Short- and long-term outcome of constraint-induced movement therapy after stroke: a randomized controlled feasibility trial.

OBJECTIVE: Constraint-induced movement therapy (CIMT) is a method to improve motor function in the upper extremity following stroke. The aim of this trial was to determine the effect and feasibility of CIMT compared with traditional rehabilitation in short and long term. DESIGN: A randomized controlled trial. SETTING: An inpatient rehabilitation clinic. SUBJECTS: Thirty patients with unilateral hand impairment after stroke. INTERVENTION: Six hours arm therapy for 10 consecutive weekdays, while using a restraining mitten on the unaffected hand. MAIN MEASURES: The patients were assessed at baseline, post-treatment and at six-month follow-up using the Wolf Motor Function Test as primary outcome measure and the Motor Activity Log, Functional Independence Measure and Stroke Impact Scale as secondary measurements. RESULTS: The CIMT group (n=18) showed a statistically significant shorter performance time (4.76 seconds versus 7.61 seconds, P= 0.030) and greater functional ability (3.85 versus 3.47, P= 0.037) than the control group (n=12) on the Wolf Motor Function Test at post-treatment assessment. There was a non-significant trend toward greater amount of use (2.47 versus 1.97, P= 0.097) and better quality of movement (2.45 versus 2.12, P=0.105) in the CIMT group according to the Motor Activity Log. No such differences were seen on Functional Independence Measure at the same time. At six-month follow-up the CIMT group maintained their improvement, but as the control group improved even more, there were no significant differences between the groups on any measurements. CONCLUSIONS: CIMT seems to be an effective and feasible method to improve motor function in the short term, but no long-term effect was found.

The prevalence of carotid artery stenosis in an unselected hospitalized stroke population.

AIM: The aim of this study was to describe the number and severity of carotid artery stenosis in an unselected stroke population in hospital. METHODS: The carotid arteries were investigated consecutively with color-coded duplex scanning in patients suspected of having stroke and admitted to a stroke unit during a 6-month period. Percent internal carotid artery stenosis by diameter reduction was described. RESULTS: A total of 144 patients were included in the investigation and the mean age was 75 years. The final diagnosis was stroke in 126 patients, while 18 had transient ischemic attacks. On the side, relevant to the neurologic deficit, a stenosis of >70% diameter reduction was observed in 4 patients and occlusion in 3. Severe stenosis and occlusion was found to have almost the same incidence on the contralateral side. Altogether 46 stenoses >30% (16.3%) were observed in 282 arteries investigated. The distribution was equal between the two sides. CONCLUSION: These findings indicate that few patients are eligible for surgery. However, routine duplex ultrasound examination in stroke patients gives information whether there are carotid arterial lesions, which could be a source of emboli. Such information can also be a guide for further medical treatment and lifestyle modification.

Frequency and effect of optimal anticoagulation before onset of ischaemic stroke in patients with known atrial fibrillation.

BACKGROUND: The aims of the study were (i) to examine which antithrombotic therapy patients with known atrial fibrillation use at the point of time when they suffer an ischaemic stroke, (ii) to evaluate the effects of optimal antithrombotic treatment on outcome and severity of the stroke. METHODS: Patients with known atrial fibrillation before onset of acute ischaemic stroke, and age >60 years were included. Antithrombotic therapy on admission was classified into four groups: no antithrombotic therapy, aspirin, sub-optimal anticoagulation (warfarin and international normalized ratio, INR<2.0) and optimal anticoagulation (warfarin and INR>or=2.0). PRIMARY OUTCOME: modified Rankin Scale (mRS) 5 or 6 at day 7 poststroke. SECONDARY OUTCOMES: (i) death or discharge to a nursing home, (ii) death, (iii) stroke severity on admission assessed by Scandinavian Stroke Scale. RESULTS: A total of 394 patients were included. On admission 109 (28%) patients used no antithrombotic therapy, 169 (43%) aspirin, 52 (13%) warfarin and had an INR<2.0, and 64 (16%) used warfarin and had an INR>or=2.0. The proportion of patients with an mRS 5 or 6 and the corresponding odds ratios were: in the warfarin group with INR<2.0, 16 (31%), OR 3.1 (CI: 1.2-8.0), (P=0.019), in the group with no antithrombotic therapy 29 (27%), 2.5 (1.1-5.9), (P=0.034), and in the aspirin group 41(24%), 2.2 (1.0-5.1) (P=0.054), compared with the warfarin group with INR>or=2.0, where eight (13%) patients had a poor outcome. A significantly higher proportion of patients died or were discharged to a nursing home in the warfarin group with an INR<2.0 (P=0.014), in the aspirin group (P=0.018) and in the no-treatment group (P=0.035), compared with the warfarin group with an INR>or=2.0. No significant differences were found regarding death alone and stroke severity on admission. DISCUSSION: Few patients with known atrial fibrillation who suffer an ischaemic stroke receive optimal antithrombotic therapy prior to the onset of stroke. Optimal anticoagulation does not only reduce the risk of ischaemic stroke, but also appears to reduce death and severe dependency as well as the need for nursing home care, if an ischaemic stroke occurs.

Evaluation of an extended stroke unit service with early supported discharge for patients living in a rural community. A randomized controlled trial.

OBJECTIVE: To evaluate the effect of an extended stroke unit service (extended service), with early supported discharge and co-ordination of further rehabilitation in co-operation with the primary health care system in three rural municipalities. DESIGN: A randomized controlled trial comparing extended service with ordinary stroke unit service (ordinary service). SUBJECTS: Sixty-two eligible patients with acute stroke living in the rural municipalities of Malvik, Melhus and Klaebu. MAIN MEASURES: The primary outcome was the proportion of patients who were independent according to Modified Rankin Scale (mRS) (independence = mRS < or = 2) 52 weeks after onset of stroke. Secondary outcomes were mRS at 6 and 26 weeks and Barthel Index (BI), Nottingham Health Profile (NHP) and Caregiver Strain Index (CSI) at 6, 26 and 52 weeks. Mortality and length of stay were registered during the 52 weeks. RESULTS: Twelve patients (39%) in the extended service group versus 16 patients (52%) in the ordinary service group were independent according to mRS at 52 weeks (p = 0.444). The odds ratio for independence (extended service versus ordinary service) was 0.33 (95% confidence interval (CI) 0.088-1.234). According to outcome by secondary measures there were no significant differences except less social isolation on NHP in the extended service group at 26 weeks (p = 0.046). There were no significant differences in length of stay. CONCLUSION: An extended stroke unit service with early supported discharge seems to have no positive effect on functional outcome for patients living in rural communities, but might give a trend toward better quality of life. There were no significant differences in length of stay.

Validity and reliability of simple questions in assessing short- and long-term outcome in Norwegian stroke patients.

The utility of simple questions for the assessment of stroke outcome in large-scale international studies has generally been approved, but their validity and reliability have not been evaluated in different cultures or at different intervals after a stroke. The study comprised 150 stroke patients who had been admitted consecutively to a stroke unit 6 weeks or 6 months earlier. Two weeks before the visit the patient received a postal questionnaire containing the simple 'dependency' question: 'In the last 2 weeks, did you require help from another person for everyday activities?' and the simple 'recovery' question: 'Do you feel that you have made a complete recovery from your stroke?'. The visit was performed by trained personnel unaware of the patient's or his carer's replies, and comprised the same 2 questions administered by the personnel, the Barthel ADL Index (BI) and the modified Rankin Scale (mRS). The patients' functional status was categorised as good or bad according to the chosen cutoff levels on BI and mRS. At 6 months the dependency question had an accuracy of 83 and 82% in identifying patients with good or bad outcome, defined as BI > or = 95 or < 95 and mRS < 3 or > or = 3, respectively, whereas the recovery question had an accuracy of 86% when compared with mRS = 0 or > 0. There was no difference in accuracy of the simple questions at 6 weeks compared with 6 months, and there was no clinically important difference between responses from patients and carers. The agreement between the responses to the questionnaire and the interview was good to moderate (kappa = 0.62 for the dependency question, and 0.55 for the recovery question). We conclude that the simple questions seem to be valid and reliable measures of stroke outcome when tested in Norwegian patients after 6 weeks or 6 months, which supports their continued use in large-scale multinational stroke studies at different intervals after stroke.

[Myocardial injury in acute stroke assessed by troponin I]. / Myokardskade ved akutte hjerneslag bedømt med troponin I.

BACKGROUND: Acute ischaemic or haemorrhagic cerebrovascular events may produce myocardial damage. Cardiac troponin I is an indicator of cardiac cell injury with very high sensitivity and specificity. MATERIAL AND METHODS: We measured troponin I in 149 acute stroke patients admitted to the stroke unit of Trondheim University Hospital, Norway, in January to June 1999. RESULTS: 40 patients (27%) had troponin I values at 0.4 microgram/l or higher, indicating myocardial injury. 10 patients (6.7%) had troponin I values above 2.0 micrograms/l. Similarly, the mean value of CK-MB vas higher in the patients with myocardial injury, and these patients had more often ECG findings suggesting myocardial ischaemia. Patients with myocardial injury had a higher rate of previous TIA and heart failure. ECG showed atrial fibrillation in 13 of 39 patients with myocardial damage. Patients with detectable levels of troponin I had more embolic brain infarctions than thrombotic brain infarctions. Patients with myocardial injury did more often have abnormal values of CRP. 9 of 10 patients with troponin I-values above 2.0 micrograms/l had abnormal CRP values. No differences in glycosylated haemoglobin, cholesterol, heart rate, blood pressure or body temperature were found. Patients with the highest troponin I values had lower systolic blood pressure, and a higher heart rate, but these differences were not statistically significant. Patients with troponin I values above 2.0 micrograms/l had lower functional and neurological scores at admittance. Patients with myocardial injury were more often discharged to nursing homes. INTERPRETATION: Many patients with an acute stroke have at the same time a myocardial injury, determined by elevated troponin I values.

[Is thrombolytic therapy effective in stroke?]. / Er trombolytisk behandling effektivt ved hjerneslag?

BACKGROUND: The Norwegian Centre for Health Technology Assessment was asked to assess the treatment of stroke by trombolytic medication. We were also asked to include an evaluation of potential consequences for the organisation of the health care system. MATERIAL AND METHODS: Relevant literature was identified on Medline, the Cochrane Library (Systematic Reviews), and INAHTA (Systematic Reviews). Of particular importance are one study from the USA and two studies originating in Europe. RESULTS: The conclusion of the working group is that the benefit of thrombolytic treatment in the studies assessed is uncertain; furthermore, intracranial haemorrhage can occur as a complication of the treatment. INTERPRETATION: Future thrombolytic treatment of stroke patients should be carried out according to a research protocol with thorough documentation of effects as well as side effects.

Benefit of an extended stroke unit service with early supported discharge: A randomized, controlled trial.

BACKGROUND AND PURPOSE: Several trials have shown that stroke unit care improves outcome for stroke patients. The aim of the present trial was to evaluate the effects of an extended stroke unit service (ESUS), with early supported discharge, cooperation with the primary healthcare system, and more emphasis on rehabilitation at home as essential elements. METHODS: In a randomized, controlled trial, 160 patients with acute stroke were allocated to the ESUS and 160 to the ordinary stroke unit service (OSUS). The primary outcome was the proportion of patients who were independent as assessed by the modified Rankin Scale (RS) (RS /=95=independent in ADL) after 26 weeks. Secondary outcomes were RS and BI scores after 6 weeks; the proportion of patients at home, in institutions, and deceased after 6 and 26 weeks; and the length of stay in institutions. RESULTS: After 26 weeks, 65.0% in the ESUS versus 51.9% in the OSUS group showed global independence (RS /=95) (P:=0.056). The odds ratios for independence (ESUS versus OSUS) were as follows: RS, 1.72 (95% CI, 1.10 to 2.70); BI, 1.54 (95% CI, 0.99 to 2.39). At 6 weeks, 54.4% of the ESUS group and 45. 6% of the OSUS group were independent according to RS (P:=0.118), and 56.3% versus 48.8% were independent according to BI (P:=0.179). The proportion of patients at home after 6 weeks was 74.4% for ESUS and 55.6% for OSUS (P:=0.0004), and the proportion in institutions was 23.1% versus 40.0%, respectively (P:=0.001). After 26 weeks, 78. 8% in the ESUS group versus 73.1% in the OSUS were at home (P:=0. 239), while 13.1% versus 17.5% were in institutions (P:=0.277). The mortality in the 2 groups did not differ. Average lengths of stay in an institution were 18.6 days in the ESUS and 31.1 days in the OSUS group (P:=0.0324). CONCLUSIONS: An ESUS with early supported discharge seems to improve functional outcome and to reduce the length of stay in institutions compared with traditional stroke unit care.

Quality of life after cerebrovascular stroke: a systematic study of patients' preferences for different functional outcomes.

OBJECTIVES: To elicit valid quality of life estimates and the highest acceptable treatment risk of different outcomes after stroke. This is a prerequisite for rational medical decision-making, especially when considering treatments like thrombolysis. SUBJECTS: Healthy people, non-stroke medical patients and stroke survivors aged 20-84 years (n = 158) INTERVENTIONS: Subjects were interviewed by a physician using three different methods ('standard gamble', 'time trade-off' and 'direct scaling') supported by an interactive computer program. MAIN OUTCOME MEASURES: We measured utility, a numerical value ranging from 0.00 (death) to 1.00 (perfect health), representing the strength of the patient's preference for an outcome. When using the standard gamble method, risk is also introduced into the measurement. RESULTS: People's preferences for stroke outcomes varied widely, and the estimates were influenced by assessment method. We found that previous stroke, marital status and age were the only independent variables influencing the utility given. Subjects in our population over the age of 45 were very comparable to the real population at risk for acute stroke regarding these three variables, and they assigned a median utility of 0.91 (10th percentile, 0.65; 90th percentile, 0.99) to a minor stroke and 0.61 (10th percentile, 0.08; 90th percentile, 0.95) to a major stroke using the standard gamble method. CONCLUSIONS: Most people do not feel that suffering from stroke is an overwhelming catastrophe and they do not accept treatment options with very high risks.

Stroke unit treatment. 10-year follow-up.

BACKGROUND AND PURPOSE: We have previously shown that treatment in our combined acute and rehabilitation stroke unit (SU) improves the outcome during the first 5 years after onset of stroke compared with that for stroke patients treated in general wards (GW). The aim of the present trial was to examine the effects of SU care after 10 years of follow-up. METHODS: In a randomized controlled trial, 110 patients with symptoms and signs of an acute stroke were allocated to the SU and 110 to GW. No significant differences existed in baseline characteristics between the groups. The outcome after 10 years was measured by the proportion of patients at home, the proportion of patients in an institution, the mortality, and the functional state as assessed by the Barthel Index, in which a Barthel Index score of >/=60 was classified as independent or partly independent and a score of >/=95 was classified as independent. RESULTS: After 10 years, 21 (19.1%) of the patients randomized to the SU and 9 (8.2%) of the patients randomized to the GW were at home (P=0.0184). Eighty-three (75.5%) of the patients from the SU and 96 (87.3%) of the patients from the GW were dead (P=0.0082), and 6 (5.4%) and 5 (4.5%), respectively, were in an institution (eg, nursing home; NS). Twenty-two (20.0%) of the SU patients and 9 (8. 2%) of the GW patients had a Barthel Index score of >/=60 (P=0.0118), and 14 (12.7%) and 6 (5.4%), respectively, had a score of >/=95 (P=0.0606). CONCLUSIONS: For the first time it has been shown that SU care improves survival and functional state and increases the proportion of patients able to live at home 10 years after their stroke. Treatment in combined acute and rehabilitation SU seems to have important long-term effects on outcome for stroke patients.

[Acute stroke--who dies in a stroke unit?]. / Akutt hjerneslag--hvem dør i en slagenhet?

Stroke unit care increases the proportions of patients able to live at home, improves functional outcome, reduces the need for institutional care, and reduces mortality. We have evaluated the data on the 69 patients who died in our stroke unit with an acute stroke, among the first 1,000 patients treated. The patients who died were older and had lower functional scores (median Barthel Index score 0 versus 70) and neurological scores (median Scandinavian Stroke Scale score 6 versus 48) at admittance. Early progression of the stroke was also more frequent in the group of patients who died. No differences in blood pressure, heart rate and body temperature were found between the groups, aside from increased diastolic pressure and heart rate in patients who died with an embolic infarction and increased systolic pressure in patients who died with an intracerebral haemorrhage.

Treatment in a combined acute and rehabilitation stroke unit: which aspects are most important?

BACKGROUND AND PURPOSE: We have previously shown that treatment of acute stroke patients in our stroke unit (SU) compared with treatment in general ward (GWs) improves short- and long-term survival and functional outcome and increases the possibility of earlier discharge to home. The aim of the present study was to identify the differences in treatment between the SU and the GW and to assess which aspects of the SU care which were most responsible for the better outcome. METHODS: Of the 220 patients included in our trial, only 206 were actually treated (SU, 102 patients; GW, 104 patients). For these patients, we identified the differences in the treatment and the consequences of the treatment. We analyzed the factors that we were able to measure and their association with the outcome, discharge to home within 6 weeks. RESULTS: Characteristic features in our SU were teamwork, staff education, functional training, and integrated physiotherapy and nursing. Other treatment factors significantly different in the SU from the GW were shorter time to start of the systematic mobilization/training and increased use of oxygen, heparin, intravenous saline solutions, and antipyretics. Consequences of the treatment seem to be less variation in diastolic and systolic blood pressure (BP), avoiding the lowest diastolic BP, and lowering the levels of glucose and temperature in the SU group compared with the GW group. Univariate analyses showed that all these factors except the level of glucose were significantly associated with discharge to home within 6 weeks. In the final multivariate Cox regression model, shorter time to start of the mobilization/training and stabilized diastolic BP were independent factors significantly associated with discharge to home within 6 weeks. CONCLUSIONS: Shorter time to start of mobilization/training was the most important factor associated with discharge to home, followed by stabilized diastolic BP, indicating that these factors probably were important in the SU treatment. The effects of characteristic features of an SU, such as a specially trained staff, teamwork, and involvement of relatives, were not possible to measure. Such factors might be more important than those actually measured.

A decision analysis of thrombolytic therapy compared with standard therapy in acute ischaemic stroke.

OBJECTIVES: Experts draw different conclusions on whether thrombolysis can be recommended or not for acute ischaemic stroke. A major problem is weighing the improvement in functional ability against the risk of increased mortality. We wanted to examine this uncertainty regarding thrombolysis using a systematic approach and with a strong emphasis on the patient's point of view. METHODS: We performed a decision analysis where the base case focused on an average stroke patient. We used published probabilities for different functional outcomes after standard supportive care and after adding tissue plasminogen activator (tPA), and we tried to estimate corresponding long-term survival. We interviewed 158 subjects with the standard gamble method to elicit their preference values (utility) for these outcomes. RESULTS: When using the baseline data for an average stroke patient, thrombolysis with tPA was the better choice, with 48 extra quality-adjusted living days; tPA was also superior in 117 individual decision analyses, giving from 10 to 173 extra days. However, sensitivity analysis showed that these results were highly susceptible to changes in utility for major disability, probability of early death, and long-term survival after thrombolysis. To increase the gain as well as the margin of safety regarding the treatment choice, thrombolysis should be restricted to patients who assign low utility values < 0.6-0.7 to major poststroke disability (death = 0.0, good health = 1.0). CONCLUSION: Evaluated by decision analysis, thrombolysis with tPA is on average superior to standard therapy for the few patients fulfilling the strict medical inclusion criteria. Individual incorporation of the patient's point of view narrows the indication even further.

Stroke unit treatment improves long-term quality of life: a randomized controlled trial.

BACKGROUND AND PURPOSE: We have previously shown that treatment of acute stroke patients in the combined acute and rehabilitation stroke unit in our hospital improves survival and functional outcome compared with treatment in general wards. The primary aim of the present trial was to examine whether the treatment in our stroke unit had an effect on different aspects of quality of life (QoL) for stroke patients 5 years after the onset of stroke. METHODS: In a randomized controlled trial, 110 patients with symptoms and signs of an acute stroke were allocated to the stroke unit and 110 to general wards. No significant differences existed in baseline characteristics between the two groups. The patients alive after 5 years were assessed by the Nottingham Health Profile (NHP) and the Frenchay Activities Index (FAI), which were the scales used as primary outcome measures for QoL. As secondary outcome measures we used a global score for the NHP and a simple visual analogue scale (VAS). RESULTS: After 5 years, 45 of the patients treated in the stroke unit and 32 of those treated in general wards were alive. All surviving patients were assessed by the FAI. Thirty-seven (82.2%) of the stroke unit patients and 25 (78.1%) of the general wards patients were assessed by the NHP; 38 (84.4%) and 28 (87.5%), respectively, were assessed by the VAS. Patients treated in the stroke unit had a higher score on the FAI (P=0.0142). Assessment with the NHP showed better results in the stroke unit group for the dimensions of energy (P=0.0323), physical mobility (P=0.0415), emotional reactions (P=0.0290), social isolation (P=0.0089), and sleep (P=0.0436), although there was no difference in pain (P=0.3186). The global NHP score and VAS score also showed significantly better results in the stroke unit group (NHP, P<0.01; VAS, P<0.001). Patients who were independent in activities of daily living had significantly better QoL assessed by these scales than patients who were dependent. CONCLUSIONS: Our study shows for the first time that stroke unit care improves different aspects of long-term QoL for stroke patients.

Epidemiology of stroke in Innherred, Norway, 1994 to 1996. Incidence and 30-day case-fatality rate.

BACKGROUND AND PURPOSE: In Norway, as well as other industrialized countries, mortality from stroke has declined over the past decades. Data on stroke morbidity are lacking. This study was conducted to determine the incidence, case fatality, and risk factors of stroke in a defined Norwegian population. METHODS: During the period 1994 to 1996, a population-based stroke registry collected uniform information about all cases of first-ever and recurrent stroke occurring in people aged > or = 15 years in the region of Innherred in the central part of Norway (target population 70,000), where the prevalence of cardiovascular risk factors was screened in 1984 to 1986 and 1995 to 1997. RESULTS: During the 2 years of registration (September 1, 1994, to August 31, 1996), 432 first-ever (72.8%) and 161 recurrent (27.2%) strokes were registered. The crude annual incidence rate was 3.12/1000 (2.85/1000 for males and 3.38/1000 for females). Adjusted to the European population, the annual incidence rate of first-ever stroke was 2.21/1000. The annual incidence rate of cerebral infarction was 2.32/1000, intracerebral hemorrhage 0.32/1000, subarachnoid hemorrhage 0.19/1000, and unspecified stroke 0.38/1000. The 30-day case-fatality rate was 10.9% for cerebral infarction, 37.8% for intracerebral hemorrhage, and 50.0% for unspecified stroke. Fourteen percent of the patients were found outside the hospital, and only 50% of the suspected stroke cases in the hospital (at admission or reviewed discharge diagnosis of ICD-9 codes 430 to 438) fitted the final inclusion criteria. CONCLUSIONS: This first population-based stroke register in Norway revealed incidence rates of stroke similar to other Scandinavian countries, and comparison between other European countries did not indicate regional variations within Western Europe.

Stroke unit treatment. Long-term effects.

BACKGROUND AND PURPOSE: We have previously shown that treatment in our combined acute and rehabilitation Stroke Unit improves outcome during the first year after onset of stroke compared with stroke patients treated in general wards. The aim of the present trial was to examine the long-term effects of the stroke unit care. METHODS: In a randomized controlled trial, 110 patients with symptoms and signs of an acute stroke were allocated to the Stroke Unit and 110 to general wards. No significant differences existed in baseline characteristics between the two groups. The outcome after 5 years was measured by the proportion of patients at home, the proportion of patients in an institution, the mortality, and the functional state assessed by Barthel Index. RESULTS: After 5 years, 38 (34.5%) of the patients randomized to the Stroke Unit and 20 (18.2%) of the patients randomized to the general wards were at home (P = .006). Sixty-five (59.1%) of the patients from the Stroke Unit and 78 (70.9%) of the patients from the general wards were dead (P = .041), while 7 (6.4%) and 12 (10.9%), respectively, were in an institution (e.g., nursing home) (P = NS). Functional state was significantly better for patients treated in the Stroke Unit. CONCLUSIONS: For the first time it is shown that stroke unit care improves long-term survival and functional state and increases the proportion of patients able to live at home 5 years after the stroke. Combined acute and rehabilitation stroke units appear to be an effective way of organizing treatment for acute stroke patients.

[Treatment in the stroke unit reduces mortality, disability and need for institutional care]. / Behandling på slagenhet reduserer dødelighet, funksjonshemning og institusjonsbehov.

The care of acute stroke patients at a stroke unit is "evidence-based" treatment associated with reductions in mortality, functional disability and hospitalisation rates comparable to those obtained in general hospital care. There are various models of stroke unit treatment and documented results are available for all of them except intensive care and stroke team models. In the combined acute-rehabilitation unit model, the efficacy of which has been shown particularly in Scandinavian hospitals, the emphasis is on constructive teamwork and a combination of systematic, standardised acute treatment and early mobilisation and rehabilitation. These units have shown that they can provide effective services for the acute stroke patient, and that the approach is also associated with economic gain to the community.

[Acute stroke. Patients treated in a stroke unit in Trondheim]. / Akutt hjerneslag. Pasienter behandlet ved slagenheten i Trondheim.

Treatment in a stroke unit raises the proportion of stroke patients who are able to live at home, improves functional outcome, reduces the need for institutional care, and brings down mortality. We have evaluated the data on the first 800 patients treated in our stroke unit. Nine patients were incorrectly registered as acute stroke victims and were excluded from the analysis. Hence, 791 patients (429 men, 362 women; mean age 72.3 years range 35-101 years) fulfilled the criteria for acute stroke or TIA. In the group of 654 patients who had suffered an acute stroke, 85 patients (13%) had intracerebral haemorrhage, 439 (67.1%) nonembolic infarction, and 130 (19.9%) embolic infarction. The majority of the patients were discharged to home (55.4%), while 23.6% were discharged to a rehabilitation institution, and 6.1% were discharged to nursing homes. 48 (6.1%) of the patients died during the stay in hospital. The mean time spent in the stroke unit was 12.1 days.

[Diagnosis and treatment of high blood pressure. How to invest?]. / Diagnostikk og behandling av høyt blodtrykk. Hvordan investere?

High blood pressure is a major risk factor for development of cardiovascular diseases. During 1992 and 1993, several national consensus reports about treatment of arterial hypertension have been published. There are discrepancies between the recommendations contained in the reports, which has caused uncertainty among physicians. We discuss the basic problems connected to evaluation and recommendation, and the demand for standardization and organization of the health service programme for patients with high blood pressure. It is possible to learn from, and thereby achieve better quality of medical practice, through a continuous registration of our routines and results. The Trondheim model is designed to depict specific information from the primary health services in a follow-up programme. This information is sampled in a data base from which primary physicians can obtain feedback on statistical evaluations twice a year. This is defined as a quality assurance programme to secure and improve the quality of the medical service to patients with high blood pressure.