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Objective: To determine tolerability and symptom changes associated with the introduction of bisoprolol treatment in older patients with heart failure.Design: Prospective observational cohort study.Setting: Geriatric medicine outpatient department of a university hospital.Patients: 51 patients (mean age 78 years, range 70-89 years) with stable symptomatic heart failure caused by left ventricular systolic dysfunction.Interventions: Bisoprolol tablets, 1.25-10.0 mg.Main Outcome Measures: Tolerability; changes in symptoms and exercise tolerance.Results: 69% of patients tolerated bisoprolol. Mean tolerated dose was 7.6 mg. There was no change in symptoms or exercise capacity in those who tolerated bisoprolol. Perceived health status and symptoms of anxiety and depression improved during the titration period.Conclusions: The rate of withdrawal from bisoprolol treatment in older patients with congestive heart failure was twice that previously reported in younger patients. The mean tolerated dose was similar to that found in trials reporting clinical efficacy. There was no evidence of a negative impact on symptoms or exercise capacity in patients who tolerated bisoprolol. [ABSTRACT FROM AUTHOR]

Insulin is neuroprotective in animal stroke models but its effects in acute stroke in humans are unknown. The Glucose Insulin in Stroke Trial (GIST-UK) is a randomised controlled trial investigating the benefits of maintaining euglycaemia in hyperglycaemic patients with acute stroke. Data are reported from a GIST-UK substudy which sought to determine the influence of glucose potassium insulin (GKI) infusion on blood pressure in acute stroke. All adult patients admitted to hospital with acute stroke with hyperglycaemia (plasma glucose 6.1-17 mmol/l) were potentially eligible. Randomised patients received either a GKI infusion (500 ml 10% glucose, 20 mmol potassium chloride, 16 units of insulin) or control therapy with 154 mmol/l (0.9%) saline at 100 ml/h for 24 hours. BM test strip glucose monitoring was performed 2 hourly, blood pressure monitoring 4 hourly, and plasma glucose sampling 8 hourly. Insulin concentration in the GKI infusate was altered according to test strip values to maintain test strip values between 4-7 mmol/l in the GKI group. Neurological impairment was determined using the European stroke scale (ESS). 145 patients were studied (73 GKI, 72 control). Mean systolic blood pressure was significantly lower during GKI infusion between 4 hours and 24 hours except at 8 hours. Median total ESS scores improved significantly between admission and day 7 in the GKI group (p<0.001) although there was no significant difference in total ESS score between groups at day 7. The significant reduction of systolic blood pressure in acute stroke associated with GKI therapy was not associated with neurological deterioration and may have been beneficial.

Atrial fibrillation is an important and independent risk factor for cerebrovascular disease and vascular dementia. There is increasing evidence that atrial fibrillation is associated with an increased risk of asymptomatic or silent cerebral infarction and as a result may confer an increased risk of progressive cognitive impairment on a person. In this study we sought to determine whether this hypothesis could be explored in a prospective case controlled design. Twenty seven patients with non-valvular atrial fibrillation (NVAF) and no history of stroke, transient ischaemic attack, dementia, and thyrotoxicosis were compared with 54 age and sex matched controls in sinus rhythm. All cases underwent clinical examination, ECG, and psychological assessment using a battery of nine neuropsychological tests. Between group analysis and a comparison of mean test scores of paired controls with cases were undertaken. The presence of atrial fibrillation was consistently associated with poorer performances on all the subtests of the neuropsychological battery. There was no association between duration of atrial fibrillation and performance. These results provide evidence to justify further examination of the hypothesis in a larger prospective study to determine whether antithrombotic therapy may protect against cognitive decline in patients at maximal risk of silent cerebral ischaemia and associated cognitive decline.

Objectives: To describe the natural recovery of visuospatial neglect in stroke patients and the distribution of errors made on cancellation tests using a standardised neuropsychological test battery., Method: A prospective study of acute (< seven days) patients with right hemispheric stroke. Patients identified with visuospatial neglect were followed up for three months with monthly clinical and neuropsychological testing, Results: There were 66 patients with acute right hemispheric stroke assessed of whom 27 (40.9%) had evidence of visuospatial neglect. Patients with neglect, on admission, had a mean behavioural inattention test (BIT) score of 56.3, range 10-126 (normal>129). Three of the subtests identified errors being made in both the right and left hemispaces. During follow up, recovery occurred across both hemispaces, maximal in the right hemispace. Recovery from visuospatial neglect was associated with improvement in function as assessed by the Barthel score. At the end of the study period only six (31.5%) patients had persisting evidence of neglect. On admission the best predictor of recovery of visuospatial neglect was the line cancellation test (Spearman's rank correlation r=-0.4217, p=0.028)., Conclusion: The demonstration of errors in both hemispaces has implications for the theory that neglect is a lateralised attentional problem and is important to recognise in planning the rehabilitation of stroke patients.