Effectiveness of The Wikipedia Collaboration of Dental Schools' Training Programme: a new Paradigm for Teaching and Learning of Evidence-Based Dentistry

BACKGROUND

The Wikipedia Collaboration of Dental Schools (WCODS) is a student-led initiative that aims to publish high quality scientific, evidence-based dental content on the Wikipedia online encyclopaedia by equipping its members to use research, critical appraisal and writing skills to create accurate content. In 2019, the Collaboration launched a standardised training programme developed by Wikimedia-trained committee members, academic dental school staff and the Cochrane Oral Health global community.

OBJECTIVE

To evaluate the effectiveness of this training programme in ensuring WCODS editors follow the processes underpinning Evidence-Based Dentistry (EBD).

METHOD

A cohort of dental students and staff (n=136) from six dental schools in the UK and Malaysia took part in a standardised and structured training programme at the annual WCODS training meeting. Participants' abilities and their perceived levels of confidence in carrying out critical analysis of the literature were measured using pre- and post-training surveys, and competency assessments.

RESULTS

Participants' skills in conducting literature searches, critical appraisal of the findings and creating and editing a Wikipedia page improved after training.

CONCLUSION

The training programme provided participants with the skill set and confidence to apply best practice to create and edit Wikipedia entries. This Collaboration intends to recruit more contributors to improve global oral health literacy using the free online Wikipedia encyclopaedia.

Hepatitis B virus infection among children of hepatitis B surface antigen positive mothers in a Malaysian hospital

INTRODUCTION

There have been no published data on the transmission of hepatitis B virus (HBV) infection among children of hepatitis B surface antigen (HBsAg) positive mothers in Malaysia.

METHODS

This is a cross-sectional study of all the children of HBsAg-positive mothers who delivered at the University of Malaya Medical Centre between 1993 and 2000.

RESULTS

A total of 60 HBsAg-positive mothers and their 154 children participated in the study. HBsAg was detected in four children (2.6%) while IgG antibody to the hepatitis B core antigen (anti-HBc IgG) was detected in seventeen children (11.0%). The mother's age at childbirth was significantly lower in the children with detectable HBsAg (22.5±6.1 years vs. 29.7±4.5 years, p=0.043) and anti-HBc IgG (26.6±6.1 years vs. 30.0±4.3 years, p=0.004). Children born in the 1980s were significantly more likely to have detectable HBsAg (18.8% vs. 0.7%, p=0.004) and anti-HBc IgG (37.5% vs. 8.0%, p=0.000) compared with those born later. All children with detectable HBsAg were born via spontaneous vaginal delivery, and hepatitis B immunoglobulin was either not given or the administration status was unknown. The majority of mothers with chronic HBV infection (70.4%) were not under any regular follow-up for their chronic HBV infection and the main reason was the lack of awareness of the need to do so (47.4%).

CONCLUSION

Transmission of HBV infection among children of HBsAg-positive mothers in Malaysia is low. However, attention needs to be given to the high rate of HBsAgpositive mothers who are not on any regular follow-up.

Outbreak of Occupational Brucellosis at a Pharmaceutical Factory in Southeast China

Brucellosis is an occupational disease affecting workers in butcher shops, the milking and dairy product industry, causing more than 500 000 new cases around the world. As a national statutory B infectious disease in China, morbidity of brucellosis is rapidly increasing in recent years. We report an occupational outbreak of brucellosis infection in a pharmaceutical factory. Exposure was a result of manual operation in the process line, close contact with sheep placentas, insufficient disinfection and repeated using of protective suits and infected by aerosol dissemination. Improved preventive methods, appropriate public health measures and spread of health education would be helpful to prevent the occupational outbreak of brucellosis in future.

Traditional and Complementary Medicine (TCM) among Study Population with Cardiovascular Risk; use and Substitution for Conventional Medicine in Pahang, Malaysia

INTRODUCTION

Cardiovascular diseases are the main cause of morbidity and mortality in Malaysia. There is evidence of high traditional and complementary medicine (TCM) use among population with cardiovascular risk and there have been anecdotal reports about substitution of conventional medicines with TCM. We investigated the prevalence of TCM use, treatment preference and substitution of conventional medicines in study population with cardiovascular risk factors in Pahang, Malaysia.

METHODS

A cross-sectional survey was conducted using an interviewer-administered questionnaire in five districts of Pahang. A total of 1250 households were chosen through proportionate and systematic sampling. Respondents aged 18 years and above were selected.

RESULTS

The study population with cardiovascular risk factors who used TCM was higher than the general population (31.7% versus 25.9%). There were no clear preferences in using TCM by gender, age groups, educational level and income even though other bumiputeras showed a slight inclination towards TCM use. Among the study population with cardiovascular risk factors who consumed TCM, 20-30% of them were using TCM as a substitute for their conventional medications. Respondents from the younger age group (18-40 years) (57.1%), highest educational level (43.2%), other bumiputeras (38.4%) and highest income group (31.4%) preferred the combination of both conventional and traditional medicine.

CONCLUSION

TCM use among population with cardiovascular risk factors is high. The high preference for combination therapy of TCM and conventional medications among young adults and the use of TCM to substitute conventional medications show that much research is needed to provide proven TCM therapies to avoid self-mismanagement of cardiovascular risk in Malaysia.

Conceptualization of a New Stroke-Specific Outcome Measure: The Stroke Impact Scale

Current stroke outcome measures are unable to detect some consequences of stroke that affect patients, families, and providers. The objective of this study was to ensure the content validity of a new stroke outcome measure. This was a qualitative study using individual interviews with patients and focus group interviews with patients, caregivers, and health care professionals. Participants included 30 individuals with mild and moderate stroke, 23 caregivers, and 9 stroke experts. Qualitative analysis of the individual and focus group interviews generated a list of potential items. Consensus panels reviewed the potential items, established domains for the measure, developed item scales, and decided on mechanisms for administration and scoring. Although the participants with stroke appeared highly recovered based on scores from conventional stroke assessments (Barthel Index and NIH Stroke Scale), stroke survivors and their caregivers identified numerous persisting impairments, disabilities, and handicaps. In general, stroke survivors described themselves as only about 50% recovered and reported that they had difficulty in activities in which they were not independent. To fully assess the impact of stroke on patients, we used the results of this qualitative study to develop a new stroke-specific outcome, the Stroke Impact Scale.

Transient ischemic attack and risk of stroke recurrence: The Lehigh Valley Recurrent Stroke Study

We investigated the effect of transient ischemic attack occurring both before and after an initial stroke on risk of recurrent stroke in a population-based study. In the Lehigh Valley Recurrent Stroke Study, patients were enrolled between July 1987 and August 1989 and followed up regularly at about 6-month intervals for up to 4 years (mean, 2 years). In addition to history of transient ischemic attack before and after the initial stroke, information on comorbidities including hypertension, myocardial infarction, cardiac arrhythmia, and diabetes mellitus was collected at the baseline visit and at follow-up visits. The 621 patients with an initial ischemic stroke constituted the cohort analyzed in this report. A history of transient ischemic attack was present at enrollment in 114 (18.4%) patients. During follow-up, 20 patients experienced a transient ischemic attack, and 77 had a recurrent stroke. Using a Cox proportional hazards model taking comorbidities, sex, and age into account, we analyzed the relationship between transient ischemic attack and recurrent stroke in the 503 patients with at least one follow-up visit. History of transient ischemic attack before the initial stroke was associated with a decreased risk of recurrent stroke (Hazards ratio, 0.3; 95% confidence interval, 0.08 to 0.86; P=.03), whereas a new transient ischemic attack after the initial stroke was associated with an increased risk of recurrent stroke (Hazards ratio, 11.7; 95% C.I. confidence interval=3.45 to 39.83; P=.0001).

Increasing incidence of diagnosed type 2 diabetes in Taiwan: analysis of data from a national cohort

AIMS/HYPOTHESIS

Epidemiological evidence shows an increasing prevalence of type 2 diabetes in Taiwan. The aim of this study was to assess the yearly incidence for this country during 1992-1996.

SUBJECTS AND METHODS

Data obtained by telephone interviews of 93,484 diagnosed diabetic patients enrolled in Taiwan's National Health Insurance programme formed the basis of this study. A total of 36,153 incident cases of type 2 diabetes (17,097 men and 19,056 women) were identified and incidence rates calculated. The trends of obesity and parental diabetes were also evaluated.

RESULTS

The overall 5-year incidences for men and women were 187.1 and 218.4 per 100,000 population, respectively. The trends from 1992-1996 were increased for all age groups in men and for most age groups in women. A 2.8-fold increase in incidence was observed for the youngest age group (<35 years), in which the increase in incidence was higher than in the older age groups. Men showed a higher fold increase in incidence than did women (3.5 vs 2.1). Obesity at interview increased from 39.2% in 1992 to 47.6% in 1996 (p<0.001) and was significant for all ages. Parental diabetes showed no yearly change when all patients were analysed together, but there was a trend towards a decrease in the youngest age group (<35 years) and a trend towards an increase in the oldest age groups (>/=55 years).

CONCLUSIONS/INTERPRETATION

An increasing incidence of diagnosed type 2 diabetes was observed for each sex in most age groups in Taiwan, but was most marked in the youngest age group. A parallel increase in obesity was observed with the increasing incidence of diabetes.

Hyperglycaemia and mortality of diabetic patients with candidaemia

AIMS

To determine whether the degree of hyperglycaemia has an impact on in-hospital mortality in diabetic patients with candidaemia.

METHODS

A retrospective cohort study of 87 diabetic patients with candidaemia admitted between June 1995 and June 2003 was carried out at two medical centres. Patients were stratified into two groups: those with moderate hyperglycaemia (7 days post-candidaemia mean blood glucose < 13.9 mmol/l) and those with severe hyperglycaemia (7 days post-candidaemia mean blood glucose > or = 13.9 mmol/l). A stepwise logistic regression analysis was performed to determine whether the degree of hyperglycaemia was a significant predictor of mortality.

RESULTS

During the follow-up period from admission till discharge, 34 (39.1%) patients had died. Nine (69.2%) of 13 patients with severe hyperglycaemia have died while 25 (33.8%) of 74 patients with moderate hyperglycaemia have died. Multivariate analysis identified three independent determinants of death; Apache II score > or = 23 [OR 8.1, 95% CI (2.6, 25.3), P = 0.0003], mean blood glucose levels 7 days post-candidaemia > or = 13.9 mmol/l [OR 6.8, 95% CI (1.2, 38.2), P = 0.03], and mechanical ventilation [OR 6.5, 95% CI (2.21), P = 0.03].

CONCLUSION

Severe hyperglycaemia is an important marker of increased mortality among hospitalized diabetic patients with candidaemia.

When the stork arrives unannounced - seven years of emergency deliveries in a non-obstetric general hospital

INTRODUCTION

Emergency department deliveries are uncommon in the Singapore setting, but when they do occur, the emergency physician has to be able to deliver the child safely, perform neonatal resuscitation if needed, and try to prevent any birth trauma to the child or complications of delivery in the mother. We present our experience of emergency room deliveries spanning 7 years in a community hospital without obstetric or neonatal backup.

MATERIALS AND METHODS

This is a retrospective case series. A search was made through our electronic medical records system for patients presenting in labour or with deliveries from March 1997 to October 2004. They were studied for demographic and social factors, gravidity and parity, as well as any complications (during birth and in the immediate post-delivery period) in both parent and child.

RESULTS

Twenty-three patients presented to our emergency department with labour contractions, and 14 progressed to vaginal deliveries. Twelve were single mothers who had hidden their pregnancies, while another 2 married patients had unsuspected pregnancies. No neonate needed resuscitation or airway support, but there were 4 patients without episiotomy who sustained perineal tears, and another 2 patients in whom the placenta could not be delivered. A child (born to a single mother without antenatal care) had a low Apgar score, but improved with oxygen and suctioning.

CONCLUSIONS

An emergency department in a non-obstetric hospital should have in place adequate preparations to cater for the occasional unexpected emergency delivery and the associated need for neonatal resuscitation. In our series, there was a high proportion of concealed (hidden) and "unaware" pregnancies presenting in labour. Prompt referral to a maternity hospital with neonatal care should be made for any complications.

Stroke Impact Scale-16: A brief assessment of physical function

OBJECTIVES

To 1) develop a short instrument (Stroke Impact Scale-16 [SIS-16]) to assess physical function in patients with stroke at approximately 1 to 3 months poststroke using items from the composite physical domain of the Stroke Impact Scale (SIS) version 3.0, and 2) compare the SIS-16 and a commonly used disability measure, the Barthel Index (BI), in terms of their ability to discriminate disability.

METHODS

A total of 621 subjects enrolled in the GAIN Americas randomized stroke trial were included in this study. Rasch analysis, which models the probability of a subject's response to an item using both subject ability and item difficulty, was used to construct the SIS-16, describe its properties, and compare its ordering and range of item difficulties to those of the BI. Box plots and analysis of variance were used to examine differences in BI and SIS-16 scores across modified Rankin categories.

RESULTS

The study sample had an average age of 68 +/- 12.4 years and 56% were men. Stroke diagnoses were classified as minor in 91 patients (NIH Stroke Scale score [NIHSS] 0 to 5), moderate in 304 (NIHSS 6 to 13), and major in 226 (NIHSS >/= 14). Twelve of the original 28 items in the SIS version 3.0 composite physical domain were eliminated to produce the SIS-16, with a minimal loss of reliability. As compared to the BI, the SIS-16 contains more difficult items that can differentiate patients with less severe limitations, and therefore has less pronounced ceiling effects. SIS-16 scores were significantly different across Rankin levels 0 to 1, 2, 3, 4, and 5, whereas BI was significantly different only across Rankin levels 0 to 2, 3, 4, and 5.

CONCLUSION

Compared to the BI, the SIS-16 is an excellent collection of items suitable for assessing a wide range of physical function limitations of patients with stroke at 1 to 3 months poststroke. Because of a less pronounced ceiling effect, the SIS-16 can differentiate lower levels of disability as compared to the BI.

Point mutation in the beta sheet of the HLA-C alpha2 domain generates a novel HLA-C allele, HLA-Cw*08012, in a Puyuma Aboriginal individual in Taiwan

We report herein the identification of a new HLA-C allele using sequence-based typing (SBT). This novel allele, HLA-Cw*08012, was found in an Aboriginal individual from the Puyuma tribe in the southern part of Taiwan. This individual was typed by the SBT method as having an HLA genotype of HLA-A*2402/2402, HLA-B*1502/4801, HLA-Cw*08011/08012, HLA-DRB1*15011/08032, HLA-DRB5*01011, and DPB1*0501/1401. This new allele differs from HLA-Cw*08011 in one of the nucleotides of the polymorphic exon 3 at codon 99 [TAT-->TAC; both code for tyrosine]. This residue is located in the beta sheet of the HLA-C alpha2 domain. This new allele was detected in a few individuals of the Puyuma tribe in Taiwan, but has not yet been observed in other populations in Taiwan.

Point mutation in the alpha helix of the HLA-C alpha2 domain generates a novel HLA-C allele,HLA-Cw*0106, in a Han Chinese individual in Taiwan

We report herein the identification of a new HLA-C allele using sequence-based typing (SBT). This novel allele, HLA-Cw*0106, was found in a Han Chinese individual from Taiwan. This individual was typed using SBT as having a class I HLA genotype of HLA-A*0206/0207, HLA-B*4601/5601, and HLA-Cw*0102/0106. This new allele differs from HLA-Cw*0102 in one of the nucleotides of the polymorphic exon 3 at codon 152 (GAG-->GTG; E152V). This residue is located in the alpha helix of the HLA-C alpha2 domain and may have the potential to affect the binding of HLA-C molecules with antigenic peptides and/or the interactions with the T cell receptor. This new allele was detected in a few individuals of Han Chinese in Taiwan, but has not yet been observed in the aboriginal populations in Taiwan.

Three-dimensional cytomorphology in fine needle aspiration biopsy of medullary thyroid carcinoma

OBJECTIVE

To elucidate three-dimensional (3-D) cytomorphology in fine needle aspiration biopsy (FNAB) of medullary thyroid carcinoma (MTC).

STUDY DESIGN

ENAB was performed on tumors from five patients with MTC. The aspirate was stained and observed under a light microscope (LM). The aspirate was also fixed, dehydrated, critical point dried, spattered with gold ions and observed with a scanning electron microscope (SEM). For transmission electron microscopy (TEM), the specimen was fixed, dehydrated, embedded in an Epon mixture, cut with an ultramicrotome, mounted on copper grids, electron doubly stained with uranium acetate and lead citrate, and observed with TEM. Findings under SEM were correlated with those under LM and TEM.

RESULTS

Under SEM, 3-D cytomorphology of MTC displayed a disorganized cellular arrangement with indistinct cell borders in three cases. The cell surface was uneven and had granular protrusions that corresponded to secretory granules observed under TEM. In one case with multiple endocrine neoplasia type IIB, there were abundant granules on the cell surface. In one case of sporadic MTC with multinucleated tumor giant cells and small cells, granular protrusions also were noted on the cell surface.

CONCLUSION

Granular protrusion was a characteristic finding in FNAB of MTC tinder SEM and might be helpful in the differential diagnosis.

New DR5 sequences: a novel DRB1*11122 allele identified in Paiwan tribe members of Taiwan and a corrected sequence for the DRB1*1201 allele

We report herein the identification of a new DRB1 allele using sequence-based typing (SBT). This novel allele, HLA-DRB1*11122, was found in an aboriginal individual (SWP71) from the Paiwan tribe in the southern part of Taiwan. This individual was typed by SBT method as having an HLA genotype of HLA-A*24021/24021, HLA-B*4001/4002, HLA-DRB1*11122/15011, HLA-DRB3*0202, and HLA-DRB5*01011. This new allele differs from DRB1*1112 in the polymorphic exon 2 only at codon 34 (CAA-->CAG; both specify glutamine) and from DRB1*1110 in the exon 2 sequence only at codon 32 (CAT-->TAT; H32T). The most likely candidate allele which is found in the aboriginal populations of Taiwan and which may mutate into this new allele is DRB1*11011. DRB1*11122 allele differs from DRB1*11011 allele in the polymorphic exon 2 at both codon 34 (CAA-->CAG) and codon 37 (TAC-->TTC; T37F). This novel HLA-DRB1*11122 allele was also found in another aboriginal individual (SWP90) from the same Paiwan tribe. This SWP90 individual was typed by SBT method as having an HLA genotype of HLA-A*24021/24021, HLA-B*4002/5502, HLA-DRB1*11122/1201, and HLA-DRB3*01011/0202. However, the original DRB1*1201 sequence from HERLUFF was found to be erroneously reported and the corrected sequence from SWP90 is now presented herein.

Use of antihypertensive and antithrombotic medications after stroke in community-based care

BACKGROUND

Secondary stroke prevention strategies include pharmacologic approaches to control hypertension and reduce thromboembolic risk.

OBJECTIVE

To describe antithrombotic and antihypertensive medication use, and rates of blood pressure control in the Kansas City Stroke Study, a prospective stroke cohort receiving community-based care after primarily mild and moderate stroke.

METHODS

Participants from 12 area hospitals provided information about medication use prior to stroke. Study personnel measured blood pressures at enrollment and at one, three, and six months, and collected medication data at six months during in-home assessment.

RESULTS

Complete data at six months were available for 355 subjects with ischemic stroke, among whom 13% had atrial fibrillation and 67% had prior hypertension. Prior to stroke, only 45% of the patients were receiving any antithrombotic (anticoagulant and/or antiplatelet) therapy; this figure rose to 77% at six months. Antithrombotic treatment rates among those with atrial fibrillation were 59% before stroke and 83% at six months, including warfarin in 64%. Approximately 70% of subjects had controlled blood pressures one, three, and six months after stroke, defined as systolic blood pressure < or = 140 mm Hg and diastolic blood pressure < or = 90 mm Hg. Use of multiple antihypertensive agents was common; calcium-channel blockers and angiotensin-converting enzyme inhibitors were used most frequently. However, 19% of subjects with uncontrolled blood pressure were untreated at six months.

CONCLUSIONS

Although room for improvement remains, these data suggest improved rates of antithrombotic and antihypertensive medication use after stroke in community-based care in a midwestern metropolitan community, compared with previous reports.

Polymorphism of human HLA-DRB1 antigens generated by genetic exchange between DR2 (DRB1*15011) and DR6 (DRB1*1405) alleles: a novel DRB1 allele (DRB1*1437) identified in a Paiwan tribe member of Taiwan

We report herein the identification of a new DRB1 allele using sequence-based typing (SBT). This novel allele, HLA-DRB1*1437, was found in an aboriginal individual from the Paiwan tribe in the southern part of Taiwan. This individual was typed by SBT method as having an HLA genotype of HLA-A*02011/0203, HLA-B*15011/3901, HLA-DRB1*11011/1437, HLA-DRB3*0202/0202, and HLA-DPB1*0501/1301. This new allele differs from DRB1*1309 in the 5'-end nucleotide sequence of polymorphic exon 2 at codon 16 (CAT-->CAA; H16Q), codon 37 (AAC-->TTC; R37F), codon 47 (TTC-->TAC; F47Y), and codon 58 (GCC-->GCT; both specify alanine). By sequence comparison, it was found that this new allele has a 5'-end sequence (from amino acid residues 7 to 66) identical to that found in the DRB1*1405 allele and a 3'-end sequence (from amino acid residues 58 to 94) identical to that found in the DRB1*15011 allele. Both DRB1*1405 and DRB1*15011 alleles have been identified among the Paiwan members (Note).

Predicting stroke recovery: three- and six-month rates of patient-centered functional outcomes based on the orpington prognostic scale

OBJECTIVE

To provide recovery rates after stroke for specific functions using the Orpington Prognostic Scale (OPS).

DESIGN

Prospective cohort.

SETTING

Hospital and community.

PARTICIPANTS

413 stroke survivors entered the study 3 to 14 days after suffering a stroke.

MEASUREMENTS

A cohort of hospitalized stroke survivors were recruited 3 to 14 days after stroke and assessed at 1, 3, and 6 months poststroke for neurological, functional, and health status. Baseline OPS score was used to predict five functional outcomes at 3 and 6 months using development and validation datasets and receiver operating characteristic (ROC) curves.

RESULTS

In 413 stroke survivors, functional recovery rates at 3 and 6 months were similar. Baseline OPS predicted significant differences in recovery rates for all five outcomes (P < .0001 for all five outcomes at 3 and 6 months). Personal care dependence was present at 3 months in only 3% of persons with baseline OPS scores of 3.2 or less compared with over 50% with OPS of 4.8 or higher. Independent personal care, meal preparation, and self-administration of medication were achieved by 80% who had baseline OPS scores of 2.4 or lower compared with less than 20% when OPS scores were 4.4 or higher. Independent community mobility was achieved in 50% of those who had OPS scores of 2.4 or lower but only 3% of those with OPS scores of 4.4 or higher. The area under ROC curves assessing OPS scores against each of the five outcomes ranged from 0.805 to 0.863 at 3 months and 0.74 to 0.806 at 6 months.

CONCLUSION

OPS scores can predict widely differing rates of functional recovery in five important functional abilities. These estimates can be useful to survivors, families, providers, and healthcare systems who need to plan for the future.

Stroke recovery profile and the Modified Rankin assessment

BACKGROUND AND PURPOSE

The purpose of this study was to examine the relationship between the Modified Rankin Scale (MRS) and poststroke recovery in neurological deficits, activities of daily living (ADL), higher level of physical and social functioning and the patients' preference for health state.

METHODS

Four hundred and fifty-nine participants in the Kansas City Stroke Study were prospectively assessed for measures of MRS, NIH Stroke Scale (NIHSS), Barthel ADL, SF-36 physical functioning, SF-36 social functioning, and Time Trade-Off (TTO). ANOVA and Bonferroni multiple comparisons were used to examine any differences in 3-month scores of NIHSS, Barthel ADL, SF-36 physical functioning, SF-36 social functioning and TTO between levels of the MRS. In addition, SF-36 physical functioning, SF-36 social functioning and TTO were characterized in patients who demonstrated improvement in global MRS outcome and also achieved a Barthel Index (BI) > or = 95 at 3 months after stroke.

RESULTS

Two hundred and eighty patients (62%) shifted at least one grade in MRS from baseline to 3 months after stroke. Only 67 or 194 patients were considered to have a favorable outcome using MRS 0/1 or MRS 0/1/2, respectively, as criteria. Mean 3-month NIHSS and Barthel ADL scores were not significantly different between Rankin 0/1 and 2, but they were significantly different among Rankin 3, 4 and 5 (all p < 0.05). Mean 3-month scores of physical functioning and SF-36 social functioning were significantly different among Rankin 0/1, 2, 3 and 4 (all pairwise p < 0.05). Proportions of patients who achieved NIHSS < or = 1 or BI > or = 95 decreased as MRS grades worsened. In patients who showed improvement in MRS global outcome and also achieved BI > or = 95, mean scores on TTO were similar.

CONCLUSIONS

Definition of favorable outcomes should include transition in the Modified Rankin score rather than MRS dichotomized as 0/1 or 0/1/2 because patients with transition in MRS scores have improvement in ADL, increased higher level of functioning and higher utility for health state.

Disposition after acute stroke: who is not sent home from hospital?

BACKGROUND

Known demographic and clinical characteristics of stroke survivors that affect selection of the facility to which they are discharged after hospitalization for an acute stroke are, for the most part, not population based and therefore may be unrepresentative. We present an analysis of such characteristics using the Lehigh Valley stroke cohort which is population based.

METHOD

We enrolled patients within 1 month of onset of their initial acute stroke who were hospitalized between 1987 and 1989 at one of the eight hospitals in the Lehigh Valley, and 662 patients were discharged alive. The facility to which they were discharged was known for 660. Data on age, sex, presence of five selected comorbidities (hypertension, myocardial infarction, cardiac arrhythmia, diabetes mellitus and transient ischemic attacks), length of hospitalization and neurologic deficits from the stroke were systematically collected on standardized forms. Polytomous logistic regression was used to determine the factors associated with not being discharged home. Relative risk (RR) associated with discharge to a nursing or rehabilitation facility for each independent predictor was calculated using as the referent, those who went home.

RESULTS

Older age was a statistically significant predictor of not being sent home (RR = 1.2 for nursing home placement), but gender and living with a spouse were not. Having a selected comorbidity did not increase the RR of not being sent home regardless of the type, nor did risk of not being sent home increase with more than one illness. Considering neurologic deficits from the stroke, patients with lower extremity weakness had a 2.6- and 3.5-fold risk of being sent to a nursing or a rehabilitation facility, respectively, compared to those without such weakness while for those with upper extremity weakness, the RR was 1.5 and 4.9, respectively. Language deficit imposed a RR of 3.1 and 2.3 of going to a nursing or rehabilitation facility, respectively. Right facial weakness also emerged as a significant risk factor for not being discharged home, perhaps because of its association with language deficit. The longer a patient was hospitalized after a stroke, the less likely it was that such a patient would go home (RR = 1.1/hospitalization day).

CONCLUSION

Using population-based data on stroke survivors, our study showed the characteristics of patients who are less likely to be discharged home and, instead, are discharged to a nursing or a rehabilitation facility. Data like ours which were population based may be useful in discharge planning for stroke patients by policy makers and health care providers.

The relation between impairments and functional outcomes poststroke

OBJECTIVE

To assess the influence of initial stroke impairments on the severity of basic and higher level functional deficits over time and to determine the cumulative impact on functional deficits beyond severity of motor deficits alone.

DESIGN

Observational study.

SETTING

Twelve participating hospitals in the Greater Kansas City area, as part of the Kansas City Stroke Study (October 1995-March 1998).

PARTICIPANTS

Individuals (n = 459) who sustained an eligible stroke were evaluated prospectively using standardized assessments at enrollment (within 14 days of stroke onset, 8.8 +/- 3.5 days).

MAIN OUTCOME MEASURES

Mobility and activities of daily living (ADLs) were assessed at 1, 3, and 6 months poststroke using the Functional Independence Measure, Barthel index, Lawton Instrumental Activities of Daily Living (IADL), and the Medical Outcomes Study Short-Form Health Survey instruments.

RESULTS

The cumulative probability of achieving independence with walking, a Barthel index of 60 or greater or 90 or greater, and independence in 3 or more IADL was significantly different for the following 4 impairment groups in descending order: motor; motor and somatosensory; motor and hemianopia; and motor, sensory, and hemianopia. Although motor severity was a strong predictor of outcome (p < .0001), the additional somatosensory and hemianopia deficits significantly (p < .05) affected time and likelihood of achieving these levels of function.

CONCLUSION

Cumulative deficits poststroke affect patients' functional outcome in the first 6 months poststroke beyond the effect of motor severity alone.

Three-dimensional cytomorphology and its relationship with clinical stage in fine needle aspiration biopsy of papillary thyroid carcinoma

OBJECTIVE

To elucidate three-dimensional (3-D) cytomorphology and its relationship with clinical stage in fine needle aspiration biopsy (FNAB) of papillary thyroid carcinoma (PTC).

STUDY DESIGN

FNAB was performed in tumors from 34 patients with PTC. The aspirate was stained and observed under a light microscope (LM). The aspirate was also fixed, dehydrated, critical point dried, spattered with gold ions and observed with a scanning electron microscope (SEM). Findings under SEM were correlated with the presentation under LM and also with clinical stage. As a control, FNAB was also performed on a normal part of the thyroid in six patients.

RESULTS

Under SEM, normal thyroid cells appeared as round, scattered cells or sheets with a uniform honeycomb cellular arrangement. In PTC, cell sheets with uniform nuclear morphology under LM usually showed a uniform cell arrangement and with distinct cell borders under SEM. Cell sheets with nuclear pleomorphism under LM usually showed a more-disorganized arrangement and with indistinct cell borders under SEM. PTC at advanced clinical stages usually presented with a disorganized cell arrangement, indistinct cell borders and loss of microvilli.

CONCLUSION

3-D cytomorphology in FNAB of PTC was related to clinical stage and might be a prognostic factor for PTC.

Defining post-stroke recovery: implications for design and interpretation of drug trials

Measurement of stroke recovery is complex because definition of successful recovery is highly variable across measures and cut-off points for defining successful outcomes vary. The purpose of this paper is to describe patterns of recovery in stroke patients of varying severity when different measures are used and when different cut-off points are selected. 459 individuals enrolled in a prospective cohort study were assessed within 14 days post stroke and re-evaluated at 1, 3, and 6 months. Recovery was assessed using the NIH Stroke Scale, the Fugl-Meyer Assessment of Motor Recovery, the Barthel Index of Activities of Daily Living, the Physical Function Index of the SF-36, and the Modified Rankin Outcome Scale. Subjects also defined their preference (utility) for their current health state with a time-trade off question. We compared patterns of recovery using the different measures and varying the cut-off points for defining successful recovery. The percentage of patients who are believed to have recovered depends on how recovery is defined. If recovery is defined at the disability level (Barthel > 90), the majority 57.3% of stroke survivors experience a full recovery. Fewer individuals are considered to be fully recovered if impairments are measured (NIH </= 1, 44.9% and Fugl-Meyer > 90, 36.8%. Less than 25% of stroke survivors are considered recovered if recovery is defined relative to reported prior function in higher levels of physical activity. Shifting the definition of recovery on the modified Rankin scale from </= 1 to </= 2 shifts the percentage of those deemed recovered from </= 25% to 53.8%. In designing drug trials the methods for defining stroke recovery should be carefully considered. If recovery is defined in terms of disability, a higher proportion of the placebo group will achieve the outcome than if impairments are used to define recovery. The benchmarks for recovery in minor strokes must include measures of higher functioning (e.g. the SF-36 physical functioning index or a Rankin 0 (no symptoms).

Reoperation after primary posterior instrumentation and fusion for idiopathic scoliosis. Toward defining late operative site pain of unknown cause

STUDY DESIGN

Retrospective case series.

OBJECTIVES

To determine the frequency and categorize the indications for reoperation in three implant systems (Harrington, Cotrel-Dubousset [C-D], and Isola). To define late operative site pain (LOSP) of no apparent cause as an indication for implant removal and determine the success of implant removal in relieving LOSP.

SUMMARY OF BACKGROUND DATA

Late operative site pain of no apparent cause has been discussed briefly in the literature but has not been investigated as a major indication for implant removal.

METHODS

One hundred eighty-two of 190 consecutive patients with idiopathic scoliosis (96%) who underwent primary surgery between January 1, 1981, and December 31, 1992, by one surgeon in one hospital, with use of Harrington, C-D, or Isola instrumentation were studied an average of 9 years after surgery to determine the indications for and frequency of reoperation.

RESULTS

The overall frequency of reoperation for all instrumentation types combined was 19%: Harrington, 19%; C-D, 24%; and Isola, 14%. By 6 years' follow-up the cumulative risk of reoperation by Kaplan-Meier analysis was Harrington, 14%; C-D, 21%; and Isola, 14%. (statistically nonsignificant difference). The most frequent indication for reoperation was LOSP of no apparent cause: 8% (14 patients) for all instrumentation types combined. The average interval between the initial operation and reoperation for LOSP was 46 months (range, 20-97 months). The frequency of each implant type was Harrington, 6%; C-D, 12%; and Isola, 6%. By 6 years' follow-up, the cumulative Kaplan-Meier risk for reoperation due to LOSP was Harrington, 5%; C-D, 13%; and Isola, 8% (statistically non-significant difference). Of the 14 patients who had instrumentation removal for LOSP, 10 (71%) had successful relief of pain after implant removal.

CONCLUSIONS

Occurring regardless of implant type, LOSP of no apparent cause after posterior instrumentation of scoliosis is a distinct clinical entity and is relieved by implant removal in most patients.

A novel HLA-A24 (A*2420) allele identified in the Atayal tribe of Taiwan

The Taiwan indigenous population groups are classified into different tribes according their linguistic classification and cultural anthropology. One of the tribes, the Atayal, showed a high frequency of A24 alleles by SSOP analysis. High-resolution sequencing based typing identified a A*2402 variant "A*2420" which was found in 6 unrelated individuals. High-resolution typing is required to identify HLA polymorphism in the Taiwanese minority groups.

Scoliosis correction maintenance in skeletally immature patients with idiopathic scoliosis. Is anterior fusion really necessary?

STUDY DESIGN

A retrospective evaluation of the occurrence of the crankshaft phenomenon in skeletally immature patients with idiopathic scoliosis.

OBJECTIVE

To determine what factors, if any, contribute to a decreased occurrence of crankshaft phenomenon in patients treated with posterior surgery only.

SUMMARY OF BACKGROUND DATA

Reports have described the progression of scoliotic deformity, termed the crankshaft phenomenon, in a region of solid posterior arthrodesis in skeletally immature patients. This has led some authors to advocate the use of concomitant anterior discectomy and fusion to prevent crankshaft.

METHODS

From 1989 through 1994, 18 Risser 0 patients with thoracic or thoracolumbar idiopathic scoliosis underwent Isola (De Puy-Acromed, Raynham, MA) posterior instrumentation and fusion. They were assessed for evidence of the crankshaft phenomenon, identified by coronal plane deformity progression of 10 degrees or more, or a rib vertebra angle difference of 10 degrees or more. The average age of the patients was 12.5 years (range, 10.5-15.5 years), and the average follow-up period was 39 months (range, 24-68 months).

RESULTS

Eleven patients (10 girls and 1 boy) had closed triradiate cartilage at the time of surgery. Their average Cobb angle was 62 degrees before surgery, 21 degrees after surgery, and 22 degrees at follow-up assessment. No patients in this group met the criteria for crankshaft. Seven patients (6 girls and 1 boy) had open triradiate cartilage at the time of surgery. Their average Cobb angle was 62 degrees before surgery, 18 degrees after surgery, and 20 degrees at follow-up evaluation. No patient had a 10 degrees or more increase in rib vertebra angle difference. One patient had more than a 10 degrees increase in her Cobb angle (11 degrees) from postoperative to latest follow-up assessment. Her instrumentation construct, performed in 1989, used sublaminar wires as the caudal anchors. Hooks and pedicle screws are now used. Two of the seven patients with open triradiate cartilage underwent surgery during or before their peak height velocity and displayed no evidence of crankshaft. No deaths, neurologic complications, or infections occurred in either group.

CONCLUSIONS

These findings suggest that scoliotic deformity progression can be prevented in skeletally immature patients with idiopathic scoliosis as young as 10 years of age with the use of stiff segmental posterior instrumentation, without the necessity of concomitant anterior arthrodesis.

Development of a comprehensive assessment toolbox for stroke

Comprehensive databases for the assessment of individuals with stroke are essential for clinical management and evaluation of outcomes for quality management and research. The purpose of this article is to describe a comprehensive data system or "toolbox" developed by clinicians and researchers at the Center on Aging at the University of Kansas Medical Center. The choice of assessments for the toolbox resulted from the Agency for Health Care Policy and Research Post-Stroke Rehabilitation Guidelines, results of the Kansas City Stroke Study, and the authors' work to develop a new stroke measure-the Stroke Impact Scale.

The stroke impact scale version 2.0. Evaluation of reliability, validity, and sensitivity to change

BACKGROUND AND PURPOSE

To be useful for clinical research, an outcome measure must be feasible to administer and have sound psychometric attributes, including reliability, validity, and sensitivity to change. This study characterizes the psychometric properties of the Stroke Impact Scale (SIS) Version 2.0.

METHODS

Version 2.0 of the SIS is a self-report measure that includes 64 items and assesses 8 domains (strength, hand function, ADL/IADL, mobility, communication, emotion, memory and thinking, and participation). Subjects with mild and moderate strokes completed the SIS at 1 month (n=91), at 3 months (n=80), and at 6 months after stroke (n=69). Twenty-five subjects had a replicate administration of the SIS 1 week after the 3-month or 6-month test. We evaluated internal consistency and test-retest reliability. The validity of the SIS domains was examined by comparing the SIS to existing stroke measures and by comparing differences in SIS scores across Rankin scale levels. The mixed model procedure was used to evaluate responsiveness of the SIS domain scores to change.

RESULTS

Each of the 8 domains met or approached the standard of 0.9 alpha-coefficient for comparing the same patients across time. The intraclass correlation coefficients for test-retest reliability of SIS domains ranged from 0.70 to 0.92, except for the emotion domain (0.57). When the domains were compared with established outcome measures, the correlations were moderate to strong (0.44 to 0.84). The participation domain was most strongly associated with SF-36 social role function. SIS domain scores discriminated across 4 Rankin levels. SIS domains are responsive to change due to ongoing recovery. Responsiveness to change is affected by stroke severity and time since stroke.

CONCLUSIONS

This new, stroke-specific outcome measure is reliable, valid, and sensitive to change. We are optimistic about the utility of measure. More studies are required to evaluate the SIS in larger and more heterogeneous populations and to evaluate the feasibility and validity of proxy responses for the most severely impaired patients.

Evaluation of the American Heart Association Stroke Outcome Classification

BACKGROUND AND PURPOSE

The purpose of this study was to evaluate the concurrent validity of the American Heart Association Stroke Outcome Classification (AHA.SOC) and compare performance of its function classification with that of the Modified Rankin Scale.

METHODS

The individuals in this study included the last 105 consecutive subjects who were part of a cohort of 459 stroke patients in the Kansas City Stroke Study. The patients were evaluated with a variety of standardized assessments at enrollment (within 14 days of stroke onset) and followed at 1, 3, and 6 months after stroke. Specifically, we examined validity of AHA.SOC by comparing its 3 domains (ie, Domain, Severe, and Function) with stroke severity. We correlated AHA.SOC-Function with scores of the Barthel Index, Lawton Instrumental Activities of Daily Living (IADL) Scale, and Medical Outcome Study 36-Item Short-Form Health Survey (SF-36) measures of physical function and mental health. Finally, we compared the discriminant ability of AHA.SOC-Function and the Modified Rankin Scale in assessing disability and handicap. These data were analyzed with the use of Spearman rank correlations and Kruskal-Wallis tests.

RESULTS

All 3 domains of the AHA.SOC were significantly associated with stroke severity and scores of Barthel Index, Lawton IADL, and SF-36 physical function (all P<0.001). Both AHA.SOC-Function and the Modified Rankin Scale discriminated well the disabilities and handicap measured by Barthel Index, Lawton IADL, and SF-36 physical function (all P<0.001).

CONCLUSIONS

The AHA.SOC was able to capture impairments, disabilities, and handicap after stroke. The AHA. SOC-Function performed equally as well as the Modified Rankin Scale in assessing disabilities related to basic activities of daily living but differentiated slightly better than the Modified Rankin Scale in assessing disabilities/handicap related to instrumental activities of daily living. Neither the AHA.SOC-Function nor the Modified Rankin Scale captured differences in mental health after stroke.

Patients' perceptions of overall function, pain, and appearance after primary posterior instrumentation and fusion for idiopathic scoliosis

STUDY DESIGN

This outcome study used patients' responses to the Scoliosis Research Society Outcomes Instrument to discriminate among patients who had undergone surgery for correction of juvenile or adolescent idiopathic scoliosis.

OBJECTIVES

To evaluate a surgically treated population by using the SRS Outcomes Instrument.

SUMMARY OF BACKGROUND DATA

The Scoliosis Research Society outcomes instrument was developed to help evaluate patient-perceived outcomes after treatment for idiopathic scoliosis. It includes 24 questions designed to investigate seven domains.

METHODS

Eligible patients underwent posterior surgery for the first time before their 21st birthdays. One surgeon performed the surgery at one medical center. Of 168 eligible patients, 121 (72%) completed the Scoliosis Research Society outcomes questionnaire.

RESULTS

Females reported better outcomes in the function after surgery (P = 0.005) and self-image after surgery (P = 0.01) domains. Preoperative curve pattern comparison demonstrated a significant difference in self-image after surgery among four groups classified according to curve pattern. The thoracolumbar and lumbar group recorded image scores of 5, the highest possible score, 85% of the time. The King-Moe (KM) V group scored 5, 75% of the time; the KM I and II group 48%; and the KM III and IV group 46% (P = 0.0015). After eliminating confounding variables, it was found that white patients reported experiencing less pain in follow-up than did black patients (P = 0.0098). Results were also suggestive that less pain was associated with increased number of fused vertebrae (P = 0.027).

CONCLUSIONS

The strongest predictors of self-perceived favorable outcome among patients were female sex and white race. It is also suggested that longer fusions to L1 through L3 lead to less perceived pain than with shorter fusions.

The selection of fusion levels using torsional correction techniques in the surgical treatment of idiopathic scoliosis

STUDY DESIGN

This is a retrospective, consecutive case series, with the index patient included.

OBJECTIVES

To evaluate the evolution and effectiveness of instrumentation techniques designed to untwist the scoliosis deformity.

SUMMARY OF BACKGROUND DATA

Three-dimensional studies of the idiopathic scoliosis deformity are consistent with the theory that the deformity or deformities evolve as an imperfect torsion or torsions.

METHODS

From 1989 through 1995, 102 consecutive patients (84 females, 18 males) underwent surgery with increasing emphasis on torsional correction. One hundred patients (98%), with an average age of 14.3 years (range, 10.5-20.8 years), were observed for an average of 40 months (range, 24-81 months). The upper instrumented vertebra evolved to be the centered vertebra. The lower instrumented vertebra was chosen based on its ability to become horizontal on contralateral bend radiographs and was termed the caudal foundation vertebra. Because these techniques evolved over the first 3 years of the study period, a split analysis was performed to evaluate improvements in correction and correction maintenance over the course of the study.

RESULTS

The average Cobb angle was 59 degrees before surgery, 18 degrees after surgery (69% correction), and 22 degrees (63% correction) at latest follow-up. A comparison of the first half of the series with the second half showed no significant demographic differences. Curve correction was significantly improved for King-Moe IIB (thoracolumbar-lumbar curve only), King-Moe III, and King-Moe V curve types in the second half of the series. In the last 4 years, curve correction at latest follow-up for King-Moe IIB curves was 61% for the thoracic curve and 65% for the thoracolumbar-lumbar curve. King-Moe III curves had a 68% correction, and King-Moe V curves had a 50% high thoracic and a 72% thoracic curve correction. Thoraco-lumbar, lumbar, and King-Moe I curves averaged 81% correction of the thoracolumbar-lumbar curve. The angle of thoracic curve inclination improvement at 1 year was maintained at latest follow-up.

CONCLUSIONS

This method of selecting instrumentation levels while using torsional correction techniques is safe and reliable. The results were improved with the evolution of these techniques and appear to provide improved correction and correction maintenance compared with that of historical controls.

Stroke survival after discharge from an acute-care hospital

BACKGROUND AND PURPOSE

Survival after a stroke is likely to be best for patients well enough to be sent home but the relative risk of dying if patients do not qualify for a home discharge has not been well studied. We investigated the survival prognosis after an initial stroke depending on the facility to which the patient was discharged after an acute initial stroke.

METHODS

All patients were enrolled between July 1, 1987, and August 1, 1989, and were followed up to 4 years (mean of 24 months) until death, second stroke, or the end of the study.

RESULTS

Among 662 patients who were discharged alive after hospitalization with an initial stroke, 128 (19%) went to a nursing home, 17(3%) to a short-term hospital, 140 (21%) to a rehabilitation facility, and 375 (57%) went home (discharge destination unknown for 2 patients). Compared to patients sent home after taking age, sex, selected baseline comorbidities, length of hospital stay, and neurological deficits into consideration, results from Cox proportional hazards model indicated that patients sent to a nursing home had 2.6 times greater risk of dying (95% CI = 1.81-4. 15) while those who were discharged to a rehabilitation facility had a death hazards ratio of 1.1.

CONCLUSIONS

Mortality was greatest in the early months after discharge and decreased thereafter. Since the analysis was adjusted for age, sex, comorbidity, length of hospital stay, and number of neurological deficits, quality of care in a nursing home setting may account for the mortality difference but other factors such as social support network and living will instructions also need to be investigated.

Prediction of functional outcome after stroke: comparison of the Orpington Prognostic Scale and the NIH Stroke Scale

BACKGROUND AND PURPOSE

This study compared the ability of 2 stroke impairment scales, Orpington Prognostic Scale and National Institutes of Health (NIH) Stroke Scale, to predict disability as measured by the Barthel activities of daily living (ADL) Index and higher level of self-reported physical functioning as measured by the SF-36 physical functioning index (PFI) at 1, 3, and 6 months after stroke.

METHODS

The participants in this ongoing study are 184 individuals who sustained an eligible stroke and were recruited for the Kansas City Stroke Study. All patients were prospectively evaluated using standardized assessments at enrollment (within 14 days of stroke onset) and followed at 1, 3, and 6 months after stroke. Coefficient of determination (R2) was used to assess the ability of the 2 stroke scales to prognosticate outcomes.

RESULTS

Means and SDs of the Orpington Prognostic Scale and NIH Stroke Scale measured at baseline were 3.6+/-1.31 and 5.5+/-4.58, respectively. The Spearman's rank correlation between the 2 baseline measures was 0.83 (P=0.0001). The Orpington Prognostic Scale and the NIH Stroke Scale explained well the variance in Barthel ADL Index (P<0.001). However, the Orpington Prognostic Scale explained more variance than did the NIH Stroke Scale. Similarly, the Orpington Prognostic Score explained more variance in higher level of physical function than did the NIH Stroke Scale. The amount of variance in Barthel ADL Index and SF-36 PFI, which were explained by both stroke severity measures, decreased over time.

CONCLUSIONS

Our results demonstrate that in a sample of mostly mild and moderate strokes, the Orpington Prognostic Scale compared with the NIH Stroke Scale is simpler to use and is a slightly better predictor of ADL and higher levels of physical function.

Cancer cluster investigation in a school district

Because of concern about a possible cancer cluster among employees of an elementary school, an industrial hygiene survey and health investigation were completed. An indoor-air quality survey was conducted by a certified industrial hygienist (CIH). A separate health survey concerning cancer occurrence was conducted by the authors among current (1995) and former (back to 1990) employees. Cancer data from the state health department registry were used to supplement self-reports. The number of observed cancers were compared to those expected based on statewide and county data. A marginally significant increased risk was found for breast cancer among female employees who had worked for the school. No other excess in cancers was found. This excess of breast cancer was unlikely to have been related to an occupational exposure. Based on the study supported by the school district, which prefers to remain anonymous, this paper discusses the conduct of cancer cluster investigations in schools and recommends that screening and education for breast cancer be conducted in schools.

Synaptic relationships between corticocuneate terminals and glycine-immunoreactive neurons in the rat cuneate nucleus

The present study describes the ultrastructural synaptic relationships between corticocuneate terminals (CCTs) and glycine-immunoreactive (glycine-IR) neurons in the cuneate nucleus of rats using anterograde tract-tracing of wheatgerm agglutinin conjugated with horseradish peroxidase (WGA-HRP) and anti-glycine immunoperoxidase labeling methods. The HRP-labeled CCTs made axodendritic synapses preferentially in the ventral part of the cuneate nucleus near the obex. In a total of 182 CCTs surveyed, 14 of them made direct synaptic contacts with immunoperoxidase-labeled glycine-IR dendrites. The present results suggest that cortical modulation on the sensory transmission of cuneate nucleus may be mediated through glycine-IR neurons.

Stroke recurrence in diabetics. Does control of blood glucose reduce risk?

BACKGROUND AND PURPOSE

Patients with diabetes are at increased risk of stroke. Risk might be reduced if blood glucose level were controlled.

METHODS

In a population-based study, we enrolled 621 patients within a month of an initial ischemic stroke and followed them regularly twice annually; 198 were diabetic. We monitored blood glucose level in 142 (72%) using glycosylated hemoglobin (HbAlc). Recurrent stroke frequency was determined by history, examination, and medical records. Cox proportional hazards models were used to examine the relationship between risk of recurrent stroke and HbAlc level. The models included interaction with time-dependent HbAlc level and history of diabetes, selected medical comorbidities, age, and sex. HbAlc level was analyzed as both a continuous and a dichotomous variable (ie, controlled versus uncontrolled); "controlled" was defined with different cut points.

RESULTS

All but 17 patients (12%) whose blood glucose was monitored were well controlled (HbAlc < 8%). HbAlc level was not associated with increased risk of stroke recurrence (hazard ratio [HR], 0.87 per 1% increment in HbAlc; 95% confidence interval [CI], 0.623 to 1.219), nor was there a trend toward increased risk of recurrent stroke as the cut point defining "controlled" increased: with HbAlc at < 6%, the HR for the uncontrolled group was 0.51 (95% CI, 0.176 to 1.503); at < 7%, it was 0.43 (95% CI, 0.089 to 1.923); and at < 8%, it was also 0.43 (95% CI, 0.057 to 3.317).

CONCLUSIONS

Among diabetic patients with an initial stroke, no association between HbAlc level over time and risk of stroke recurrence was found. However, most patients in this cohort were well controlled, and any adverse effect of poor control could not be adequately tested.

Prognosis for survival after an initial stroke

BACKGROUND AND PURPOSE

We studied prognosis for survival after an initial stroke in 662 patients who survived at least 30 days after onset while taking into account age, sex, the number of neurological deficits from the initial stroke, stroke type, and five selected medical conditions: hypertension, myocardial infarction, cardiac arrhythmia, diabetes mellitus, and history of transient ischemic attacks.

METHODS

All patients were enrolled between July 1, 1987, and August 1, 1989, and were followed regularly at about 6-month intervals until death or the end of the study (mean of 24 months).

RESULTS

At 6 months, 90.8% of the 30-day stroke survivors were still alive. At 1, 2, 3, and 4 years, the cumulative survival rates were 86.9%, 78.7%, 73.2%, and 72.0%, respectively. Older age and the number of neurological deficits at onset of initial stroke increased risk of death. Compared with patients of the same age, sex, number of neurological deficits, and comorbidities, increased risk of death is present among those with myocardial infarction, cardiac arrhythmia, and diabetes mellitus. Hazard ratios were 1.7 (P = .006), 1.5 (P = .023), and 1.4 (P = .059), respectively. Hypertension and transient ischemic attacks were not significantly associated with increased mortality.

CONCLUSIONS

This study clarifies prognosis for survival after an initial stroke by taking into account other confounding variables that could also contribute to risk of death.

Hypertension and risk of stroke recurrence

BACKGROUND AND PURPOSE

Hypertension is a risk factor for initial stroke, but its relation to stroke recurrence is unclear. Therefore, we sought to analyze the effect of hypertension and its control on risk of stroke recurrence.

METHODS

Within 1 month of onset, a population-based cohort of 662 patients from the Lehigh Valley with an initial stroke were enrolled. Hypertension was determined at enrollment by history. Blood pressure was also measured at enrollment and at each follow-up at 4- to 6-month intervals for up to 48 months (mean, 24 months). Stroke recurrence was verified by history, examination, and review of medical reports. Various criteria for control of blood pressure were defined. History of hypertension, measured blood pressure, and its control were analyzed in relation to stroke recurrence frequency using Kaplan-Meier and univariate, multivariate, and time-dependent Cox proportional hazards models.

RESULTS

At enrollment, 59.4% of the cohort had a history of hypertension and 81 patients had a second stroke. Those with a history of hypertension had a significantly higher stroke recurrence rate than those without such a history (P = .01). Among those with measured diastolic blood pressure at enrollment > or = 95 mm Hg, 43% had a stroke recurrence by the end of the study compared with only 19% below this cutoff (P = .005). Recurrence risk was reduced in a multivariate analysis as quality of diastolic blood pressure control increased (relative risk = 8.4, 3.9, and 2.0 among those with poor, fair, and good control, respectively, compared with nonhypertensive subjects). Systolic blood pressure and its control appeared less or not significantly associated with stroke recurrence.

CONCLUSIONS

History of hypertension and elevated measured diastolic pressure after the initial stroke were associated with an increased risk of second stroke. Controlling diastolic pressure substantially reduced this risk.

A multifactorial analysis of risk factors for recurrence of ischemic stroke

BACKGROUND AND PURPOSE

Risk factors for stroke recurrence have usually been evaluated as single variables. This study is a multivariate analysis of five risk factors (hypertension, myocardial infarction, cardiac arrhythmia, diabetes mellitus, and transient ischemic attacks) for second stroke after an initial ischemic stroke.

METHODS

Six hundred twenty-one patients with an acute ischemic stroke were followed prospectively first at 4 months after onset and then at approximately 6-month intervals until death, recurrence of stroke, or the end of the study. The five risk factors were measured at each visit. A Cox multifactorial regression analysis was conducted using the risk factor status at enrollment and adjusted for age and sex.

RESULTS

Follow-up averaged 24 months (range, 1 to 48 months). Men comprised 52% of the cohort and were slightly older; 97% of the cohort was white, and 57% had multiple risk factors. Hypertension occurred in 59%, cardiac arrhythmia in 47% (of which 16% had atrial fibrillation), diabetes mellitus in 30%, myocardial infarction in 25%, and transient ischemic attacks in 18%. Only history of hypertension and atrial fibrillation by electrocardiogram were associated with increased risk of second stroke independently and significantly (P = .01 and P = .04, respectively).

CONCLUSIONS

Among the five factors analyzed, control of hypertension and atrial fibrillation appear to offer the greatest chance of reducing risk of stroke recurrence after an ischemic stroke.

Lymph node classification systems in cutaneous T-cell lymphoma. Evidence for the utility of the Working Formulation of Non-Hodgkin's Lymphomas for Clinical Usage

BACKGROUND

This study was undertaken to compare three classification schemes used to evaluate lymph nodes (LN) obtained from patients with cutaneous T-cell lymphoma (CTCL): a modified Rappaport classification, the National Cancer Institute-Veterans Administration (NCI-VA) classification based on the relative numbers of cerebriform cells in the paracortical areas, and the Dutch classification based on the presence of cerebriform cells with large nuclei in mycosis fungoides (MF) and diffuse infiltration by cerebriform cells in Sézary syndrome.

METHODS

A study set of 195 LN obtained from patients with CTCL (MF, Sézary syndrome, and nonepidermotropic T-cell lymphomas) and 14 LN from patients with benign dermatoses was reviewed independently by three groups of pathologists familiar with each classification system.

RESULTS

Each classification system provided useful prognostic information. However, contrary to prior reports, no significant difference in survival was apparent in patients with uneffaced LN when classified according to the NCI-VA (LN0-2 versus LN3) or Dutch (Gr0-1 versus Gr2) ratings. In addition, all classification systems demonstrated a poor survival time associated with effaced LN. By combining results from the modified Rappaport and Dutch classifications, three prognostic groups could be identified based on cell morphology: a low-grade category with a small cell histologic subtype (median survival time, 40 months); a high-grade immunoblastic subtype (median survival time, 9 months) composed of cells with an oval nucleus containing a large, usually solitary central nucleolus; and an intermediate-grade category composed of all cases without the distinctive small cell and immunoblastic morphologies (median survival time, 26 months).

CONCLUSIONS

The authors propose that clearly involved LN in CTCL can be categorized on the basis of cell morphology into prognostic groups analogous to what has been proposed for the Working Formulation for Non-Hodgkin's Lymphomas for Clinical Usage.

The Lehigh Valley Recurrent Stroke Study: description of design and methods

A community-based, prospective study was carried out in the Lehigh Valley to determine how 5 selected risk factors and their control affected the frequency of stroke recurrence and death after an initial stroke. The initial stroke was verified clinically and by computerized tomography. Between 1987 and 1989, 662 patients with an initial stroke were enrolled and followed regularly every 4-6 months for up to 7 visits. The average follow-up period was 2 years. The risk factors selected included hypertension, myocardial infarction, cardiac arrhythmia, diabetes mellitus and transient ischemic attacks. Interim death and its cause were noted. Surviving patients were interviewed and examined to determine whether a second stroke has occurred. At enrollment, 51.4% of the cohort was male. The average age of men was 69.6, while women were older, averaging 74.3 years. Stroke types were thrombosis, 14%; embolus, 23%; lacune, 9%; nonspecific infarct, 48%, and intracerebral hemorrhage, 6%. There were 138 deaths (21%) and 81 second strokes (12%) during follow-up. The frequency of risk factors at enrollment was as follows; hypertension, 59%; myocardial infarction, 25%, cardiac arrhythmia, 47% (of which 16% had atrial fibrillation); diabetes mellitus, 29%, and transient ischemic attack, 18%. Of course many patients had multiple risk factors. We analyzed whether the presence of a risk factor at enrollment and its quality of control during follow-up affected stroke recurrence frequency and the mortality rates. These results will be reported in future papers.(ABSTRACT TRUNCATED AT 250 WORDS)

High resolution electron microscopic investigation of atomic structural images in human atherosclerotic plaque

Atomic structural images in the calcified matrix of human atherosclerotic plaques were characterized by high-resolution electron microscopy (HREM). The mineral elements distributed in the calcified matrix were analysed by energy dispersive X-ray microanalysis. Careful HREM observations revealed that a large number of microcrystallites and crystal particles with a broad spectrum of crystal size and perfection were embedded in the amorphous matrix of the calcified plaques. The amorphous phase in the calcified matrix was made up of a dense network of granulo-fibrillar substructures. The lattice-fringes with regular arrangement of atom columns along the lattice arrays were clearly demonstrated in the crystalline particles of the calcified plaques. A number of characteristic granulo-fibrillar substructures in the amorphous phase could be seen to be tightly connected to the lattice-fringes in the crystalline phase along the interfaces between the amorphous and crystalline phases. The crystal lattices at the boundary between two crystals were very well matched with the periodicity of visible atoms continuous through the two crystals. The mineral elements such as calcium and phosphorus were detected to be diffusely distributed in the calcified matrix of the atherosclerotic plaques. Based on these findings, it is concluded that: (1) an interlacing network of granulo-fibrillar substructures in the amorphous matrix may play a structural and/or regulatory role for the organic matrix by providing sites for nucleation; and (2) the deposition of the mineral elements may be effective for the transformation of the amorphous nucleation phase to well-crystallized nucleation phase.

Lymph node histopathologic findings in cutaneous T-cell lymphoma. A prognostic classification system based on morphologic assessment

The histopathologic features of 251 lymph nodes obtained from 200 patients with various clinical expressions of cutaneous T-cell lymphoma (mycosis fungoides and Sezary syndrome) were reviewed retrospectively. Lymphomatous involvement, defined as partial or complete effacement of lymph node architecture by malignant cells, was identified in 89 specimens (35%) and was characterized by morphologic variability from case to case. The involved specimens were classified into four major histologic subtypes according to the morphologic appearance of the malignant cells in a manner analogous to a modified Rappaport classification of diffuse non-Hodgkin's lymphomas. Although lymph node involvement was associated with a poor prognosis regardless of histologic subtype, the survival of patients with small cell (cerebriform) subtype was found to be significantly better (median survival time, 40 months) than other subtypes (median survival time, 20 months), possibly because this type of involvement sometimes preceded the development of the more aggressive mixed and large cell subtypes. Dermatopathic lymphadenopathy compared to other reactive patterns had no special prognostic importance other than its more frequent occurrence in black patients and in patients with more extensive skin involvement.

Decreased bone mineral density in patients with prolonged thyrotoxicosis before and after treatment

To investigate the effects of prolonged thyrotoxicosis, we measured the bone mineral densities (BMD) of 24 untreated patients who had suffered from symptoms of thyrotoxicosis for at least 1 year. We also recruited 116 healthy Chinese women residing in the Taipei area as normal controls. The BMDs of these 24 patients for the whole body skeleton, lumbar spine, femoral neck, greater trochanter and Ward's triangle were all significantly lower than those of normal controls (one sample t-test, two-tailed alternative). Older patients had lower absolute values and a trend towards more severe bone loss, which was most significant at the femoral trochanter and Ward's triangle (p less than or equal to 0.05). The decrease in BMD was more pronounced in the vertebral bodies than in the proximal femur for all patients, implying predominantly trabecular bone loss in this disease. The BMDs of 10 patients were reevaluated 1 year after successful medical treatment. These 10 patients had remained euthyroid for 1 year with antithyroid drugs and showed a small, but significant, improvement in their BMDs at the lumbar spine and the proximal femur on reevaluation. However, the recovery was far from complete. Our findings suggest that thyrotoxicosis causes a remarkable loss of bone mineral, which cannot be compensated for after 1 year of successful treatment. Thus, early diagnosis and therapeutic intervention are important for preventing osteoporotic fractures, especially in elderly patients.

Intracranial calcification and brachydactyly mimicking Albright's hereditary osteodystrophy in an adult patient with lingual thyroid and prolactinoma-like lesion

Hyperprolactinemia and prolactinoma in patients with long-term primary hypothyroidism have been recognized for decades. We report a case of 57-year-old female patient with lingual thyroid and cretinism who had a high serum prolactin level (greater than 200 ng/ml) and a pituitary tumor with suprasellar and parasellar extension. The tumor regressed to a size undetectable by CT scan after 2 years of thyroid hormone replacement therapy, but complete normalization of the hyperprolactinemia required additional bromocriptine therapy. This patient showed generalized short metacarpal and phalangeal bones, calcification of the basal ganglia and dentate nuclei bilaterally, and subcutaneous calcification at both gluteal regions, while serum calcium, phosphorus and c-PTH levels were all normal. Thus in addition to short stature, brachydactyly, a round face, and obesity, which are related to hypothyroidism, she also presented features uniquely mimicking the Albright's hereditary osteodystrophy seen in patients with pseudohypoparathyroidism and pseudopseudohypoparathyroidism. Since she had no family history of pseudohypoparathyroidism and had a normal level of Gs alpha protein on the membrane of the red blood cells, there is no evidence of pseudopseudohypoparathyroidism. The cause of the ectopic calcification remains unknown.

Sonographic presentation in autoimmune thyroiditis

We used real-time ultrasonography to examine 60 patients with autoimmune thyroiditis, then correlated the ultrasonic pictures with thyroid function, thyroid autoantibodies and fine needle aspiration cytology. In these 60 patients, 45 (75%) showed diffuse goiter, 6 (10%) showed multinodular goiter, and 9 (15%) had a solitary thyroid nodule sonographically. One of the 9 patients with a solitary nodule was a case of autoimmune thyroiditis combined with papillary carcinoma. The echogenicity of the thyroid was more than, the same as, or less than that of the adjacent muscles in 17, 22, and 21 patients, respectively. The groups were classified as hyperechoic, isoechoic, and hypoechoic, respectively. The mean serum T4 level was significantly lower in the hypoechoic group than in the hyperechoic or isoechoic groups (p less than 0.01 and p less than 0.05, respectively), and the incidence of hypothyroidism was significantly higher in the hypoechoic group than in the hyperechoic or isoechoic groups (p less than 0.001 and p less than 0.005, respectively). In addition, high titers of the antithyroid microsomal antibody (greater than or equal to 1280) were present more frequently in the hypoechoic group than in the hyperechoic or isoechoic groups (p less than 0.01 and p less than 0.05, respectively). There was no significant correlation between the cytomorphology and echogenicity of the thyroid in these cases. We conclude that sonography has two major uses in evaluating autoimmune thyroiditis: First, it is useful in excluding the coexistence of thyroid nodules; and second, marked hypoechogenicity of the thyroid implies an active cytotoxic autoimmune process and possibly a hypothyroid state.

Margosa oil poisoning as a cause of toxic encephalopathy

Margosa Oil is an extract of the seed of the Neem tree and is widely used as a traditional medicine by Indians in India, Sri Lanka, Burma, Thailand, Malaysia and Indonesia. Used mainly for external applications, it is often administered orally to neonates and infants regularly in small amounts. Margosa Oil causes toxic encephalopathy particularly in infants and young children. The usual features are vomiting, drowsiness, tachypnea and recurrent generalised seizures. Leucocytosis and metabolic acidosis are significant laboratory findings. Management is aimed primarily towards the control of convulsions although supportive management is equally important. Prognosis is usually good but fatalities and neurological deficits have been reported. We report here two infants with Margosa Oil poisoning presenting with encephalopathy.

Duplex Doppler and spectral flow analysis of racial differences in cerebrovascular atherosclerosis

We compared carotid artery disease in 99 black and 106 white patients using duplex ultrasonography (B-mode imaging and Doppler spectral analysis). Blacks had significantly less stenosis of the extracranial internal carotid artery than whites. Among the risk factors investigated, hypertension alone, ischemic heart disease, diabetes mellitus, and smoking failed to explain the racial difference. Although carotid stenosis of greater than or equal to 40% correlated significantly with age in both races (p = 0.001 in whites and p = 0.005 in blacks), blacks had significantly less carotid stenosis of any degree even when age was taken into account. Multivariate analysis showed that race is a significant and independent risk factor for carotid stenosis (p less than 0.0001). Hypertension interacting with race was also significant. Our results require verification in population-based studies. Carotid duplex ultrasonography offers a noninvasive method for carrying out such studies.

Idiopathic hypothalamic hypogonadism with polyostotic fibrous dysplasia: report of a case

A 48-year-old man with Albright's syndrome and hypogonadism is presented. Eunuchoid status, hypogenitalia and hypogonadotropinemia were associated with pathological fracture and deformity of bones. GnRH test revealed minimal LH response and delayed FSH peak. After pulsatile GnRH priming, the LH response to GnRH increased. Results of other provocative hypothalamic-pituitary tests were consistent with hypothalamic lesions. To the best of our knowledge, this is the first report of a male patient with Albright's syndrome and idiopathic hypothalamic hypogonadism. The hypothesis of endocrinopathy and its relation to other components of this syndrome were reviewed.