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The Stroke in Sierra Leone (SISLE) Register is a prospective observational stroke register that aims to study stroke risk factors, patient care, and outcomes in Sierra Leone. The register recruited 986 patients with confirmed stroke from two hospitals in Freetown and collected data on various variables such as demographics, risk factors, stroke type, and mortality rates. The register has informed the development of a strategic action plan for non-communicable diseases in Sierra Leone and has led to the establishment of a specialized stroke unit. The data from the register are available for further research and collaboration. The register found that severe strokes occur in younger patients who were previously independent, and the case fatality rate is high. Functional improvement is most likely to occur between 7 and 90 days post-stroke. Risk factors such as hypertension, diabetes, dyslipidemia, and atrial fibrillation were identified. [Extracted from the article]

Stroke remains one of the most important causes of death and disability worldwide. Effective prevention could reduce the burden of stroke dramatically. The management of stroke has undergone a revolution over the last few decades, particularly with the development of techniques for revascularisation of patients with ischaemic stroke. Advanced imaging able to identify potentially salvageable brain is further increasing the potential for effective acute treatment. However, the majority of stroke patients won't benefit from these treatments and will need effective specialist stroke care and ongoing rehabilitation to overcome impairments and adapt to living with a disability. There are still many unanswered questions about the most effective way of delivering rehabilitation. Likewise, research into how to manage primary intracerebral haemorrhage has yet to transform care. [ABSTRACT FROM AUTHOR]

Objectives: to identify explanatory factors for the association between depression at 3 months after stroke and physical disability at 3 years. Methods: data from the South London Stroke Register (1998--2013) were used. Patients (n = 3,612) were assessed at stroke onset. Follow-up at 3 months included assessment for depression with the Hospital Anxiety and Depression scale (scores ≥ 7 = depression), physical disability (Barthel index) cognitive function, smoking habit, selective serotonin reuptake inhibitors (SSRIs) use, perception of recovery and social support. Physical disability was reassessed at 3 years. The associations between depression at 3 months and physical disability at 3 years were estimated with multinomial regression adjusting for age, gender, ethnicity, stroke severity and possible explanatory factors for the association (introduced in the models first individually and then sequentially): pre-stroke medical history and physical disability, cognitive function, smoking, SSRIs, perception of recovery and social support at 3 months. Results: one thousand three hundred and seven survivors were assessed at 3 months, of which 418 (32.0%) had depression. Survivors with depression had a higher physical disability rate at 3 years. These associations remained significant after adjustment for individual explanatory factors but were not significant after adjustment for combined explanatory factors. Physical disability at 3 months was a relevant explanatory factor for this association. SSRIs were associated with severe, relative risk: 6.62 (2.92-15.02) P < 0.001, and moderate physical disability, relative risk: 3.45 (1.58-7.52) P = 0.002, at 3 years. Conclusion: the association between depression and physical disability appears to be multifactorial. The use of SSRIs after stroke requires further research. [ABSTRACT FROM AUTHOR]

Background: evidence on the long-term natural history, predictors and outcomes of anxiety after stroke is insufficient to inform effective interventions. This study estimates within 10 years of stroke: (i) the incidence, cumulative incidence, prevalence, and time of onset of anxiety. (ii) Predictors of anxiety and its association with depression. (iii) The association between anxiety 3 months after stroke and mortality, stroke recurrence, disability, cognitive impairment and quality of life (QoL) at follow-up.Methods: data from the South London Stroke Register (1995–2010). Patients were assessed at the time of the stroke, at 3 months, 1 year and then annually for up to 10 years. Baseline data included socio-demographics and stroke severity. Follow-up data included assessments for anxiety and depression (hospital anxiety and depression scale), disability, cognition and QoL. Multivariate regression was used to investigate predictors and associated outcomes of anxiety.Results: incidence of anxiety up to 10 years ranged from 17 to 24%. Cumulative incidence: 57%. Prevalence range: 32–38%. Amongst patients with anxiety, 58% were anxious at 3 months. 57–73% of patients with anxiety had co-morbid depression. Predictors of anxiety included age under 65, female gender, inability to work, depression treatment, smoking and stroke severity. Anxiety at 3 months was associated with lower QoL at follow-up.Conclusions: anxiety is a frequent problem affecting stroke survivors in the long term. Clinicians should pay attention to patients at risk of anxiety since it is associated with lower QoL and depression. [ABSTRACT FROM AUTHOR]

Background Telemedicine is increasingly used in the UK to deliver thrombolysis. It is primarily used to enable assessment of people presenting with an acute stroke by a remote specialist in stroke care, and to determine eligibility for thrombolysis with alteplase (recombinant tissue plasminogen activator). This study aims to evaluate the process of acute stroke care, safety and outcome profiles when comparing face-to-face evaluation and telemedicine in the delivery of thrombolysis. Methods This was a retrospective single centre cohort study, evaluating patients thrombolysed from July 2007 to December 2009 inclusive. All patients were given treatment within a 3-hour window from onset of symptoms. Of the 97 patients thrombolysed, 45 (46%) were evaluated by telemedicine. Process times of the steps taken to deliver thrombolysis for the two groups were compared. The authors include the rates of symptomatic intracranial haemorrhage (SICH). Outcome data include 3-month mortality and functional status. Results Process times were significantly better in face- to-face: Admission to CT (p=0.001), CT to treatment (p≤0.001) and admission to treatment (p≤0.001). SICH occurred in four patients (7.7%) in the face-to-face group compared with the two patients (4.4%) in the telemedicine group (p=0.7). Favourable outcome: a modified Rankin score of 0-2 was observed in 19 patients (36.5%) in the face-to-face group compared with 19 patients (42%) in the telemedicine group (p=0.9). Conclusions This analysis shows that the use of telemedicine compared with face-to-face evaluation is feasible in the delivery of thrombolysis during out of hours. There are several areas of our emergency process of hyper-acute stroke care that need improving when using telemedicine. [ABSTRACT FROM AUTHOR]

Some patients with anosognosia for hemiplegia, i.e. apparent unawareness of hemiplegia, have been clinically observed to show ‘tacit’ or ‘implicit’ awareness of their deficits. Here we have experimentally examined whether implicit and explicit responses to the same deficit-related material can dissociate. Fourteen stroke patients with right hemisphere lesions and contralesional paralysis were tested for implicit and explicit responses to brief sentences with deficit-related themes. These responses were elicited using: (i) a verbal inhibition test in which patients had to inhibit completing each sentence with an automatic response (implicit task) and (ii) a rating procedure in which patients rated the self-relevance of the same sentences (explicit task). A group of anosognosic hemiplegic patients was significantly slower than a control group of aware hemiplegic patients in performing the inhibition task with deficit-related sentences than with other emotionally negative themes (relative to neutral themes). This occurred despite their explicit denial of the self-relevance of the former sentences. Individual patient analysis showed that six of the seven anosognosic patients significantly differed from the control group in this dissociation. Using lesion mapping procedures, we found that the lesions of the anosognosic patients differed from those of the ‘aware’ controls mainly by involving the anterior parts of the insula, inferior motor areas, basal ganglia structures, limbic structures and deep white matter. In contrast, the anosognosic patient without implicit awareness had more cortical lesions, mostly in frontal areas, including lateral premotor regions, and also in the parietal and occipital lobes. These results provide strong experimental support for a specific dissociation between implicit and explicit awareness of deficits. More generally, the combination of our behavioural and neural findings suggests that an explicit, affectively personalized sensorimotor awareness requires the re-representation of sensorimotor information in the insular cortex, with possible involvement of limbic areas and basal ganglia circuits. The delusional features of anosognosia for hemiplegia can be explained as a failure of this re-representation. [ABSTRACT FROM AUTHOR]

Background: urinary incontinence (UI) after stroke is associated with significant morbidity and mortality. The UK National Sentinel Audits of Stroke have collected data on UI which has not previously been reported. Methods: data on standards relating to both organisations and process of care were extracted from the audits to look for trends in service provision, continence care planning and discharge destination of incontinent versus continent stroke survivors. In addition, 2004 data was analysed statistically to look for a link between stroke units meeting certain standards and the likelihood of patients having continence plans. Results: UI rates have changed little over the four audit cycles. The influence of UI on discharge destination has also altered little. Stroke unit care is more strongly associated with management planning for UI in stroke. [ABSTRACT FROM AUTHOR]

Study objectives: to measure the quality of secondary prevention of stroke provided to patients in England, Wales and Northern Ireland. Design: retrospective case note analysis. Setting: 235 hospitals (95% of all such hospitals), providing care for acute stroke patients in England, Wales and Northern Ireland and primary health care for follow-up data. Patients: 8,200 patients admitted with stroke between 1st April and 30th June 2001. Data on up to 40 consecutive cases submitted by each hospital. Audit tool: Royal College of Physicians Intercollegiate Stroke Working Party Stroke Audit. Results: 24% of patients with previous cerebrovascular disease were not on anti-thrombotic medication at the time of admission. Nine percent of appropriate patients were not taking anti-thrombotic medication at discharge. Patients left with moderate to very severe disability (Barthel scores 14 or less) compared with those independent with mild disability (Barthel score 15-20) were more likely not to have anti-thrombotic treatment (18% versus 8%). Fifty-four percent of patients with known hyperlipidaemia and 21% of those with previous ischaemic heart disease were on lipid lowering therapy on admission. Sixty-four percent of patients had lipids measured during their hospital stay and of those with high total cholesterol or LDL the rate of non-treatment was 36%. Older patients (75+ years) were less likely to be treated (54%) than those <65 years (71%). Seventy-nine percent of known patients with hypertension were on treatment at admission, with 78% being treated by discharge from hospital. At 6 months after stroke a systolic blood pressure of 140mmHg or less, and a diastolic of 85 mmHg or less, was achieved in 41% of known pre-stroke hypertensives on treatment, 31% of previously untreated hypertensives hut on treatment at follow-up and 40% of patients not previously labelled as hypertensive. Conclusions: major deficiencies in... [ABSTRACT FROM AUTHOR]

Presents a study that described the organization and staffing of specialist hospital-based stroke services in Great Britain by the British Association of Stroke Physicians. Methods; Results; Discussion.

Background: Stroke patients have a 15-fold increased risk of a recurrence, but management of risk factors following stroke has been found to be unsatisfactory. Little is known about health service follow-up of patients after stroke or, consequently, the opportunities for providing secondary prevention to patients.Objective: The aim of the present study was to investigate the relationship between health service follow-up and management of risk factors after stroke.Methods: The study used data from the population-based South London Stroke Register, collected prospectively between 1995 and 1998. Main measures included risk factor change and follow-up by hospital physicians, GPs and district nurses. Logistic regression was used to determine relationships between these measures.Results: Seven hundred and seventeen stroke survivors were registered with first stroke between 1995 and 1998. Most patients were followed-up on at least one occasion by at least one service within the first 3 months after stroke: 51% saw a hospital specialist; 72% saw a GP; and 14% saw a community nurse. However, 14% of patients did not see a doctor at all. Disabled patients were less likely to see a doctor, only 17% of severely disabled patients seeing a hospital specialist [odds ratio (OR) 0.17; 95% confidence interval (CI) 0.07-0.41]. Doctor-led follow-up was related to treatment of physiological risk factors (e.g. 73% of hypertensive patients who had seen a GP were treated compared with 59% who had seen only a hospital specialist and 47% who had seen neither). Contact with health services was not associated with behavioural risk factor change.Conclusions: Opportunities for delivering secondary prevention existed through a range of services, but problems of continuity and effectiveness of care are evident. Further investigation is needed to determine how best to intervene to address these issues. In other words, whether interventions should concentrate on improving access and availability of current services, or whether the focus should be on making current strategies more effective. [ABSTRACT FROM AUTHOR]

Discusses the identification of pulmonary embolism (PE) and pneumonia in acute stroke. Frequency of the two complications after acute stroke; Patients at risk for the complications; Co-existence of PE and pneumonia.

Objectives: to identify the factors associated with hospital admission and the differences in management and outcome of stroke patients between hospital and home. Design: a prospective community stroke register (1995–8) with multiple notification sources. Setting: an inner city multi-ethnic population of 234 533 in South London, UK. Participants: 975 subjects with first in a lifetime strokes, whether or not they were admitted to hospital. Patients dying suddenly and those already hospitalized at the time of stroke were excluded. Main outcome measures: factors associated with hospital admission; differences in management in the acute phase of stroke; mortality and dependency assessed by the Barthel index 3 months post-stroke. Results: 812 patients were admitted to hospital for stroke; 163 were managed in the community. Factors independently associated with hospital admission included stroke severity, pre-stroke independence, atrial fibrillation, having an intracranial haemorrhage and having a non-lacunar infarction. Computed tomography scan rates were higher in admitted (78%) than non-admitted patients (63%; P =0.001). By 3 months, 285 (35%) of the admitted patients had died compared with 13 (8%) of non-admitted patients ( P <0.001). Of the admitted patients, 241 (47%) had a Barthel index ≥18 compared with 106 (72%) of those who were not admitted ( P <0.001). After adjusting for case-mix variables, the odds ratios for death and dependency (Barthel index<18) in admitted and non-admitted patients were 2.21 (0.96–5.12) and 2.39 (1.35–4.22) respectively. Conclusion: patients with clinical indicators for a more severe stroke were more likely to be admitted to hospital. Hospitalized stroke patients may have poorer survival and disability rates than those who remain at home, even after adjustment for case mix. There may be some aspects of acute hospital care that may be detrimental to outcome in certain groups of stroke patients. This r... [ABSTRACT FROM AUTHOR]

Analyzes the word externalism and looks at the relation between the two kinds of externalism. Definition of externalism; Assessment of these two kinds of externalism; Reference to various views on externalism.

Comments on the diagnosis and treatment for transient ischaemic attacks (TIA). Diagnostic inaccuracy among non-specialists; Symptoms that are not acceptable as evidence of a TIA in isolation; Interventions that are likely to reduce vascular risk.

Abstract Case report: a 72-year-old woman presented after a series of falls with a history of malaise, lethargy, cold hands and arm weakness for several months. She had undergone extensive investigation for what remained an unexplained anaemia during this period. Examination revealed cold hands with absent radial pulses. Axillary Doppler studies confirmed grossly diminished systolic pressures. The erythrocyte sedimentation rate was markedly elevated. An arch aortogram showed obliteradve changes selectively affecting the subclavian and axillary arteries. In spite of clinically normal temporal arteries, and the absence of headache, temporal artery biopsy revealed giant cell arteritis. Discussion: aortic arch syndrome is an important but under-appreciated complication of giant cell arteritis and may be the presenting feature. In this case, it resulted in falls consequent upon arm claudication when using a walking frame. [ABSTRACT FROM AUTHOR]

The authors reflect on the concept of telemedicine for stroke called telestroke. According to the authors, the concept of telestroke aims to overcome inequalities for care of stroke patients between hospitals and stroke specialists. The authors also mention that a telestroke team must have information technologists to ensure the reliability of computer-based technology.

Discusses the management of blood pressure after acute stroke. Details of a study on the variation of acute physiological support after stroke and blood pressure management using European stroke registers; Identification of the extent of variations in anti-hypertensive therapy; Number of stroke patients assessed.