Burden and perceived health status among caregivers of stroke patients.

OBJECTIVE: To identify the main determinants of burden and perceived health status in caregivers of Brazilian stroke survivors. METHODS: Cross-sectional study. Caregivers answered the Hospital Anxiety and Depression Scale (HADS), Zarit caregiver burden interview (ZCBI) and EuroQol. Patients were assessed with the National Institute of Health Stroke Scale, Barthel index (BI), modified-Rankin scale (m-RS), Mini Mental State Examination and HADS. RESULTS: 200 caregiver-patient dyads were assessed. Caregivers were significantly younger (42 vs. 57.7 years) and had more years of formal education (10 vs. 7.8 years); p < 0.0001. Seventy-seven percent of caregivers were females, and 41% were spouses. The prevalence of anxiety disorders was significantly higher in female caregivers than in males (26.1 vs. 10.9%; p = 0.04). ZCBI mean score was 27.2, and female caregivers had significantly worse scores (28.7 vs. 22.3, p = 0.003). ZCBI mean score significantly increased (worsened) as the severity of the disease, based on m-RS, increased. ZCBI mean scores were significantly higher in wives than in other relatives (31.4 vs. 22.6; ANOVA, p < 0.0001). The EuroQol-5D and EuroQol-Visual Analog Scale mean scores were 0.7 (range: 0.04-0.85) and 75.2 (range: 1-100), respectively. Adequate convergent validity (r = -0.38 to -0.40) between EuroQol and ZBCI mean scores was observed. Patient s disability (as measured by the BI) and caregiver's factors (female sex, depression as measured by HADS-depression) were independent predictors of caregiver's burden (r2 adjusted = 0.48; p < 0.0001) in the multivariate regression analysis. CONCLUSIONS: Caregiver's mood was the most consistent factor influencing caregiver burden and perceived health in stroke caregivers.

Self- and proxy-report agreement on the Stroke Impact Scale.

BACKGROUND AND PURPOSE: The purpose of this study was to examine proxy-patient agreement on the domains of the Stroke Impact Scale (SIS), as per the proxy-proxy perspective. METHODS: Stroke patients were prospectively assessed by means of the NIH Stroke Scale, Barthel index, and modified Rankin scale. Proxies and patients answered the Hospital Anxiety and Depression Scale and the SIS 3.0. Comparisons of patient-proxy mean scores (paired t test), effect size, and intraclass correlation coefficients (ICC) were calculated for each of the SIS domains, and weighted kappa for individual items. RESULTS: 180 proxy-patient pairs were assessed. Proxies were younger (mean age: 43.1 versus 57.9 years) and had a higher education level (P<0.0001). The bias between patient-proxy mean differences was low (from 5.3, Strength, to 0.1, Communication). Proxies significantly scored patients as more severely affected in Strength (41.7 versus 36.6; P<0.0001) and ADL (46.2 versus 43.1; P=0.01) domains, and Composite Physical Domain (CPD; 39.7 versus 34.9; P<0.0001). The magnitude of difference was small (size effect: 0.21). ICC values for the SIS domains ranged from 0.17 (Emotion) to 0.79 (Hand function). The ICC value for the CPD was 0.83. Memory, Communication, Emotion, and Social Participation domains had ICC lower values. The weighted kappa values for the SIS items ranged from 0.09 (item 4e) to 0.80 (item 7d). Highest values (moderate/high agreement) were observed for the SIS-16 and CPD (kappa values: 0.31 to 0.80). CONCLUSIONS: Agreement between stroke patients and proxies was acceptable for most SIS domains and SIS-16. Proxy's assessment of SIS subjective domains should be taken with caution.

Poststroke depression: prevalence and determinants in Brazilian stroke patients.

BACKGROUND: Poststroke depression (PSD) is one of the most important long-term adverse psychosocial consequences in stroke survivors. Our objective was to assess the prevalence of PSD in Brazilian stroke patients and identify significant associated factors. METHODS: A cross-sectional study of stroke patients consecutively admitted for rehabilitation was conducted. The patients were evaluated by means of the NIH Stroke Scale, Mini-Mental State Examination, Barthel Index, Lawton Scale, modified Rankin Scale, Hospital Anxiety and Depression Scale (HADS), Geriatric Depression Scale (GDS) and MOS-Short Form 36. Patients with a HADS-depression subscale score > or = 11 and/or GDS score > or = 8 were classified as depressed. RESULTS: Three hundred stroke survivors were assessed (mean age: 56.3 years; 51.7% males). Half (46.7%) of the stroke patients had an m-RS score < or = 2. The proportion of stroke patients who scored > or = 11 points on the HADS-depression and HADS-anxiety subscales were 19.2 and 23.7%, respectively. One third (29.7%) had a GDS mean score > or = 8. The GDS scores significantly correlated (p < 0.0001) with the HADS-depression (r = 0.51) and HADS-anxiety subscales (r = 0.54). The prevalence of mood disorders was significantly higher in females than in males (24.8 vs. 14.2%; x(2), p = 0.03). PSD was significantly associated (p < 0.0001) with work status (housewife), education level, lower social and cognitive functioning, dependence in the instrumental activities of daily living and presence of diabetes in the multivariable regression analysis (R adjusted = 0.32). CONCLUSIONS: PSD was highly prevalent in the chronic phase of stroke. Early detection and recognition of associated risk factors is important to treat and prevent PSD in a rehabilitation setting.

Chronic spinal epidural abscess caused by Scedosporium prolificans in an immunocompetent patient.

STUDY DESIGN: Case report and clinical discussion. OBJECTIVE: To describe a rare case of chronic spinal epidural abscess caused by Scedosporium prolificans in an immunocompetent patient. SUMMARY OF BACKGROUND DATA: S. prolificans is an emerging multiresistant fungal pathogen that may cause a wide variety of infections, whose severity depends of the patient's immune status. METHODS: A 35-year-old Brazilian man developed a 5-year chronic progressive paresis in lower limbs followed by sphincter dysfunction. Spinal magnetic resonance imaging revealed a thoracic-lumbar epidural mass that heterogeneously enhanced gadolinium. Spinal biopsy showed a chronic inflammatory process localized in epidural thoracic spine. S. prolificans was isolated in a specific culture. RESULTS: He was treated with endovenous voriconazole for 2 weeks followed by oral voriconazole for 90 days. Three months later, a T9-T10 epidural mass was detected on a new magnetic resonance imaging. The abscess was drained, and the culture of the material confirmed the persistence of infection by S. prolificans. A progressive paraparesis due to chronic meningo-myelitis was observed at a 6-month follow-up. Although patient was treated with caspofungin, terbinafine, and voriconazole, no improvement was observed. CONCLUSION: S. prolificans can cause chronic epidural abscess and spine infection in immunocompetent patients. The potential resistance of S. prolificans to antifungal agents should be borne in mind.