Presentation outside office hours does not negatively influence treatment times for reperfusion therapy for acute ischemic stroke

BACKGROUND

Treatment outside office hours has been associated with increased workflow times for intravenous thrombolysis (IVT) in acute ischemic stroke (AIS). Limited data suggest that this "off-hours effect" also exists for endovascular treatment (EVT). We investigated this phenomenon in a well-organized acute stroke care region in the Netherlands.

METHODS

Retrospective, observational cohort study of consecutive patients with AIS who received reperfusion therapy in the Greater Amsterdam Area, consisting of 14 primary stroke centers and 1 comprehensive stroke center (IVT: 2009-2015, EVT: 2014-2017). Office hours were defined as presentation during weekdays between 8 AM and 5 PM, excluding National Festive days. Primary outcome was door-to-treatment time (door-to-needle [DNT] for IVT, door-to-groin [DGT] for EVT). For DGT, we used the door time of the first hospital. Other outcomes were in-hospital mortality, modified Rankin Scale (mRS) score at 90 days and symptomatic intracranial hemorrhage (sICH). We performed multivariable linear and logistic regression analyses and used multiple imputation to account for missing values.

RESULTS

In total, 59% (2450/4161) and 61% (239/395) of patients treated with IVT and EVT, respectively, presented outside office hours. Median DNT was minimally longer outside office hours (32 vs. 30 min, p = 0.024, adjusted difference 2.5 min, 95% CI 0.7-4.2). Presentation outside office hours was not associated with a longer DGT (median 130 min for both groups, adjusted difference 7.0 min, 95% CI - 4.2 to 18.1). Clinical outcome and sICH rate also did not differ.

CONCLUSION

Presentation outside office hours did not lead to clinically relevant treatment delays for reperfusion therapy in patients with AIS.

Case report: persistently seronegative neuroborreliosis in an immunocompromised patient

Background

Infection with Borrelia burgdorferi sensu lato complex (B. b. sl) spirochetes can cause Lyme borreliosis, manifesting as localized infection (e.g. erythema migrans) or disseminated disease (e.g. Lyme neuroborreliosis). Generally, patients with disseminated Lyme borreliosis will produce an antibody response several weeks post-infection. So far, no case of neuroborreliosis has been described with persistently negative serology one month after infection.

Case presentation

We present a patient with a history of Mantle cell lymphoma and treatment with R-CHOP (rituximab, doxorubicine, vincristine, cyclofosfamide, prednisone), with a meningo-encephalitis, who was treated for a suspected lymphoma relapse. However, no malignant cells or other signs of malignancy were found, and microbial tests did not reveal any clues, including Borrelia serology. He did not recall being bitten by ticks, and a Borrelia PCR on CSF was negative. After spontaneous improvement of symptoms, he was discharged without definite diagnosis. Several weeks later, he was readmitted with a relapse of symptoms of meningo-encephalitis. This time however, a Borrelia PCR on CSF was positive, confirmed by two independent laboratories, and the patient received ceftriaxone upon which he partially recovered. Interestingly, during the diagnostic process of this exceptionally difficult case, a variety of different serological assays for Borrelia antibodies remained negative. Only P41 (flagellin) IgG was detected by blot and the Liaison IgG became equivocal 2 months after initial testing.

Conclusions

To the best of our knowledge this is the first case of neuroborreliosis that is seronegative on repeated sera and multiple test modalities. This unique case demonstrates the difficulty to diagnose neuroborreliosis in severely immunocompromised patients. In this case, a delay in diagnosis was caused by broad differential diagnosis, an absent known history of tick bites, negative serology and the low sensitivity of PCR on CSF. Therefore, awareness of the diagnostic limitations to detect Borrelia infection in this specific patient category is warranted.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3273-8) contains supplementary material, which is available to authorized users.

Analysing completion times in an academic emergency department: coordination of care is the weakest link

Congestion with prolonged stay in the emergency department (ED) is associated with poor health outcomes. Many factors contribute to ED congestion. This study investigates the length of time spent in the ED (time to completion) and the factors contributing to prolonged stay in an academic ED. Data of ED patients were prospectively collected during four weeks in February 2010. Presentation time, referrer, discharge destination, and medical specialities involved were registered in 2510 patients. Additional detailed data about relevant time steps were collected from 66 patients in the triage category Emergency Severity Index (ESI) 3. The Pearson's chi-square test and the Mann-Whitney test were used for statistical analysis. Time to completion was longer than four hours in 13% of patients (average in total population 2:23 hours). In ESI 3 patients, 24% stayed longer than four hours in the ED (p<0.001). Internal medicine had most patients exceeding the four-hour target (37%), followed by neurology (29%). Undergoing a CT scan, treatment by multiple specialities, age above 65 years and hospital admission were associated with exceeding the four-hour target (p<0.001). The elapsed time between receiving test results and admission/discharge also influenced the completion time (p<0.001). A significant percentage of vulnerable and ill patients with triage category ESI 3 exceeded the four-hour completion time in our ED. Absence of coordination of care when multiple specialists were involved and delay in the process of decision-making after completion of all diagnostics on the ED were among other factors responsible for this prolonged stay. Improving the coordination of care will, in our opinion, speed up the decision-making process and lead to shortening of completion times in many patients.

Deep frontal and periventricular age related white matter changes but not basal ganglia and infratentorial hyperintensities are associated with falls: cross sectional results from the LADIS study

BACKGROUND

Global age related white matter changes (ARWMC) are associated with progressive gait disturbances and falls, hypothesised to result from interruptions of cortico-subcortical circuits controlling balance, posture and locomotion.

METHODS

The location of ARWMC in a large cohort of elderly non-disabled individuals with reported falls was analysed, using the cross sectional data of the Leukoaraiosis and Disability (LADIS) study. Detailed anatomical distributions of ARWMC assessed by MRI studies were analysed with respect to falls and balance performance.

RESULTS

The severity of global ARWMC was significantly associated with a history of falls in the year prior to study inclusion (22.2% in the mild, 31.6% in the moderate and 37.3% in the severe ARWMC group according to the Fazekas scale; p = 0.002). Analysing the anatomical distribution of ARWMC, using the semiquantitative Scheltens scale, in multivariate analysis, periventricular (p = 0.006) and frontal deep (p = 0.033) ARWMC were independently associated with falls. Furthermore, logistic regression identified frontal deep (p = 0.003) ARWMC, but not basal ganglia and infratentorial hyperintensities, as significantly associated with balance disturbances.

CONCLUSION

The association of frontal and periventricular ARWMC with falls supports the hypothesis that interruption of frontal subcortical motor circuits lead to balance disturbances and hence to an increased risk for falls in ARWMC.

Cost-effectiveness of post-diagnosis treatment in dementia coordinated by Multidisciplinary Memory Clinics in comparison to treatment coordinated by general practitioners: an example of a pragmatic trial

BACKGROUND

With the rising number of dementia patients with associated costs and the recognition that there is room for improvement in the provision of dementia care, the question arises on how to efficiently provide high quality dementia care.

OBJECTIVE

To describe the design of a study to determine multidisciplinary memory clinics' (MMC) effectiveness and cost-effectiveness in post-diagnosis treatment and care-coordination of dementia patients and their caregivers compared to the post-diagnosis treatment and care-coordination by general practitioners (GP). Next, this article provides the theoretical background of pragmatic trials, often needed in complex interventions, with the AD- Euro study as an example of such a pragmatic approach in a clinical trial.

METHOD

The study is a pragmatic multicentre, randomised clinical trial with an economic evaluation alongside, which aims to recruit 220 independently living patients with a new dementia diagnosis and their informal caregivers. After baseline measurements, patient and caregiver are allocated to the treatment arm MMC or GP and are visited for follow up measurements at 6 and 12 months. Primary outcome measures are Health Related Quality of Life of the patient as rated by the caregiver using the Quality of Life in Alzheimer's Disease instrument (Qol-AD) and self-perceived caregiving burden of the informal caregiver measured using the Sense of Competence Questionnaire (SCQ). To establish cost-effectiveness a cost-utility analysis using utilities generated by the EuroQol instrument (EQ-5D) will be conducted from a societal perspective. Analyses will be done in an intention-to-treat fashion.

RESULTS

The inclusion period started in January 2008 and will commence until at least December 2008. After finalising follow up the results of the study are expected to be available halfway through 2010.

DISCUSSION

The study will provide an answer to whether follow-up of dementia patients can best be done in specialised outpatient memory clinics or in primary care settings with regard to quality and costs. It will enable decision making on how to provide good and efficient health care services in dementia.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT00554047.

[Blood pressure control in patients with a symptomatic carotid artery stenosis]

Carotid artery stenosis is an important cause of transient ischaemic attacks (TIAs) and ischaemic strokes, and is associated with a particularly high risk of recurrent stroke both in the acute phase and the long-term. Early secondary preventive measures would therefore seem warranted. Carotid endarterectomy (CEA) is an effectively therapy in patients with a severe symptomatic stenosis. Hypertension is an important risk factor for recurrent stroke both in the acute phase and the long-term. Moreover, hypertension is an important risk factor for complications of CEA. In patients on the waiting list for CEA, following a TIA or a non-disabling ischaemic stroke, it would seem worthwhile to attempt to start antihypertensive treatment after approximately 24 h, and to at least strive after a preoperative systolic blood pressure of < 180 mmHg and a diastolic blood pressure of < 90 mmHg. In patients who cannot undergo surgery in the desirable short run, hypotensive treatment must be considered in the context of secondary prevention. The blood pressure target level depends on the presence or absence of a severe unilateral or bilateral stenosis (> 70% lumen diameter). In postoperative hypertension one must strive after a blood pressure < 140/90 mmHg, thereby avoiding an excessively rapid hypotensive response (> 25% daily). Patients with a TIA or an ischaemic stroke and a carotid artery stenosis must also be treated with antiplatelet agents and a statin, while other vascular risk factors must be controlled.

Self-perceived memory impairment and cognitive performance in an elderly independent population with age-related white matter changes

OBJECTIVES

To determine whether self-perceived memory impairment is associated with the severity of white matter changes (WMC) and is related to cognitive impairment.

METHODS

Data were drawn from the multinational Leukoaraiosis and Disability Study (LADIS), which investigates the impact of WMC on global functioning. WMC severity was rated using the Fazekas scale. Medial temporal lobe atrophy (MTA) was scored visually and mean values were calculated. The neuropsychological battery consisted of the Mini-Mental State Examination, a modified version of the VADAS-Cog, Trail making and Stroop tests. A question about self-perceived memory impairment was used as a measure for presence of memory complaints. Cognitive performance was analysed test-by-test and in three main domains: memory, executive functions and speed/motor control. The Geriatric Depression Scale (GDS) was used as a measure of depressive symptoms.

RESULTS

Six hundred and thirty-eight subjects were included in this study. No association was found between memory complaints and the severity of WMC. Subjects with memory complaints (n = 399) had a higher GDS score [t((637)) = -7.15; p<0.02] and performed worse on almost all cognitive tests and on the three cognitive domains. Multiple linear regression showed that the worse performance on the memory domain was associated with memory complaints independently of depressive symptoms, WMC severity and MTA (R(2) = 0.183; F = 17.09, beta = -0.126; p<0.05).

CONCLUSION

In a sample of non-disabled elderly subjects with WMC, self-perceived memory impairment is significantly associated with objective memory impairment independently of the WMC severity, depressive symptoms and MTA.

Association of gait and balance disorders with age-related white matter changes: the LADIS study

OBJECTIVE

In the Leukoaraiosis and Disability (LADIS) Study, 11 European centers are evaluating the role of age-related white matter changes (ARWMC) as an independent determinant of the transition to disability in the elderly (65 to 84 years). We aimed at determining the influence of ARWMC on different objective measures of gait and balance.

METHODS

Six hundred thirty-nine nondisabled individuals were prospectively enrolled and are being followed-up for 3 years. Subjects are graded in three standardized categories of ARWMC (mild, moderate, and severe) according to central MRI reading. Quantitative tests of gait and balance include the Short Physical Performance Battery (SPPB; range: 0 [poor] to 12 [normal]), a timed 8-m walk, and a timed single leg stance test.

RESULTS

In cross-sectional analysis, deficiencies in gait and balance performance were correlated with the severity of ARWMC (SPPB: 10.2 +/- 2.1 in the mild, 9.9 +/- 2.0 in the moderate, 8.9 +/- 2.6 in the severe group; p < 0.001). Walking speed correlated with the severity of ARWMC (1.24 +/- 0.28 m/second in the mild, 1.18 +/- 0.32 m/second in the moderate, and 1.09 +/- 0.31 m/second in the severe group; p < 0.001). Balance was best in individuals with mild ARWMC (single leg stance time: 18.9 +/- 10.8 seconds) compared with moderate and severe ARWMC (16.4 +/- 10.8 and 13.6 +/- 11.2 seconds) (p < 0.001). Physically inactive individuals had a higher risk of a pathologic SPPB score (moderate vs mild ARWMC: odds ratio 1.60, 95% CI 1.02 to 2.52; severe vs mild ARWMC: odds ratio 1.75, 95% CI 1.09 to 2.80).

CONCLUSIONS

Our findings support a strong association between the severity of age-related white matter changes and the severity of gait and motor compromise. Physical activity might have the potential to reduce the risk of limitations in mobility.

[Carotid calcification on a panoramic radiograph: what to do?]

A 71-year-old man is discussed in whom the oral and maxillofacial surgeon observed, by chance, a radiopacity on the panoramic radiograph that was highly suggestive of a calcification at the bifurcation of the internal and external carotid artery. While, on the basis of international literature, various treatments are advanced with respect to the importance of vascular investigation and possible surgical removal of significant calcification, at present the view in The Netherlands is that the family doctor has the responsibility to assess whether such patient should be referred for further evaluation by the neurologist or vascular surgeon. The same applies to the possible indication for prescription of antitrombotics.

Modeling the emergency cardiac in-patient flow: an application of queuing theory

This study investigates the bottlenecks in the emergency care chain of cardiac in-patient flow. The primary goal is to determine the optimal bed allocation over the care chain given a maximum number of refused admissions. Another objective is to provide deeper insight in the relation between natural variation in arrivals and length of stay and occupancy rates. The strong focus on raising occupancy rates of hospital management is unrealistic and counterproductive. Economies of scale cannot be neglected. An important result is that refused admissions at the First Cardiac Aid (FCA) are primarily caused by unavailability of beds downstream the care chain. Both variability in LOS and fluctuations in arrivals result in large workload variations. Techniques from operations research were successfully used to describe the complexity and dynamics of emergency in-patient flow.

CSF levels of angiogenesis-related proteins in patients with leptomeningeal metastases

The authors determined the levels of vascular endothelial growth factor (VEGF) and urokinase-type plasminogen activator (uPA) in the CSF of patients with leptomeningeal metastases (LM; n = 53), cancer patients without LM (n = 18), and subjects without malignancy (n = 25). Median levels of uPA and VEGF were significantly higher in patients with LM, supporting the hypothesis that angiogenesis contributes to LM. VEGF was negatively correlated with survival in patients with LM, suggesting its use as a prognostic factor.

[Four family members with proximal myotonic myopathy]

A 41-year-old woman had a 15-year history of pain in her thighs and arms, which also became weaker, and a decrease in visual acuity. Her 35-year-old brother, their 38-year-old sister and their 64-year-old mother also had myalgia, myotonia and proximal muscle weakness, and the women also had cataracts. Additional examinations and tests led to a diagnosis of proximal myotonic myopathy (PROMM) in all four cases. Neurological and ophthalmological follow-up was provided on a yearly basis, including ECG. The clinical features of PROMM display similarities to the adult form of myotonic dystrophy (MD) but differ in the proximal localisation of the muscle weakness and the frequent occurrence of pain in the affected muscles. PROMM is an autosomal dominant hereditary multisystemic disorder with a less serious course than MD and is rarely accompanied by cognitive disorders. In most cases, a genetic defect on chromosome 3q21 is the cause of the disease. A probable diagnosis can be made on the basis of the clinical symptoms and the results of simple laboratory tests, and can be confirmed via DNA analysis. As yet, the disorder can only be treated symptomatically, preferably via a multidisciplinary approach by a neurologist, an ophthalmologist, a cardiologist and a rehabilitation specialist.

[Neuromonitoring of patients following severe brain trauma]

To a considerable extent, the neurological outcome of patients with severe brain trauma is determined by the primary injury caused by the accident. Substantial progress has been made in our understanding of the pathophysiological processes resulting in secondary brain damage after brain trauma, partly as a result of the introduction of advanced techniques of neuromonitoring. Early recognition and treatment of the symptoms leading to this type of brain damage seems crucial to the effort to improve the neurological outcome in these patients. Useful modern neuromonitoring techniques include: measurement of the intracranial and cerebral perfusion pressure and continuous electroencephalography. Methods that are also reliable and readily applicable, but less relevant clinically, include cerebral microdialysis of fluid from the extracellular space, determination of the parenchymal oxygen tension, and determination of the venous oxygen saturation. Other techniques that are not clinically applicable include: determination of the cerebral blood flow, the cortical tissue perfusion or the regional cerebral oxygenation.

['Body-packer' syndrome: an important disease with forensic-medical aspects]

A 45-year-old man called for the hospital in a confused and anxious state. Another man of around 30 walked into a hospital sweating and complaining of abdominal pain, and subsequently suffered several epileptic seizures and died before being recognised as a body packer. A 39-year-old man suffered an epileptic seizure on the aeroplane and a 21-year-old man was found dead, having suffered from abdominal pain the previous day. All were found to have swallowed cocaine packets. The two eldest men underwent emergency surgery: one died as the result of cocaine intoxication and one recovered. Body packers, people carrying cocaine packets in their bodies, are arriving in Europe in increasing numbers, mainly from South America. Body-packer syndrome consists of intestinal occlusion or potentially lethal intoxication caused by rupture of the packets. Awareness of the body packers' circumstances and the clinical signs of body-packer syndrome makes early recognition possible. In Amsterdam, the identification of body packers after arrival at the airport by the Schiphol-team and the medical follow-up by the Forensic Medicine Department of the Municipal Health Service of Amsterdam, result in a relatively low mortality risk. Early detection of intoxication will save lives.

Persistent impaired emotional functioning in survivors of a myocardial infarction?

The quality of life (QoL) of survivors of a myocardial infarction (MI) remains lower than that of their peers long after the acute event. Previous research on this subject has indicated, however, that this difference might lessen somewhat over time for the dimension 'emotional functioning' (as measured by the sickness impact profile (SIP): a generic instrument for QoL). The present study explores this phenomenon further using two instruments that specifically measure emotional functioning i.e. the hospital anxiety and depression scale (HAD) and the heart patients psychological questionnaire (HPPQ). Ninety-nine participants of a large population-based cohort (the Rotterdam study), who had been admitted to the hospital because of an MI in the previous 6-60 months, and 101 reference subjects, without a history of infarction of heart or brain, from the same age and gender-groups, were interviewed twice (at 1- to 3-year time intervals). The results of the present study confirm earlier findings that the emotional functioning (in terms of 'anxiety', 'depression', 'well-being', 'feeling disabled', and 'displeasure') of MI survivors is impaired when compared to their unaffected peers. Moreover, they did not show any improvement in 'anxiety', 'depression', 'well-being' and 'displeasure' over time in the MI survivors. The results did, however, show that the difference between MI survivors and referents became less in time in the dimension 'feeling disabled'. This decrease was partly because MI survivors improved and partly because referents felt more disabled over time. One explanation for this might be that referents (51% aged 70 years and over) had difficulties in adapting emotionally to decreasing levels of physical functioning with increasing age, while the MI survivors tended to adjust to and accept the impairments they had contracted several years earlier.

Extension of the clinical range of facioscapulohumeral dystrophy: report of six cases

Consensual diagnostic criteria for facioscapulohumeral dystrophy (FSHD) include onset of the disease in facial or shoulder girdle muscles, facial weakness in more than 50% of affected family members, autosomal dominant inheritance in familial cases, and evidence of myopathic disease in at least one affected member without biopsy features specific to alternative diagnoses. Six patients did not meet most of these criteria but were diagnosed as FSHD by DNA testing, which showed small EcoRI fragments on chromosome 4q. Their clinical signs and symptoms and results of auxiliary investigations are reported. The patients presented with foot extensor, thigh, or calf muscle weakness. None of them had apparent facial weakness, only one complained of weakness in the shoulders, none had a positive family history. Expert physical examination, however, showed a typical facial expression, an abnormal shoulder configuration on lifting the arms, or scapular winging. This raised the suspicion of FSHD, whereupon DNA analysis was done. In conclusion, the clinical expression of FSHD is much broader than indicated by the nomenclature. The possibility to perform DNA tests is likely to greatly expand the clinical range of FSHD.

Measuring quality of life in patients with myocardial infarction or stroke: a feasibility study of four questionnaires in The Netherlands

OBJECTIVE

To test in patients with a history of myocardial infarction or stroke the feasibility of four quality of life measurements--the Nottingham health profile (NHP), the heart patients psychological questionnaire (HPPQ), the sickness impact profile (SIP), and the hospital anxiety and depression scale (HAD).

DESIGN

Subjects were tested and retested after an interval of 14 days: questionnaires were self assessed.

SUBJECTS

Participants were randomly selected from the Rotterdam stroke data bank (stroke patients; n = 16, mean (SD) age 66.0 (11.0) years and from the population based Rotterdam study (myocardial infarction; n = 20, mean (SD) age 72.7 (7.9) years, controls; n = 17, mean (SD) age 72.8 (7.3) years.

MEASUREMENTS AND MAIN RESULTS

Mean (SD) administration times for the NHP, HPPQ, SIP, and HAD were 7.9 (3.5), 10.5 (4.3), 21.0 (9.8), and 5.5 (2.8) minutes respectively. On average, the test-retest reliability was good, with Spearman correlations ranging from 0.31 to 0.95. In spite of the limited size of the study, all instruments were able to show differences between the study groups. For instance, median SIP total scores for myocardial infarction and stroke patients were 12.4 (interquartile range 7.0-19.1) and 11.4 (5.9-15.4) respectively, compared with 7.7 (3.7-11.3) in the control group (p values of 0.04 and 0.14 respectively).

CONCLUSIONS

This study suggests that use of the four instruments tested may be feasible and reliable for assessing aspects of quality of life in patients with a history of a myocardial infarction or stroke.

[Risk factors for cardiovascular diseases in the elderly; the ERGO study (Erasmus Rotterdam Health and the Elderly)]

OBJECTIVE

To determine the prevalence of risk factors for cardiovascular disease among elderly people.

DESIGN

Prospective cohort study.

SETTING

A district of Rotterdam, the Netherlands.

METHODS

As a part of the Rotterdam Study information about smoking habits, blood pressure, Quetelet index and serum cholesterol of 7,983 responding persons (78%) (3,105 men and 4,878 women) of 55 years and older was obtained by an interview and physical examination during two visits to a research center.

RESULTS

Among men and women there were 29.7% and 16.7% smokers and 60.1% and 25.9% ex-smokers, respectively. Among men the proportion of smokers decreased from 31.0% in the age category 55-59 years to 15.9% in de category > or = 85 years, among women from 28.0% to 2.7%. Systolic blood pressure increased with age in both sexes, while diastolic blood pressure hardly changed. Hypertension (systolic blood pressure 160 mmHg and/or diastolic blood pressure > or = 95 mmHg at a single measurement and/or use of antihypertensive drugs) occurred in 23.3% of men and 28.0% of women. In men, total serum cholesterol decreased gradually with age, whereas in women there was a slight increase up to the category 70-74 years. No evident change in HDL cholesterol with increasing age was observed in men, but in women a decrease was observed until the same level was reached as in men. Thirty-five per cent of men and 49.5% of women had an elevated level of serum cholesterol (> or = 6.5 mmol/l). The prevalence of obesity (Quetelet index > 25 kg/m2) was about 50% in both men and women but was less in the categories from 75 years onwards. Approximately 80% of men and women had at least one risk factor, while in almost half of them two or more risk factors were found.

CONCLUSION

Risk factors for cardiovascular disease are common among elderly people.

A comparison of three quality of life instruments in subjects with angina pectoris: the Sickness Impact Profile, the Nottingham Health Profile, and the Quality of Well Being Scale

Three instruments for the assessment of quality of life, the Quality of Well Being index (QWB), the Nottingham Health Profile (NHP) and the Sickness Impact Profile (SIP) were assessed in 59 patients with angina pectoris. The NHP showed increased statistically significant impairment with higher New York Heart Association (NYHA) class in 4 out of 6 subscales but not in single responses to questions on daily life. In the SIP 9 out of 11 dimensions increased with NYHA grade as did the physical and psychosocial subscores and the total score. There were statistically significant increases in six of the eleven dimensions. In the QWB an increase was observed only for two out of four categories employed in this instrument. The QWB was the most difficult to administer and thought likely to be insensitive to changes in anginal pain. There was a high level of agreement in similar dimensions of NHP and SIP. A psychological distress score was evaluated using the Symptom Rating Test and correlated with all summary dimensions of both instruments. The coefficients of variation were lower in SIP than in NHP categories. In conclusion quality of life instruments like NHP and SIP may be able to identify treatment effects in angina patients and so yield a useful addition to the traditional measures employed for the assessment of their condition.

[Interobserver variation in the application of 2 disability scales in heart patients]

OBJECTIVE

To examine the use of the Rankin scale for the assessment of disability in patients with ischaemic heart disease.

SETTING

University Hospital Utrecht.

DESIGN

Prospective interobserver study.

PATIENTS AND METHODS

Fifty-two outpatients with heart disease (previous myocardial infarction, angina or both) were separately interviewed by four physicians (residents or specialists), viz., two cardiologists and two neurologists. The degree of disability was recorded by each observer on two different scales: the modified Rankin scale, a six-point scale developed from a neurological background, and the four-point scale developed by the New York Heart Association (NYHA). The agreement rates for the observers (23 in all) were corrected for chance (kappa-statistics; maximum 1.0).

RESULTS

Total agreement on both scales was found for six of the participating 51 patients and for 10 and 11 patients when the Rankin scale and the NYHA scale were considered separately. Kappa values were 0.21 for the Rankin scale and 0.24 for the NYHA scale. The weighted kappa values were 0.56 and 0.47, respectively. The agreement among neurologists and cardiologists was comparable.

CONCLUSION

The agreement rates of cardiologists and neurologists in the use of the Rankin scale and the NYHA scale in outpatients with heart disease are at best satisfactory. The good results of an earlier study with the Rankin scale in stroke patients were not achieved. This study indicates that the Rankin scale may be useful for the assessment of disability from heart disease particularly in patients with neurological disease, but there is room for further improvement.

Interobserver agreement for the assessment of handicap in stroke patients

Interobserver agreement for the assessment of handicap in stroke patients was investigated in a group of 10 senior neurologists and 24 residents from two centers. One hundred patients were separately interviewed by two physicians in different combinations. The degree of handicap was recorded by each observer on the modified Rankin scale, which has six grades (0-5). The agreement rates were corrected for chance (kappa statistics). Both physicians agreed on the degree of handicap in 65 patients; they differed by one grade in 32 patients and by two grades in 3 patients. Kappa for all pairwise observations was 0.56; the value for weighted kappa (with quadratic disagreement weights) was 0.91. Our results confirm the value of the modified Rankin scale in the assessment of handicap in stroke patients; nevertheless, further improvements are possible.

Determinants of rise in blood pressure in normotensive children

Thirty-nine initially normotensive children (25 girls) with a large increase in systolic blood pressure (SBP) over a period of 7 years were compared with 78 children with a small increase, matched for age and gender. They were selected from a random sample of 596 Dutch children who were examined at an initial examination and 4 weeks later, and at yearly intervals thereafter. Body weight, height and Quetelet index at baseline were similar in children with a large rise in SBP and those with a small rise. Children with a large increase had a larger weight gain during follow-up than those with a small rise. Parental blood pressure (BP) and parental history of diabetes mellitus and cardiovascular diseases did not differ between the study groups. Cardiovascular reactivity as assessed by a cold-pressor test at baseline did not differ between the study groups, nor did urinary sodium excretion during follow-up. Total tobacco consumption was larger in those with a small increase. Children with a large rise in SBP experienced a larger fall in SBP from the initial to the 4-week examination. The individual variability of BP over the whole observation period did not differ between the study groups. These observations suggest that a fall in BP after a short follow-up period may be indicative of high BP in the years to come.