BACKGROUND: Cholinesterase inhibitors produce small improvements in cognitive and global assessme... more BACKGROUND: Cholinesterase inhibitors produce small improvements in cognitive and global assessments in Alzheimer's disease. We aimed to determine whether donepezil produces worthwhile improvements in disability, dependency, behavioural and ...
Unilateral visual neglect, an attentional disorder, might show variability on repeated testing. T... more Unilateral visual neglect, an attentional disorder, might show variability on repeated testing. This study investigated test-retest stability in elderly patients post-stroke, 85 with and 83 without neglect. Subjects repeated three common clinical tests for neglect within the hour; the ...
Mild hypoxia is common in stroke patients and may have significant adverse effects on the ischemi... more Mild hypoxia is common in stroke patients and may have significant adverse effects on the ischemic brain after stroke. The use of oxygen treatment is rapidly increasing in European stroke units but is not without side effects. It impedes early mobilization, could pose an infection risk, and may encourage the formation of toxic free radicals, leading to further damage to the ischemic brain. In the Stroke Oxygen Pilot Study (2 or 3Â L/min for 72Â hours) neurological recovery at one week was better in the oxygen group than in controls, and after correction for difference in baseline stroke severity and prognostic factors, there was a trend to better outcome with oxygen at six months. Oxygen was as effective in mild as in severe strokes.Oxygen saturation is lower at night than during the day, and episodes of oxygen desaturation are common during sleep. Nocturnal oxygen supplementation is likely to reduce the burden of hypoxia without interfering with daytime mobilization and rehabilitation.Before wider use of oxygen supplementation becomes established it is important to obtain better evidence on which patients benefit from such treatment. Participants will be randomized to one of three groups: the first will receive continuous oxygen for 72Â hours (at a rate of 2 or 3Â L/min depending on baseline oxygen saturation), the second group will receive nocturnal oxygen only (at a rate of 2 or 3Â L/min depending on baseline oxygen saturation) and the third group will not receive any oxygen (control). A baseline assessment is performed at randomization and a one-week follow-up completed. Outcome data at three, six and twelve months will be obtained via a questionnaire sent to the patient by the trial center. This study will provide evidence on the effectiveness of oxygen supplementation for the treatment of stroke and whether nocturnal oxygen is a potentially beneficial therapy regimen. This trial is registered with the ISRCTN register ID number ISRCTN52416964.
Hypoxia is common after stroke, and monitoring by pulse oximetry is suggested in the acute phase.... more Hypoxia is common after stroke, and monitoring by pulse oximetry is suggested in the acute phase. Physical changes on the affected side or intravenous infusions may affect oximeter readings. This study was designed to test whether pulse oximetry recordings are the same on the affected and nonaffected sides in stroke patients. Oxygen saturation (SpO(2)) and heart rate (HR) were assessed simultaneously in the left and right hands in patients with hemiparetic stroke over a 3-hour period with 2 Minolta Pulsox-3i oximeters attached to the index fingers. Fifteen patients (53% men; 67% left hemiparesis; mean age, 73 years [SD, 7.5 years]) were recruited. HR and SpO(2) (12 measurements per minute) were monitored. The maximum difference between simultaneous left and right arm readings was 2% SpO(2). HR fluctuated more, but no affected/nonaffected side pattern was seen. Means for each patient of HR and SpO(2) for the affected and nonaffected sides were compared by t tests. Mean SpO(2) was 96% (SD, 1%) on both sides. Mean HR was 81 bpm (SD, 11 bpm) on the affected side and 80 bpm (SD, 10 bpm) on the nonaffected side. There was no significant difference between the 2 sides for either parameter (n=15; P=0.86 for SpO(2) and P=0.91 for HR). Oximeters can be attached to either the affected or nonaffected side in hemiparetic stroke.
To involve stroke patients and carers in the design of a study of oxygen supplementation in acute... more To involve stroke patients and carers in the design of a study of oxygen supplementation in acute stroke and to obtain their views on the importance of the study, consent issues, relevance, and acceptability of the outcome measures, and the preferred method of follow-up. This study involved qualitative and quantitative research. Three focus group meetings were held with individuals who have had personal experience of stoke, mostly stoke patients and their partners or carers (an association of young stroke sufferers and 2 dysphasia support groups each from a different town in the West Midlands, UK). The researchers explained the planned oxygen supplementation study and encouraged participants to comment and make suggestions in a semistructured interview. The audience was then asked to complete a questionnaire relating to the study. Seventy-three people (67% stroke patients and 33% carers; mean age 64; range 31 to 86 years; and 47% males) attended the 3 meetings. The overall response rate to the questionnaires was 70%. Most of the respondents considered the study worthwhile (97%) and the planned outcome measures relevant. In addition, assessment of speech, memory, sleep, and cognitive function was raised by >20% of respondents as important outcomes. Seventy-five percent would agree with assent from a family member on behalf of incompetent patients, and 92% would agree to a doctor recruiting incompetent patients to the study and seeking consent/assent later. The majority of respondents (80%) preferred personal contact with the researcher or a representative to a questionnaire for follow-up. Involvement of stroke patients and carers helped us identify outcome measures that are important to the stroke population but not routinely addressed in stroke assessment scales. A high proportion of respondents asked for waiver of consent and agreed to family's assent on behalf of incompetent patients. Although consumer involvement has helped us to make the study more relevant to the public, it has also led to difficult scientific and ethical conflicts in protocol design.
THE LANCET Jick H, Jiclt SS, Derby LE. Validation of information recorded on general-practitioner... more THE LANCET Jick H, Jiclt SS, Derby LE. Validation of information recorded on general-practitioner based computerised data resource in the United Kingdom. BMJ 1991; 302; 766-68. Jick H, Terris BZ, Derby LE, Jick SS. Further validation ...
Journal of Stroke and Cerebrovascular Diseases, 2007
Hypoxia is common after acute stroke. Most studies of oxygenation after stroke were done at night... more Hypoxia is common after acute stroke. Most studies of oxygenation after stroke were done at night. The objective of this study was to determine whether there are differences in oxygenation between day and night early after stroke. Patients with an acute stroke were recruited within 24 hours of admission. Patients who were hypoxic (oxygen saturation < 90%) were excluded. Oxygen saturation was assessed by pulse oximetry over 24 hours. Daytime recordings were taken from 9 am to 9 pm and nighttime recordings from 10 pm to 6 am. Respiratory rate and sleep/awake status were recorded twice during the day and the night. Forty patients were recruited (mean age 77 years [range 55-93 years], 53% men; median [range] Glasgow Coma Scale score 15 [10-15] and Scandinavian Stroke Scale score 31 [4-56]; 80% cerebral infarcts, 20% hemorrhages). The median (range) respiratory rate was 20 (14-30) breaths/min in the day and 18 (12-32) breaths/min in the night (P < .01, Wilcoxon paired test). The median (range) oxygen saturation was 95.5% (87%-98.6%) in the day and 94.3% (80%-98%) at night (P < .001, Wilcoxon paired test). The median (range) 4% oxygen desaturation index was 1.7 (0.0, 18.0) in the day and 3.0 (0.0, 39.4) at night (P < .001, Wilcoxon paired test). Respiratory rate, oxygen saturation, and 4% oxygen desaturation index during the day and night were strongly correlated. All indicators of oxygenation assessed in this study were significantly worse at night than in the day. Because daytime and nighttime results were strongly correlated, borderline hypoxia during the day is strongly predictive of overt hypoxia at night.
The National Institute of Health Stroke Scale (NIHSS) and the Scandinavian Stroke Scale (SSS) are... more The National Institute of Health Stroke Scale (NIHSS) and the Scandinavian Stroke Scale (SSS) are commonly used in clinical stroke trials. Use of different scales in trials makes comparison of outcomes difficult. Adult patients with an acute stroke were recruited within 24 h of onset, and NIHSS, SSS and Glasgow Coma Scale scores were assessed at baseline and repeated at 1 week. A total of 144 patients were included (46% males, mean age = 73 years). At presentation the median SSS score was 38 (2-58), and a week later 40 (4-58), the median NIHSS score at presentation was 5 (0-29) and a week later 3 (0-27). Changes in both scales were strongly correlated, r = 0.76, p < 0.001. Both were good predictors of mortality. Linear regression analysis produced an equation relating the two: SSS = 50 - 2 x NIHSS.
Oxprenolol in an Oros 8/130 sustained release osmotic pump system (equivalent to 120 mg oxprenolo... more Oxprenolol in an Oros 8/130 sustained release osmotic pump system (equivalent to 120 mg oxprenolol hydrochloride in a conventional formulation and releasing 8 mg h-1) was given to eight normal young subjects (mean age 23 years) and eight elderly hypertensive patients (mean age 77 years). The plasma concentration-time profiles of oxprenolol were determined over 32 h using gas liquid chromatography after the initial dose and following seven doses. The elderly patients had a significantly higher AUC and maximum plasma oxprenolol concentration following both the first and final doses studied. It is unlikely that this difference is due to a prolonged absorption phase in the elderly patients. Reduced drug clearance seems the most probable explanation.
Rechecking the position of the nasogastric tube after oropharyngeal suction is not common practic... more Rechecking the position of the nasogastric tube after oropharyngeal suction is not common practice. Our patient deteriorated after oropharyngeal suction was performed, whilst nasogastric feeding continued. We suggest that nasogastric feeding should be stopped during oropharyngeal suction and the tube position should be checked every time an oropharyngeal suction is performed.
BACKGROUND: Cholinesterase inhibitors produce small improvements in cognitive and global assessme... more BACKGROUND: Cholinesterase inhibitors produce small improvements in cognitive and global assessments in Alzheimer's disease. We aimed to determine whether donepezil produces worthwhile improvements in disability, dependency, behavioural and ...
Unilateral visual neglect, an attentional disorder, might show variability on repeated testing. T... more Unilateral visual neglect, an attentional disorder, might show variability on repeated testing. This study investigated test-retest stability in elderly patients post-stroke, 85 with and 83 without neglect. Subjects repeated three common clinical tests for neglect within the hour; the ...
Mild hypoxia is common in stroke patients and may have significant adverse effects on the ischemi... more Mild hypoxia is common in stroke patients and may have significant adverse effects on the ischemic brain after stroke. The use of oxygen treatment is rapidly increasing in European stroke units but is not without side effects. It impedes early mobilization, could pose an infection risk, and may encourage the formation of toxic free radicals, leading to further damage to the ischemic brain. In the Stroke Oxygen Pilot Study (2 or 3Â L/min for 72Â hours) neurological recovery at one week was better in the oxygen group than in controls, and after correction for difference in baseline stroke severity and prognostic factors, there was a trend to better outcome with oxygen at six months. Oxygen was as effective in mild as in severe strokes.Oxygen saturation is lower at night than during the day, and episodes of oxygen desaturation are common during sleep. Nocturnal oxygen supplementation is likely to reduce the burden of hypoxia without interfering with daytime mobilization and rehabilitation.Before wider use of oxygen supplementation becomes established it is important to obtain better evidence on which patients benefit from such treatment. Participants will be randomized to one of three groups: the first will receive continuous oxygen for 72Â hours (at a rate of 2 or 3Â L/min depending on baseline oxygen saturation), the second group will receive nocturnal oxygen only (at a rate of 2 or 3Â L/min depending on baseline oxygen saturation) and the third group will not receive any oxygen (control). A baseline assessment is performed at randomization and a one-week follow-up completed. Outcome data at three, six and twelve months will be obtained via a questionnaire sent to the patient by the trial center. This study will provide evidence on the effectiveness of oxygen supplementation for the treatment of stroke and whether nocturnal oxygen is a potentially beneficial therapy regimen. This trial is registered with the ISRCTN register ID number ISRCTN52416964.
Hypoxia is common after stroke, and monitoring by pulse oximetry is suggested in the acute phase.... more Hypoxia is common after stroke, and monitoring by pulse oximetry is suggested in the acute phase. Physical changes on the affected side or intravenous infusions may affect oximeter readings. This study was designed to test whether pulse oximetry recordings are the same on the affected and nonaffected sides in stroke patients. Oxygen saturation (SpO(2)) and heart rate (HR) were assessed simultaneously in the left and right hands in patients with hemiparetic stroke over a 3-hour period with 2 Minolta Pulsox-3i oximeters attached to the index fingers. Fifteen patients (53% men; 67% left hemiparesis; mean age, 73 years [SD, 7.5 years]) were recruited. HR and SpO(2) (12 measurements per minute) were monitored. The maximum difference between simultaneous left and right arm readings was 2% SpO(2). HR fluctuated more, but no affected/nonaffected side pattern was seen. Means for each patient of HR and SpO(2) for the affected and nonaffected sides were compared by t tests. Mean SpO(2) was 96% (SD, 1%) on both sides. Mean HR was 81 bpm (SD, 11 bpm) on the affected side and 80 bpm (SD, 10 bpm) on the nonaffected side. There was no significant difference between the 2 sides for either parameter (n=15; P=0.86 for SpO(2) and P=0.91 for HR). Oximeters can be attached to either the affected or nonaffected side in hemiparetic stroke.
To involve stroke patients and carers in the design of a study of oxygen supplementation in acute... more To involve stroke patients and carers in the design of a study of oxygen supplementation in acute stroke and to obtain their views on the importance of the study, consent issues, relevance, and acceptability of the outcome measures, and the preferred method of follow-up. This study involved qualitative and quantitative research. Three focus group meetings were held with individuals who have had personal experience of stoke, mostly stoke patients and their partners or carers (an association of young stroke sufferers and 2 dysphasia support groups each from a different town in the West Midlands, UK). The researchers explained the planned oxygen supplementation study and encouraged participants to comment and make suggestions in a semistructured interview. The audience was then asked to complete a questionnaire relating to the study. Seventy-three people (67% stroke patients and 33% carers; mean age 64; range 31 to 86 years; and 47% males) attended the 3 meetings. The overall response rate to the questionnaires was 70%. Most of the respondents considered the study worthwhile (97%) and the planned outcome measures relevant. In addition, assessment of speech, memory, sleep, and cognitive function was raised by >20% of respondents as important outcomes. Seventy-five percent would agree with assent from a family member on behalf of incompetent patients, and 92% would agree to a doctor recruiting incompetent patients to the study and seeking consent/assent later. The majority of respondents (80%) preferred personal contact with the researcher or a representative to a questionnaire for follow-up. Involvement of stroke patients and carers helped us identify outcome measures that are important to the stroke population but not routinely addressed in stroke assessment scales. A high proportion of respondents asked for waiver of consent and agreed to family's assent on behalf of incompetent patients. Although consumer involvement has helped us to make the study more relevant to the public, it has also led to difficult scientific and ethical conflicts in protocol design.
THE LANCET Jick H, Jiclt SS, Derby LE. Validation of information recorded on general-practitioner... more THE LANCET Jick H, Jiclt SS, Derby LE. Validation of information recorded on general-practitioner based computerised data resource in the United Kingdom. BMJ 1991; 302; 766-68. Jick H, Terris BZ, Derby LE, Jick SS. Further validation ...
Journal of Stroke and Cerebrovascular Diseases, 2007
Hypoxia is common after acute stroke. Most studies of oxygenation after stroke were done at night... more Hypoxia is common after acute stroke. Most studies of oxygenation after stroke were done at night. The objective of this study was to determine whether there are differences in oxygenation between day and night early after stroke. Patients with an acute stroke were recruited within 24 hours of admission. Patients who were hypoxic (oxygen saturation < 90%) were excluded. Oxygen saturation was assessed by pulse oximetry over 24 hours. Daytime recordings were taken from 9 am to 9 pm and nighttime recordings from 10 pm to 6 am. Respiratory rate and sleep/awake status were recorded twice during the day and the night. Forty patients were recruited (mean age 77 years [range 55-93 years], 53% men; median [range] Glasgow Coma Scale score 15 [10-15] and Scandinavian Stroke Scale score 31 [4-56]; 80% cerebral infarcts, 20% hemorrhages). The median (range) respiratory rate was 20 (14-30) breaths/min in the day and 18 (12-32) breaths/min in the night (P < .01, Wilcoxon paired test). The median (range) oxygen saturation was 95.5% (87%-98.6%) in the day and 94.3% (80%-98%) at night (P < .001, Wilcoxon paired test). The median (range) 4% oxygen desaturation index was 1.7 (0.0, 18.0) in the day and 3.0 (0.0, 39.4) at night (P < .001, Wilcoxon paired test). Respiratory rate, oxygen saturation, and 4% oxygen desaturation index during the day and night were strongly correlated. All indicators of oxygenation assessed in this study were significantly worse at night than in the day. Because daytime and nighttime results were strongly correlated, borderline hypoxia during the day is strongly predictive of overt hypoxia at night.
The National Institute of Health Stroke Scale (NIHSS) and the Scandinavian Stroke Scale (SSS) are... more The National Institute of Health Stroke Scale (NIHSS) and the Scandinavian Stroke Scale (SSS) are commonly used in clinical stroke trials. Use of different scales in trials makes comparison of outcomes difficult. Adult patients with an acute stroke were recruited within 24 h of onset, and NIHSS, SSS and Glasgow Coma Scale scores were assessed at baseline and repeated at 1 week. A total of 144 patients were included (46% males, mean age = 73 years). At presentation the median SSS score was 38 (2-58), and a week later 40 (4-58), the median NIHSS score at presentation was 5 (0-29) and a week later 3 (0-27). Changes in both scales were strongly correlated, r = 0.76, p < 0.001. Both were good predictors of mortality. Linear regression analysis produced an equation relating the two: SSS = 50 - 2 x NIHSS.
Oxprenolol in an Oros 8/130 sustained release osmotic pump system (equivalent to 120 mg oxprenolo... more Oxprenolol in an Oros 8/130 sustained release osmotic pump system (equivalent to 120 mg oxprenolol hydrochloride in a conventional formulation and releasing 8 mg h-1) was given to eight normal young subjects (mean age 23 years) and eight elderly hypertensive patients (mean age 77 years). The plasma concentration-time profiles of oxprenolol were determined over 32 h using gas liquid chromatography after the initial dose and following seven doses. The elderly patients had a significantly higher AUC and maximum plasma oxprenolol concentration following both the first and final doses studied. It is unlikely that this difference is due to a prolonged absorption phase in the elderly patients. Reduced drug clearance seems the most probable explanation.
Rechecking the position of the nasogastric tube after oropharyngeal suction is not common practic... more Rechecking the position of the nasogastric tube after oropharyngeal suction is not common practice. Our patient deteriorated after oropharyngeal suction was performed, whilst nasogastric feeding continued. We suggest that nasogastric feeding should be stopped during oropharyngeal suction and the tube position should be checked every time an oropharyngeal suction is performed.
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