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We describe a rare case of pulmonary and central nervous system (CNS) Nocardia beijingensis infection in an immunocompetent patient presenting with stroke like symptoms and newly discovered pulmonary and brain mass. Initial work up suggested lung cancer with metastasis to the brain. However, further evaluation revealed disseminated N. beijingensis. A literature review of N. beijingensis infections in immunocompetent host is also presented.

Summary Background Most patients who have had a stroke are dependent on informal caregivers for activities of daily living. The TRACS trial investigated a training programme for caregivers (the London Stroke Carers Training Course, LSCTC) on physical and psychological outcomes, including cost-effectiveness, for patients and caregivers after a disabling stroke. Methods We undertook a pragmatic, multicentre, cluster randomised controlled trial with a parallel cost-effectiveness analysis. Stroke units were eligible if four of five criteria used to define a stroke unit were met, a substantial number of patients on the unit had a diagnosis of stroke, staff were able to deliver the LSCTC, and most patients were discharged to a permanent place of residence. Stroke units were randomly assigned to either LSCTC or usual care (control group), stratified by geographical region and quality of care, and using blocks of size 2. Patients with a diagnosis of stroke, likely to return home with residual disability and with a caregiver providing support were eligible. The primary outcome for patients was self-reported extended activities of daily living at 6 months, measured with the Nottingham Extended Activities of Daily Living (NEADL) scale. The primary outcome for caregivers was self-reported burden at 6 months, measured with the caregivers burden scale (CBS). We combined patient and caregiver costs with primary outcomes and quality-adjusted life-years (QALYs) to assess cost-effectiveness. This trial is registered with controlled-trials.com, number ISRCTN 49208824. Findings We assessed 49 stroke units for eligibility, of which 36 were randomly assigned to either the intervention group or the control group. Between Feb 27, 2008, and Feb 9, 2010, 928 patient and caregiver dyads were registered, of which 450 were in the intervention group, and 478 in the control group. Patients' self-reported extended activities of daily living did not differ between groups at 6 months (adjusted mean NEADL score 27·4 in the intervention group versus 27·6 in the control group, difference –0·2 points [95% CI –3·0 to 2·5], p value=0·866, ICC=0·027). The caregiver burden scale did not differ between groups either (adjusted mean CBS 45·5 in the intervention group versus 45·0 in the control group, difference 0·5 points [95% CI –1·7 to 2·7], p value=0·660, ICC=0·013). Patient and caregiver costs were similar in both groups (length of the initial stroke admission and associated costs were £13 127 for the intervention group and £12 471 for the control group; adjusted mean difference £1243 [95% CI –1533 to 4019]; p value=0·380). Probabilities of cost-effectiveness based on QALYs were low. Interpretation In a large scale, robust evaluation, results from this study have shown no differences between the LSCTC and usual care on any of the assessed outcomes. The immediate period after stroke might not be the ideal time to deliver structured caregiver training. Funding Medical Research Council.

Multimodal CT or MR imaging may be helpful in guiding reperfusion therapy for stroke. However, access to multimodal imaging may frequently be limited. We hypothesised that certain clinical and non-enhanced CT (NECT) findings at initial assessment can potentially predict mismatch on CT perfusion (CTP) in patients with acute ischaemic stroke.We undertook an analysis of prospectively collected clinical and imaging data of consecutive patients with anterior circulation ischaemic stroke who underwent CTP during their initial assessment. NECT was read for early ischaemic change as measured by the Alberta Stroke Program Early CT Score (ASPECTS), and for hyperdense middle cerebral artery sign (HMCAS). CTP images were evaluated for mismatch. Independent clinical and imaging predictors of a CTP mismatch were identified using stepwise logistic regression.Of the 202 patients, 92 (46%) demonstrated a mismatch, 23 (11%) a matched deficit, and 87 (43%) no perfusion deficit. HMCAS on NECT (OR 13.65, 95% CI 6.04-30.81, p0.001), female gender (OR 2.37, 95% CI 1.19-4.72, p = 0.015), atrial fibrillation (OR 2.05, 95% CI 1.02-4.11, p = 0.044), and absence of a history of hypertension (OR 0.46, 95% CI 0.22-0.96, p = 0.037) were independent predictors of a CTP mismatch. HMCAS had 58% sensitivity, 91% specificity, 84% positive predictive value and 72% negative predictive value.A HMCAS on the initial NECT is associated with a high probability of mismatch in acute ischaemic stroke, and may identify patients most likely to benefit from recanalisation treatments when access to multimodal CT or MR facilities is limited.

Previous research has shown that prism adaptation (prism adaptation) can ameliorate several symptoms of spatial neglect after right-hemisphere damage. But the mechanisms behind this remain unclear. Recently we reported that prisms may increase leftward awareness for neglect in a task using chimeric visual objects, despite apparently not affecting awareness in a task using chimeric emotional faces ( Sarri et al., 2006 ). Here we explored potential reasons for this apparent discrepancy in outcome, by testing further whether the lack of a prism effect on the chimeric face task task could be explained by: i) the specific category of stimuli used (faces as opposed to objects); ii) the affective nature of the stimuli; and/or iii) the particular task implemented, with the chimeric face task requiring forced-choice judgements of lateral ‘preference’ between pairs of identical, but left/right mirror-reversed chimeric face tasks (as opposed to identification for the chimeric object task). We replicated our previous pattern of no impact of prisms on the emotional chimeric face task here in a new series of patients, while also similarly finding no beneficial impact on another lateral ‘preference’ measure that used non-face non-emotional stimuli, namely greyscale gradients. By contrast, we found the usual beneficial impact of prism adaptation (prism adaptation) on some conventional measures of neglect, and improvements for at least some patients in a different face task, requiring explicit discrimination of the chimeric or non-chimeric nature of face stimuli. The new findings indicate that prism therapy does not alter spatial biases in neglect as revealed by ‘lateral preference tasks’ that have no right or wrong answer (requiring forced-choice judgements on left/right mirror-reversed stimuli), regardless of whether these employ face or non-face stimuli. But our data also show that prism therapy can beneficially modulate some aspects of visual awareness in spatial neglect not only for objects, but also for face stimuli, in some cases.

Prism adaptation to rightward optical shifts during visually guided pointing is considered a promising intervention in right-hemisphere stroke patients with left spatial neglect. Conventionally, prism adaptation is assessed via aftereffects, on subjective straight ahead (SSA) pointing with eyes closed; or by visual open-loop pointing (VOL), i.e. pointing to a visual target without seeing the hand. Previous data suggest indirectly that prism aftereffects in neglect patients may be larger (pathologically so) when assessed by SSA than by VOL. But these measures have never been directly compared within the same patients after identical prism exposure. Accordingly we implemented both measures here within the same group of 13 neglect patients and 13 controls. Prism aftereffects were much larger for SSA than VOL in neglect patients, falling outside the normative range only for SSA. This may arise because the SSA task can itself involve aspects of neglect that may be ameliorated by the prism intervention, hence showing abnormal changes after prisms. The extent of SSA change after prisms varied between patients, and correlated with improvements on a standard cancellation measure for neglect. The lesions of patients who did versus did not show neglect improvement immediately after prisms provide an initial indication that lack of improvement may potentially relate to cortical damage in right intraparietal sulcus and white matter damage in inferior parietal lobe and middle frontal gyrus. Future studies of possible rehabilitative impact from prisms upon neglect may need to consider carefully how to measure prism adaptation per se, separately from any impact of such adaptation upon manifestations of neglect.

Organised specialist care for stroke improves outcome, but the merits of different methods of organisation are in doubt. This study compares the efficacy of stroke unit with stroke team or domiciliary care.A single-blind, randomised, controlled trial was undertaken in 457 acute-stroke patients (average age 76 years, 48% women) randomly assigned to stroke unit, general wards with stroke team support, or domiciliary stroke care, within 72 h of stroke onset. Outcome was assessed at 3, 6, and 12 months. The primary outcome measure was death or institutionalisation at 12 months. Analyses were by intention to treat.152 patients were allocated to the stroke unit, 152 to stroke team, and 153 to domiciliary stroke care. 51 (34%) patients in the domiciliary group were admitted to hospital after randomisation. Mortality or institutionalisation at 1 year were lower in patients on a stroke unit than for those receiving care from a stroke team (21/152 [14%] vs 45/149 [30%]; p0.001) or domiciliary care (21/152 [14%] vs 34/144 [24%]; p=0.03), mainly as a result of reduction in mortality. The proportion of patients alive without severe disability at 1 year was also significantly higher on the stroke unit compared with stroke team (129/152 [85%] vs 99/149 [66%]; p0.001) or domiciliary care (129/152 [85%] vs 102/144 [71%]; p=0.002). These differences were present at 3 and 6 months after stroke.Stroke units are more effective than a specialist stroke team or specialist domiciliary care in reducing mortality, institutionalisation, and dependence after stroke.

Large intervention studies suggest that aspirin may reduce mortality when given to patients who present with strokes or transient ischemic attacks. We sought to determine whether patients who were already using aspirin at the time of an ischemic stroke had a lower mortality than those who were not.A prospective cohort study was undertaken in patients (mean age 76 +/- 15 years) with acute ischemic stroke. Detailed information on demography, stroke characteristics, and aspirin use prior to the stroke was collected from patients, medical records, and other sources. Patients were classified by cause and subtype of stroke using standard criteria. Mortality was measured 4 weeks after the initial episode.Of the 1,457 patients, 650 (45%) were using aspirin (median dose 75 mg; range 75 to 300 mg) prior to the stroke. Prior use of aspirin was associated with lower 4-week mortality (14% versus 20%, P0.01 ). Beneficial effects of prior aspirin use on mortality were seen in patients with atherosclerotic strokes (15% versus 21%, P0.05) and with cardioembolic strokes (21% versus 34%, P0.05), but not among patients with strokes due to small vessel occlusion (10% versus 11%, P = 0.8). Prior aspirin use was also associated with lower mortality in patients in whom the cause of ischemic stroke could not be determined (15% versus 22%, P0.01). The effect of prior aspirin use on mortality was independent of age, gender, other risk factors, and use of other medication.Prior use of low-dose aspirin may be associated with a small but significant reduction in stroke mortality.

Lalit Kalra, MD, Fellow, Division of Infectious Diseases; Margaret Miller, MT(ASCP)M, CIC, Infection Prevention Coordinator; Ping Du, MD, PhD, Assistant Professor, Departments of Medicine and Public Health Sciences; Cynthia Whitener, MD, Crystal Zalonis, DO, MS, Assistant Professor of Medicine and Orthopedics, Division of Infectious Diseases and Epidemiology; Marissa Grifasi, PharmD, BCPS, Clinical Pharmacy Specialist, Infectious Diseases; Kathleen Julian, MD, Assistant Professor of Medicine, Division of Infectious Diseases, Associate Hospital Epidemiologist; Penn State Milton S. Hershey Medical Center, Hershey, PA

A controlled double-blind crossover study of ocular complications associated with nebulized ipratropium bromide and salbutamol therapy for respiratory distress was undertaken in 46 chronic bronchitis patients. There was no significant rise in intraocular pressure or change in anterior chamber angle in patients with open-angle glaucoma, narrow-angle glaucoma or control subjects following treatment with either drug. However, when the two drugs were used in combination, intraocular pressure rose in patients with narrow-angle glaucoma but not in patients with open-angle glaucoma or in control subjects. Transient angle closure was seen in five of these patients. Intraocular pressures did not rise when swimming goggles were used to protect the eyes or when antiglaucoma treatment was continued. Nebulized bronchodilator therapy is safe in nonglaucomatous patients and those with open-angle glaucoma. Ocular complications can follow combined ipratropium bromide and salbutamol nebulization in patients with narrow-angle glaucoma, but can be prevented by using the drugs separately, protecting the eyes and ensuring continued antiglaucoma measures.