Satisfaction with information and advice received by stroke patients

OBJECTIVE

To determine levels of satisfaction with information and advice received about stroke disease and relevant issues by community-dwelling stroke survivors.

DESIGN

An interview questionnaire survey.

SETTING

A family health services authority area in northern England.

SUBJECTS

Stroke survivors identified by a valid screening questionnaire from a stratified random sample of 2000 subjects aged 45 years and over.

MAIN OUTCOME MEASURE

Proportion of subjects interviewed responding positively to the question 'Do you think you have received enough advice and information on ...?' eighteen topics considered relevant to stroke survivors.

RESULTS

The screening process identified 116 stroke survivors, of whom 76 agreed to be interviewed. The majority (> 80%) of patients were satisfied with information and advice received on lifestyle and health promotion issues, incontinence and their current treatment. However, satisfaction was poor for the areas of stroke disease in general, its effects, available services, and legal and financial affairs (range, 28-75% satisfied).

CONCLUSIONS

Deficits in the provision of adequate information and advice to stroke patients on relevant issues have beer identified in this study of a representative sample of community-dwelling stroke survivors. These deficits need to be addressed by those providing care for stroke patients in order to improve patients satisfaction.

The incidence of diabetes mellitus in an English community: a 20-year follow-up of the Whickham Survey

The original Whickham Survey documented the prevalence of diabetes and lipid disorders in a sample of 2779 adults aged 18 years and over, which matched the British population structure. The aim of the 20-year follow-up study was to determine the incidence and natural history of diabetes. Outcomes in terms of morbidity and mortality at follow-up were determined in over 97% of the original population. Ninety-four subjects had been identified and treated for diabetes since the first survey, including 17 subjects identified as having a fasting plasma glucose > or = 7.8 mmol l-1 at follow-up. The incidence of diabetes for the total population was 2.2 1000-1 year-1 (95% confidence interval 1.8, 2.6). The risk factors identified at first survey were corrected for age, cut-off at the 95 centile and entered into a log linear model. Those which strongly predicted development of diabetes in the total population were fasting blood glucose (odds ratio (OR) (with 95% confidence intervals) = 2.3 (1.5, 3.5)) and body mass index (OR = 2.2 (1.5, 3.3)) in men, and fasting blood glucose (OR = 2.6 (1.7, 4.1)) and fasting serum triglyceride (OR = 2.8 (1.8, 4.4)) in women. A logit model has enabled the calculation of the probability of developing diabetes 20 years later. It was the characteristics of becoming older such as obesity, hypertriglyceridaemia, and raised fasting blood glucose, rather than age itself, which were associated with the development of diabetes.

Does alcohol contribute to accident and emergency department attendance in elderly people?

OBJECTIVE

To evaluate the possible contribution of alcohol to presentation of elderly subjects at a hospital accident and emergency (A&E) department.

METHODS

105 patients aged 70 years and over who attended the department were interviewed by a single observer using a structured questionnaire based on previously validated general population surveys. Details of alcohol consumption within the previous 24 hours were recorded. Usual consumption of alcohol in the preceding 12 months was estimated by the quantity frequency method. Alcohol dependence was screened for by the CAGE questionnaire. An assessment of disability was made using the Barthel index. Breath alcohol was measured.

RESULTS

In only 2% of attenders was alcohol thought to be a contributory factor. Breath alcohol measurements were technically unsatisfactory in this age group. Regular drinkers were functionally and socially more independent than non-regular drinkers. Drinking patterns in this age group may partly be determined by the physical ability to obtain alcohol.

CONCLUSIONS

Alcohol was not found to be a major factor in A&E attendance in elderly people.

The development of ischemic heart disease in relation to autoimmune thyroid disease in a 20-year follow-up study of an English community

The original Whickham Survey documented risk factors for cardiovascular disease and the prevalence of thyroid disorders in a sample of 2779 adults that closely matched the British population. A 20-year follow-up study has determined outcomes in terms of morbidity and mortality from ischemic heart disease in over 97% of the original survey population. Analysis of deaths from all causes and from ischemic heart disease showed no association with antithyroid antibody status identified at first survey. A multiple logistic regression using the development of ischemic heart disease in the total population at follow-up as the dependent variable found that the significant predictor variables for men were age, cholesterol, mean arterial blood pressure, smoking history, and skinfold thickness index. For women only age, cholesterol, and mean arterial blood pressure were significant. The presence of autoimmune thyroid disease, as defined by either hypothyroidism, positive antithyroid antibodies, or raised serum thyrotropin at first survey, was not significant. A retrospective cohort study of a subsample of women identified at first survey with positive antithyroid antibodies or raised serum thyrotropin and closely matched controls found no significant association with mortality or development of ischemic heart disease. There is no evidence from this study to suggest that evidence of autoimmune thyroid disease identified 20 years ago is associated with an increased risk of ischemic heart disease.

Service provision and use of anticoagulants in atrial fibrillation

Several large trials have shown that the risk of stroke in patients with non-valvar atrial fibrillation is reduced by treatment with warfarin. Implementing this research evidence requires not only an understanding of the trials' results and of the changes that they imply for clinicians' treatment decisions but also an appreciation of the organisation, quantity, and quality of services required to support these changes. Understanding of these implications is crucial for developing services that allow changes in practice to produce reductions in stroke incidence while minimising the risks of treatment. This article considers the developments in service provision that will probably be required to support the changes in clinical practice suggested by the trials' results. These services will be provided largely by doctors, and their development has implications for doctors in both primary and secondary care.

Validation of a population screening questionnaire to assess prevalence of stroke

BACKGROUND AND PURPOSE

A cross-sectional survey is the best method for determining the prevalence of a chronic condition such as stroke. Before embarking on a large population study, a valid screening instrument is necessary. This study aimed to validate a self-completion postal screening questionnaire for assessing lifetime history of stroke.

METHODS

A random sample of 2000 people aged 45 years and over was selected from the Family Health Services Authority register. A brief self-completion questionnaire requesting self-reported history of stroke was mailed to each individual. Responders reporting a history of stroke received a request for a standardized home assessment visit. Confirmation of the diagnosis of stroke was made based on information from the home visit together with multiple sources of case ascertainment. False-negative responses and assessment of nonresponse bias were documented.

RESULTS

The response rate for the questionnaire was 88%. Of the sample, 120 (6%) who were wrongly registered were excluded; 173 (10%) of the 1663 responders reported a history of stroke. The question "Have you ever had a stroke?" had a sensitivity of 95% and a specificity of 96%.

CONCLUSIONS

This simple self-completion questionnaire is a valid means of screening for cases of stroke in the community and could form the basis for subsequent studies of prevalence and health needs.

The incidence of thyroid disorders in the community: a twenty-year follow-up of the Whickham Survey

BACKGROUND AND OBJECTIVE

The original Whickham Survey documented the prevalence of thyroid disorders in a randomly selected sample of 2779 adults which matched the population of Great Britain in age, sex and social class. The aim of the twenty-year follow-up survey was to determine the incidence and natural history of thyroid disease in this cohort.

DESIGN, PATIENTS AND MEASUREMENTS

Subjects were traced at follow-up via the Electoral Register, General Practice registers, Gateshead Family Health Services Authority register and Office of Population Censuses and Surveys. Eight hundred and twenty-five subjects (30% of the sample) had died and, in addition to death certificates, two-thirds had information from either hospital/General Practitioner notes or post-mortem reports to document morbidity prior to death. Of the 1877 known survivors, 96% participated in the follow-up study and 91% were tested for clinical, biochemical and immunological evidence of thyroid dysfunction.

RESULTS

Outcomes in terms of morbidity and mortality were determined for over 97% of the original sample. The mean incidence (with 95% confidence intervals) of spontaneous hypothyroidism in women was 3.5/1000 survivors/year (2.8-4.5) rising to 4.1/1000 survivors/year (3.3-5.0) for all causes of hypothyroidism and in men was 0.6/1000 survivors/year (0.3-1.2). The mean incidence of hyperthyroidism in women was 0.8/1000 survivors/year (0.5-1.4) and was negligible in men. Similar incidence rates were calculated for the deceased subjects. An estimate of the probability of the development of hypothyroidism and hyperthyroidism at a particular time, i.e. the hazard rate, showed an increase with age in hypothyroidism but no age relation in hyperthyroidism. The frequency of goitre decreased with age with 10% of women and 2% of men having a goitre at follow-up, as compared to 23% and 5% in the same subjects respectively at the first survey. The presence of a goitre at either survey was not associated with any clinical or biochemical evidence of thyroid dysfunction. In women, an association was found between the development of a goitre and thyroid-antibody status at follow-up, but not initially. The risk of having developed hypothyroidism at follow-up was examined with respect to risk factors identified at first survey. The odds ratios (with 95% confidence intervals) of developing hypothyroidism with (a) raised serum TSH alone were 8 (3-20) for women and 44 (19-104) for men; (b) positive anti-thyroid antibodies alone were 8 (5-15) for women and 25 (10-63) for men; (c) both raised serum TSH and positive anti-thyroid antibodies were 38 (22-65) for women and 173 (81-370) for men. A logit model indicated that increasing values of serum TSH above 2mU/l at first survey increased the probability of developing hypothyroidism which was further increased in the presence of anti-thyroid antibodies. Neither a positive family history of any form of thyroid disease nor parity of women at first survey was associated with increased risk of developing hypothyroidism. Fasting cholesterol and triglyceride levels at first survey when corrected for age showed no association with the development of hypothyroidism in women.

CONCLUSIONS

This historical cohort study has provided incidence data for thyroid disease over a twenty-year period for a representative cross-sectional sample of the population, and has allowed the determination of the importance of prognostic risk factors for thyroid disease identified twenty years earlier.

Alcohol and stroke. A case-control study of drinking habits past and present

BACKGROUND AND PURPOSE

Previous studies have reported a U-shaped relation between alcohol consumption and stroke. Those studies have been criticized for failing to distinguish between lifelong abstainers from alcohol and those who have given up drinking.

METHODS

We examined current and previous drinking habits of 364 cases of acute stroke and 364 community-based control subjects matched for age, sex, and family practitioner.

RESULTS

Stroke patients were more likely to have been lifelong abstainers from alcohol than were the control subjects. The odds ratio (OR) or lifelong abstainers versus those who had ever drunk regularly was 2.36 (95% confidence interval [CI], 1.67 to 3.37). No relation was found between stroke and current nondrinkers. Current male heavy drinkers also had an increased risk of stroke (OR, 2.88; 95% CI, 1.08 to 2.31).

CONCLUSIONS

Lifelong abstention from alcohol is associated with an increased risk of stroke. Moderate alcohol consumption may protect against cerebrovascular disease.

Adrenocortical suppression presenting with agitated depression, morbid jealousy, and a dementia-like state

A 66-year-old woman showed profound neuropsychiatric disturbance after withdrawal from prolonged corticosteroid treatment. Reintroduction of an alternative corticosteroid, at low dose, produced a return to premorbid mental state.

Bacterial endocarditis of the tricuspid valve after insertion of a central venous catheter

Central venous cannulation is a commonly used technique in the management of seriously ill patients. In experienced hands, the complication rate is low and primarily includes sepsis, thrombosis and local trauma. For chronic indwelling central venous catheters, thrombus formation within the right atrium has been described, particularly in premature infants, and a recent case has been reported in an adult. Valvular damage in the right heart is recognised and more often diagnosed at autopsy. This report describes the presence of tricuspid vegetations in a diabetic woman, related to the insertion of a central venous cannula.

Comparative study of 5% permethrin cream and 1% lindane lotion for the treatment of scabies

A multicenter, randomized, investigator-blind controlled trial was conducted to compare the safety and efficacy of a single, whole-body application of 5% permethrin cream with that of 1% lindane lotion for the treatment of scabies in 467 patients. At 14 +/- 3 days after treatment, the mean active lesion count decreased from pretreatment levels of 85 (range, 4 to 600) in both treatment groups to 14 (range, 0 to 133) in the permethrin group and to 15 lesions (range, 0 to 500) in the lindane group. At 28 +/- 7 days after treatment, complete resolution had occurred in 181 (91%) of 199 patients treated with permethrin and in 176 (86%) of 205 patients given lindane. Pruritus due to scabies persisted at 28 +/- 7 days in 14% of the permethrin group and in 25% of the lindane group. The most frequent adverse effects were new or increased pruritus and mild, transient burning or stinging; the latter was slightly more frequent following permethrin treatment and appeared to be related to severity of infestation. Because of a lower potential for neurologic toxicity, permethrin may be preferable to lindane for the treatment of scabies particularly in children.

Acute renal failure: a study of elderly patients

Two hundred and forty-six patients over the age of 65 years treated for acute renal failure (ARF) between 1960 and 1987 are reviewed. Although the fatality has apparently not changed over the duration of the study, it is possible to identify groups with a relatively good prognosis with renal replacement therapy. This particularly applies to patients with an underlying medical illness or with urological problems (excluding neoplasia). ARF following surgery with perioperative sepsis continues to carry a poor prognosis. We would recommend early referral of elderly patients with acute renal failure to a specialist unit, as a substantial proportion of survivors will regain normal renal function and quality of life.

Microscopic polyarteritis: clinical features and treatment

The clinical features, treatment and survival of 36 patients with microscopic polyarteritis diagnosed between 1957-1988 have been reviewed. All had a focal segmental necrotizing glomerulonephritis on renal biopsy with evidence of a small vessel vasculitis. Most had a prodromal illness of less than 1 month. Severity of renal disease varied from microscopic haematuria which has a good prognosis to acute oliguric renal failure which carries a high mortality. The prognosis of microscopic polyarteritis can be improved if the condition is recognized early and treated with steroids and cyclophosphamide.

Digital subtraction angiography: first 900 cases

The Radiography Department at St Thomas' Hospital, London, produced their first digital subtraction angiogram in May last year, and since then over 900 patients have been examined with this technique. Examinations have included pulmonary, cardiac, neurological, central and peripheral, vascular and renal studies. The aim of this article is to share their initial experiences in this new field.