, family contact and mobilization were observed in the Western European centres than the Eastern European and Russian centres. Differences in case mix may explain some, but not all, of these differences. Direct observation has some limitations; however, it could be developed in future studies to help identify other key aspects of effective stroke care.

Frequency and predictors for the risk of stroke recurrence up to 10 years after stroke: the South London Stroke Register.

BACKGROUND: Data estimating the risk of, and predictors for, long-term stroke recurrence are lacking. METHODS: Data were collected from the population-based South London Stroke Register. Patients were followed up for a maximum of 10 years. Kaplan-Meier estimates and Cox proportional hazards models were used to assess the cumulative risk of and predictors for first stroke recurrence. Variables analysed included sociodemographic factors, stroke subtype (defined as cerebral infarction, intracerebral haemorrhage and subarachnoid haemorrhage), stroke severity markers and prior-to-stroke risk factors. RESULTS: Between 1995 and 2004, 2874 patients with first-ever stroke were included. The mean follow-up period was 2.9 years. During 8311 person-years of follow-up, 303 recurrent events occurred. The cumulative risk of stroke recurrence at 1 year, 5 years and 10 years was 7.1%, 16.2% and 24.5% respectively. No differences in stroke recurrence were noted between the stroke subtypes. Factors increasing the risk of recurrence at 1 year were previous myocardial infarction (HR 1.73; 95% CI 1.08 to 2.78) and atrial fibrillation (HR 1.61; 95% CI 1.04 to 4.27); at 5 years, hypertension (HR 1.47; 95% CI 1.08 to 1.99) and atrial fibrillation (HR 1.79; 95% CI 1.29 to 2.49); and at 10 years, older age (p = 0.04), and hypertension (HR 1.38, 95% CI 1.04 to 1.82), myocardial infarction (HR 1.50, 95% CI 1.06 to 2.11) and atrial fibrillation (HR 1.51, 95% CI 1.09 to 2.09). CONCLUSIONS: Very-long-term risk of stroke recurrence is substantial. Different predictors for stroke recurrence were identified throughout the follow-up period. Risk factors prior to initial stroke have a significant role in predicting stroke recurrence up to 10 years.

Sociodemographic differences in return to work after stroke: the South London Stroke Register (SLSR).

BACKGROUND: Loss of employment contributes significantly to the burden of stroke on individuals and society. There is limited information on factors influencing return to work after stroke. OBJECTIVES: To investigate the frequency and determinants of return to paid work after stroke in a multi-ethnic urban population. METHODS: Patterns of return to work were examined among people with first ever stroke registered in the population based South London Stroke Register. Employment status and functional outcome (Barthel Index (BI), Frenchay Activity Index (FAI)) were assessed 1 year after stroke. Associations between baseline characteristics and return to paid work were analysed by multivariable logistic regression analysis. RESULTS: Among 2874 patients with first ever strokes in 1995-2004, 400 (15%) were working before the stroke. At 1 year, 94 (35%) of 266 survivors had returned to paid work. Black ethnicity (OR 0.41; 95% CI 0.19 to 0.88), female sex (0.43; 0.21 to 0.91), older age (p<0.001), diabetes (0.25; 0.08 to 0.79) and dependence (BI < or = 19) in the acute phase (0.24; 0.11 to 0.49) were independently associated with lower odds of return to work in multivariable analysis. Better functional outcome at 1 year was associated with return to paid work (p<0.001) but 53% of 161 independent (BI > 19) and 39% of 96 very active (FAI > 30/45) individuals had not resumed work. CONCLUSIONS: There were important sociodemographic differences in return to work after stroke that were independent of clinical and service use variables included in the analysis. A large proportion of patients did not resume work despite excellent functional outcome.

Predictors of survival after haemorrhagic stroke in a multi-ethnic population: the South London Stroke Register (SLSR).

OBJECTIVES: To identify the predictors of long-term survival after haemorrhagic stroke. METHODS: Data were collected within the population-based South London Stroke Register covering a multiethnic source population of 271,817 inhabitants (2001) in South London. Death data were collected at post-stroke follow-up. The impact of patients' demographic and clinical characteristics, ethnic origin, pre-stroke risk factors and acute treatment on long-term survival were investigated. Survival methods included Kaplan-Meier curves and Cox's proportional hazards model. RESULTS: Between January 1995 and December 2004, a total of 566 patients with first-ever haemorrhagic stroke (395 primary intracerebral haemorrhage; 171 subarachnoid haemorrhage) were registered. Mean age was 62.3 years; 365 (64.5%) were white, 132 (23.3%) were black and 69 (12.2%) were other or unknown ethnic origin; there were 1340 person-years of follow-up. After multivariable adjustment, age (p<0.001) and having diabetes (hazard ratio (HR), 1.69; 95% CI 1.06-2.70) were associated with increased risk of death. Patients with severe stroke (Glasgow Coma Scale (GCS) <9) had an increased risk of death (HR 6.5; 95% CI 4.68 to 8.90) compared with those with mild stroke (GCS >12). Treatment on a stroke unit reduced the long-term risk of death (HR 0.70; 95% CI 0.50 to 0.98). Black patients had a reduced risk of death (HR 0.62; 95% CI 0.42 to 0.92) compared with white patients. CONCLUSIONS: Age, diabetes, stroke severity and stroke unit care influenced the long-term risk of death after haemorrhagic stroke. An independent survival advantage was observed in black patients. These factors can be utilised for clinical predictions but the cause of the observations in black patients remains unclear.

Variations in the use of diagnostic procedures after acute stroke in Europe: results from the BIOMED II study of stroke care.

Valid classification of stroke is essential to initiate effective acute management and early secondary prevention strategies. To accurately evaluate stroke subtype a number of diagnostic procedures have to be performed. This study sought to investigate variations in use of diagnostic procedures across selected European hospitals. First-ever stroke patients were sampled over a 1-year period through 11 hospital-based registers across 10 European countries. We defined a diagnostic standard for valid aetiological classification of ischemic stroke including brain imaging, vascular imaging and echocardiography. The impact of socio-demographic, clinical and structural characteristics on performance of the diagnostic standard was assessed using multivariate logistic regression analyses. A total of 1721 patients were included in the study. 83.1% received brain imaging, ranging from 32.8% to 100%. The diagnostic standard was performed in 40.4% of stroke patients, ranging from 0% to 77.2%. Patients with increasing age (P < 0.001) and with more severe strokes (P = 0.001) were less probably to receive the diagnostic standard. Patients treated in stroke units and neurological departments were more frequently investigated with the diagnostic standard (P < 0.001). Less than half of hospitalized stroke patients across Europe underwent diagnostic procedures to allow for aetiological classification of stroke, which may hamper the initiation of effective early management and secondary prevention.

Involving older people in health research.

BACKGROUND: It is a UK policy requirement to involve patients and the public in health research as active partners. OBJECTIVE: We reviewed published reports of studies which involved older people in commissioning, prioritizng, designing, conducting or disseminating research. Search strategy and selection criteria: systematic searches of databases (PubMed, SCI-EXPANDED, SSCI, A&HCI, ASSIA, Embase, CINAHL and Medline) for English language studies published between 1995 and 2005 which had involved older people as partners n the research process as opposed to research subjects. Articles were reviewed by two authors using a standardised matrix for data extraction. RESULTS: Thirty studies were included and classified according to the stage in the research process in which older people were involved. Barriers to involving older people were: cultural divisions, language barriers, research skills capacity, ill health, time and resources. Four of the studies had been formally evaluated to identify the impact of involvement. Evaluation focussed on the impact on participants rather than on impact on research processes and outcomes. Benefits to participants included: increased knowledge, awareness and confidence, meeting others in similar situations, empowering older people to become active in their community regarding decisions/policies which affect them. CONCLUSIONS: Factors hindering the involvement of older people in research were the same as reported factors hindering involvement of younger people, suggesting that age, per se, is not a barrier. To demonstrate the impact of user involvement on research quality, the definition of user involvement requires clarification, and systematic evaluation of research involving older people needs to be developed.

Clinical determinants of long-term quality of life after stroke.

OBJECTIVES: To determine factors that independently predict health-related quality of life (HRQOL) 1 and 3 years after stroke. METHODS: Subjects numbering 397, from a population-based register of first-ever strokes were assessed for HRQOL using the Short Form 36 (SF36) 1 year after stroke. Physical (PHSS) and mental health (MHSS) summary scores were derived from the eight domains of HRQOL in the SF36. Multivariate stepwise regression analyses were conducted to determine independent predictors of these scores; beta coefficients with 95% CI were obtained.beta coefficient is the difference between average value of the variable (e.g. male) and average value under consideration (e.g. female). Demographic and stroke risk factors, neurological impairments and cognitive impairment (MMSE <24) were included in the models. Similar analyses were undertaken on 150 subjects 3 years post-stroke. RESULTS: A year after stroke, independent predictors of the worst PHSS were of females (beta coefficient -3.3: 95% CI -5.7 to -0.8), manual workers (-3.2: -5.9 to -0.4), diabetes (-4.2: -7.7 to -0.8), right hemispheric lesions (-4.9: -8.7 to -1.2), urinary incontinence (-7.8: -11.6 to -4.1) and cognitive impairment (-2.7: -5.5 to -0.1); the worst MHSS were associated with being Asian (-11.8: -20.6 to -3.0), ischaemic heart disease (-2.7: -5.4 to -0.03), cognitive impairment (-3.04: -5.8 to -0.3). Subjects aged 65-75 years (5.4: 2.5 to -8.4) had better MHSS than those <65 years. Three years post-stroke, independent predictors of worse PHSS were hypertension (-8.7: -13.5 to -3.9), urinary incontinence (-8.1: -15 to -1.1) and cognitive impairment (-8.3: -13.2 to -3.5). CONCLUSIONS: Determinants of HRQOL vary both over time after stroke and whether physical or psychosocial aspects of HRQOL are being considered. This study provides valuable information on factors predicting long-term HRQOL, which can be taken into consideration in audits of clinical practice or in future interventional studies aiming to improve HRQOL after stroke.

Long-term outcome after stroke: does dysphagia matter?

BACKGROUND: swallowing problems (dysphagia) are common following acute stroke and are independent predictors of short-term outcome. It is uncertain as to whether these swallowing problems are associated with outcome in the longer-term. AIM: insert to determine whether dysphagia present in the first week of acute stroke associated with long-term outcome. METHODS: a population-based long-term follow-up of people with first in a life-time stroke. Dysphagia was assessed within 1 week of stroke and patients were followed up at 3 months and yearly for 5 years by face-to-face interview. Outcome was defined by survival and place of residence, using multinomial logistic regression. Barthel Scores were divided into the two groups 15-20 and 0-14, and modelled using multiple logistic regression. RESULTS: there were 567 patients with dysphagia (mean age 74.3 years) and 621 with a safe swallow (mean age 69.6 years). Following multinomial logistic regression, residence in a nursing home was more likely to occur in those who failed the swallow test during the first week of their stroke; however, this only reached statistical significance at 3 months (relative risk ratio (RRR)=1.73; 95% confidence interval (CI) 1.02 to 2.95), and years 4 (RRR 3.35, 1.37-8.19) and 5 (RRR 3.06, 1.06-8.83). There was also a significant association with increased mortality only during the first three months (RRR 2.03, 1.12 to 3.67). CONCLUSION: this study confirms that the presence of dysphagia during the acute phase of stroke is associated with poor outcome during the subsequent year, particularly at 3 months, and is associated with increased institutionalisation rate in the long term.

Relationships between long-term stroke disability, handicap and health-related quality of life.

OBJECTIVES: To estimate levels of disability, handicap and health-related quality of life (HRQOL) up to 3 years after stroke and examine the relationships between these domains. DESIGN: A longitudinal, observational study SETTING: Population-based register of first-ever strokes METHODS: Subjects, registered between 1 January 1995 and 31 December 1997, were assessed at 1 year (n = 490) and 3 years (n = 342) post-stroke for disability [Barthel index (BI)], handicap [Frenchay activity index (FAI)] and HRQOL (SF-36). BI was categorised as severe, moderate, mild and independent (0-9, 10-14, 15-19 and 20); FAI was categorised as inactive, moderately active and very active (0-15, 16-30 and 31-45). SF-36 domains include: Physical Functioning (PF), Role Physical (RP), Bodily Pain (BP), General Health (GH), Vitality (VT), Social Functioning (SF), Role Emotional (RE) and Mental Health (MH). Physical (PHSS) and Mental Health (MHSS) Summary Scores were computed. RESULTS: at 1 and 3 years, 26.1 and 26.3%, respectively, were disabled (BI < 15); 55 and 51%, respectively, were handicapped (FAI = 0-15); and survivors had low mean PHSS (37.1 and 37.9), but satisfactory mean MHSS (46.6 and 47.7). There was a graded positive relationship between all SF-36 domains and the categories of BI and FAI. Spearman rank correlations were significant between BI and all SF-36 domains at both time points: strong (r > 0.70) with PF, moderate (r = 0.31-0.70) with RP, SF and PHSS, but weak (r < 0.30) with other domains. Correlations between FAI and SF-36 domains were strong with PF, weak with BP, RE and MHSS, and moderate with other domains. CONCLUSIONS: Disability and handicap remain highly prevalent up to 3 years after stroke. Patients' perception of physical health is persistently low, but mental health perception is satisfactory up to 3 years. Due to variable correlations between different HRQOL domains with disability and handicap, it is suggested that disability, handicap and HRQOL should all be assessed to acquire a broader measure of stroke outcome.

Obstetric hysterectomy in a population of South East England.

The aim of this study was to estimate the incidence and outcome of obstetric hysterectomy. Of 48,865 women who delivered after 24 weeks' gestation in the South East Thames Region between March 1997 and February 1998, 22 women with obstetric hysterectomy were identified, and 15 prospectively followed-up (71% response rate). The incidence of obstetric hysterectomy was 0.45/1,000 deliveries with one maternal death (4.5%). Identified risk factors were delivery by caesarean section (68%), previous caesarean section (33%) and placenta praevia (24%). Mean blood loss and replacement were 5.2 l and 17 units, with a 38% risk of re-operation and 21% risk of urinary tract injury. Follow-up showed poor general health 6-9 months after delivery with 10 women (67%) attending outpatients and four (27%) requiring emergency admission to hospital. This population survey found a low rate of obstetric hysterectomy but severe morbidity. Obstetric hysterectomy is a good candidate for a national morbidity audit.

Effect of recommended positioning on stroke outcome at six months: a randomized controlled trial.

OBJECTIVE: To evaluate the effect on patient outcome of a teaching package for nurses designed to improve the positioning of stroke patients. DESIGN: Cluster randomized controlled trial with six-month follow-up. SETTING: Ten stroke rehabilitation hospital units located within one UK inner city region. These were randomized to control or intervention group. SUBJECTS: A sample of 120 patients admitted within four weeks of a first stroke and with a hemiplegia. No eligible patient refused to participate. Eighty-three (69%) completed the study. INTERVENTION: All nursing staff on the intervention units received a group teaching package to improve their clinical practice in patient positioning. MAIN OUTCOME MEASURE: Rivermead Mobility Index (RMI) at six months post stroke. Patient's position was recorded using an established observational tool. RESULTS: After the teaching there was some evidence of better positioning in the intervention than the control group (difference in percentage of correct positions per patient 4.9%, 95% confidence interval (Cl -0.1% to 9.9%, p = 0.055). There was no evidence of differences between the two groups in any of the outcome measures at six months although there was a trend towards increased elbow flexor tone in the control group. CONCLUSIONS: A teaching intervention to improve patient positioning made no significant impact on outcome at six months post stroke. However, following the teaching there was only a slightly higher incidence of recommended patient positioning within the intervention group. Thus, a teaching package may not be powerful enough to enable any effect on patient outcome to be measured.

Variations in care and outcome in the first year after stroke: a Western and Central European perspective.

BACKGROUND: There are significant variations in the short term patterns of care and outcome after a first stroke in Europe. OBJECTIVE: To estimate the variation in stroke care and outcome up to 1 year after a stroke in selected European centres. METHODS: Hospital based stroke registers were established in 11 hospitals in seven western and central European countries to collect demographic, clinical, and resource use data at the time of first ever stroke during 1993-4. At 3 and 12 months, details of survival, activities of daily living score, and use of services were recorded. Univariate comparisons between centres were made using the chi2 test and stepwise regression was used to identify associations between centre, case mix, therapy provision, and outcomes. RESULTS: Of the 4048 patients registered, 23% were lost to follow up and 38% had died at 1 year. The proportions of survivors who felt they needed assistance at 12 months ranged from 35% in Italy to 77% in UK2. There were comparatively high amounts of therapy provided up to 1 year in UK3, France and Germany 1, mainly at home. At 1 year, social services were still providing support in UK1, UK5 and France, with some support in Germany 1 and family support was provided in France. In multivariate analysis, after adjustment for case mix and receipt of rehabilitation, non-UK centres had improved activities of daily living (p<0.001). Older age was indicative of more need for assistance, but less likelihood of assistance from the family. Those in France were more likely to get assistance from their family than any other centre. Mainland European patients were more likely to get help from their family than those in the UK. Patients in all areas except UK2 and UK3 were more likely to be dead or dependent at 1 year than patients in UK1. CONCLUSIONS: There were significant variations in the pathways of care for stroke across European centres in the mid 1990s, which were associated with variation in outcome, and remain unexplained. Family support is more prevalent in southern Europe and service support more prevalent in the UK.

Older stroke patients in Europe: stroke care and determinants of outcome.

BACKGROUND: in order to implement cost-effective stroke services for older patients, it is necessary to identify how stroke care is currently provided for these patients and how provision relates to outcome. OBJECTIVES: to estimate the structure and process of care, and identify independent factors associated with 3 month mortality and functional outcome in patients aged over 75 years compared with younger stroke patients across Europe. SETTING: 13 hospitals in 10 European countries. SUBJECTS AND METHODS: 1,847 subjects with first in a lifetime stroke admitted to hospital. Sociodemographic details, acute case severity, resource use and 3-month survival and dependency were collected. RESULTS: from a total of 1,847 patients, 1,112 patients (60%) were under 75 years. Older stroke patients were more likely to be incontinent, dysphasic, dysphagic and comatose (P < 0.001). Computed tomography scan rates were higher in younger (87%) than in older patients (79%) (P < 0.001). Access to organised stroke care was higher in older (58%) than in younger patients (51%) (P = 0.002). Median acute length of stay was longer in younger (14 days, range 7-21 days) than in older patients (11 days, range 8-22 days) (P = 0.04). Nursing time in hospital was higher in older patients (P = 0.01), whilst therapy time was higher in younger patients (P = 0.03). By 3 months, younger patients were more likely to receive outpatient care (P < 0.001), physiotherapy (P < 0.001) and occupational therapy (P < 0.001). For older stroke patients, not having a computed tomography scan (OR = 0.2, 95% confidence intervals (CI) = 0.01-0.6, P = 0.003) was significantly related to mortality at 3 months after adjusting for case mix. Access to organised stroke care was significantly associated with reduced 3-month mortality in younger patients only (OR = 0.29, 95% CI = 0.14-0.6, P < 0.001). CONCLUSION: stroke care varies considerably across European centres, with older people more likely to gain access to organised stroke care in many centres but less likely to receive diagnostic investigations, therapy input and outpatient review. Where there is evidence of age discrimination for access to stroke services, guidelines need to be adopted to ensure patients of all ages receive optimal evidence-based stroke care at all stages of their illness.

Reliability and validity of a postal version of the Reintegration to Normal Living Index, modified for use with stroke patients.

OBJECTIVE: To adapt the Reintegration to Normal Living Index (RNLI) for postal use with stroke patients. DESIGN: Reliability was examined using test-retest on 26 stroke patients. Construct validity was tested on 76 patients by examining correlations between the modified RNLI and related scales. SUBJECTS: Patients at three months to one year post stroke. RESULTS: All items demonstrated better than chance agreement between test and retest and seven items substantial agreement (kappa = >0.61). The modified RNLI correlated positively with related scales. Patients with stronger reintegration to normal living had better outcomes in anxiety, depression, daily activity and quality of life. CONCLUSION: This postal instrument appears reliable and valid and may be a useful outcome measure in stroke studies.