Seriously Emotionally Disturbed Youth: A Needs Assessment

A desire to improve outcomes for children and families led Erie County, New York to collaborate with the University at Buffalo Department of Family Medicine on a needs assessment of children with emotional disturbance. Demographic and behavioral characteristics, as well as service needs were identified through case-based interviews conducted with key informants who provided services to children with emotional disturbance. Family interviews were conducted whenever possible. Results demonstrate a need for enhanced case management, service coordination, services specific to children and families, and expanded community-based services.     

Long term trend analysis of geographical disparity in aging and disability: Taiwanese population approach

Purposes of the present paper were to describe the overtime change of disability prevalence among the elderly (65 years and older), and to analyze the geographic disparity of the disability prevalence during the year 2000-2010 in Taiwan. Study data mainly come from two public web-access information: (1) The physically and mentally disabled population by age and grade, 2000-2010; (2) Taiwan general population by age, 2000-2010. We used statistical methods include number, percentage and geographical information system (GIS) to describe the disability prevalence among the elderly people by year and administrative area, and a trend test was conducted to examine the overtime change of disability prevalence in the elderly people. The results found that the mean of disability prevalence rate in the elderly population was 14.8% and it was significantly increased during the past 11 years (R² = 0.901; p < 0.0001). With regards to the elderly disability prevalence disparity in administrative areas, those areas of higher elderly disability prevalence were more likely to occur in east-mountain areas—Taitung County (24.2%), Yilan County (21.0%), Hualien County (20.3%), and central-agricultural counties such as Yunlin County (21.8%), Nantou County (17.6%) and Chiayi County (17.3%). The most relative change areas of disability prevalence rate in the elderly population during the past 11 years were more likely to occur in central or east areas in Taiwan. The present study highlights the authorities should pay much attention to increasing rate and the geographical disparity of disability prevalence in the elderly population, to allocate appropriate health and welfare resources for this vulnerable population.     

Type, causes, and prognosis of stroke recurrence in the province of Teruel, Spain. A 5-year analysis

Recurrent strokes are an important cause of morbidity and mortality. Identification of the causes of recurrence and its treatment may play an essential role in the prevention of further strokes. The aim of our work is to analyze the type and causes of stroke recurrence in a 5-year period and to determine if recurrent stroke is of the same type as index stroke. In a retrospective study, we reviewed the clinical records and database of our hospitals and found a total of 1108 patients admitted because of primary stroke. The patients with recurrent stroke were selected for a comprehensive analysis. Age, vascular risk factors and fatality rates of these patients were compared with those obtained in recurrence-free patients. We identified 135 patients with recurrent stroke. The most frequent type of recurrence was large vessel atherothrombotic stroke followed by the cardioembolic or lacunar stroke. The major contributing factors were hypertension, atrial fibrillation, and cardiomyopathies. The fatality rate did not differ from the overall mortality by stroke in these years, but the majority of deaths occurred in long-term recurrences. The functional status was worse after recurrent stroke than after index stroke. Although any pattern of recurrence is possible. There is a major trend to occur in the same vascular territory by the same pathophysiologic mechanism. Recurrent stroke frequently carries a worse functional status than index stroke. In many patients, despite the appropriate treatment, stroke recurrence was an unavoidable consequence. Received: 24 August 2000 / Accepted in revised form: 11 December 2000     

Rearrest and linkage to mental health services among clients of the Clark County mental health court program

OBJECTIVE: This study examined rearrest and linkage to mental health services among 368 misdemeanants with severe and persistent mental illness who were served by the Clark County Mental Health Court (MHC). This court, established in April 2000, is based on the concepts of therapeutic jurisprudence. This study addressed the following questions about the effectiveness of the Clark County MHC: Did MHC clients receive more comprehensive mental health services? Did the MHC successfully reduce recidivism? Were there any client or program characteristics associated with recidivism? METHODS: A secondary analysis of use of mental health services and jail data for the MHC clients enrolled from April 2000 through April 2003 was conducted. The authors used a 12-month pre-post comparison design to determine whether MHC participants experienced reduced rearrest rates for new offenses, reduced probation violations, and increased mental health services 12 months postenrollment in the MHC compared with 12 months preenrollment. RESULTS: The overall crime rate for MHC participants was reduced 4.0 times one year postenrollment in the MHC compared with one year preenrollment. One year postenrollment, 54 percent of participants had no arrests, and probation violations were reduced by 62 percent. The most significant factor in determining the success of MHC participants was graduation status from the MHC, with graduates 3.7 times less likely to reoffend compared with nongraduates. CONCLUSIONS: The Clark County MHC successfully reduced rearrest rates for new criminal offenses and probation violations and provided the mental health support services to stabilize mental health consumers in the community.     

William M. Feinberg Lecture: stroke therapy in the year 2025: burden, breakthroughs, and barriers to progress

BACKGROUND: More than 700 000 strokes occurred in the United States during 2002, of which approximately 500 000 are first-ever strokes and 200 000 recurrent strokes. If we would decrease the enormous burden of stroke throughout the world, we first need to know the barriers that we have to overcome. These are quite similar to the barriers that we have tried to surmount during the last 25 years. STOKE PREVENTION: We have developed many successful primary and secondary therapies to prevent stroke over the past 25 years and have begun to understand some of the genetic risk factors underlying stroke. Yet, the incidence rate of stroke in Rochester, Minn, remained unchanged from 1975 to the mid-1990s, and mortality rates for Ohio have changed little for men, women, blacks, and whites over the past decade. The primary reason that we have made little progress in decreasing the burden of stroke is that we have made little progress in modifying the primary risk factors for stroke in the population. Other barriers of improved stroke prevention in the future include costs of therapy and aging of blood vessels and brain, which is the most important risk factor for stroke. ACUTE STROKE: Breakthroughs in acute stroke treatment are likely to follow the steps of cardiology with the primary focus for ischemic stroke on the restoration of oxygenated blood flow to ischemic brain as quickly as possible. To improve acute stroke therapy in the year 2025, we need to have more focused messages sent to the lay public about stroke warning signs, better and safer methods to open arteries quickly, truly effective neuroprotection in the setting of reperfusion, regional organization for acute stroke therapy, and large randomized trials to find clinically important but smaller benefits. A scientifically proven treatment for treatment of acute intracerebral hemorrhage is another major goal. RECOVERY AFTER STROKE: Brain recovery after stroke is the area of scientific discovery with the largest potential for advances far into the next century. Obstacles that block effective therapies in the recovery from stroke include the extent of initial injury from stroke, the brain plasticity of a given patient, and, most importantly, understanding the "neural code"-how the brain is organized and how cells communicate with one another.     

The role of intima-media-thickness, ankle-brachial-index and inflammatory biochemical parameters for stroke risk prediction: a systematic review

Background: Despite important advances in therapeutic approaches in stroke, the options of acute treatment are still limited. Primary prevention represents another potentially highly efficient strategy. For effective prevention the early detection of subjects at risk is of utmost importance. Coinciding with a change in current understanding of atherosclerosis as an inflammatory, cross‐organ disease, new parameters to assess the individual risk are emerging. Methods: Systematic review of the potential of selected parameters for prediction of cerebrovascular events beyond detection of traditional risk factors that might expand the repertoire of primary prevention programs in stroke. Results: An absolute carotid intima‐media thickness difference of 0.1 mm increases the future risk of stroke by 13–18%. An ankle‐brachial index <0.9 was associated with a relative risk of 2.33 (95% CI 2.02–2.68) for stroke. In patients with acute stroke and ABI values < 0.9 the risk for a new vascular event is significantly increased (HR 2.1; 95% CI 1.6–2.8). Measurements of several molecular biomarkers may be used to predict future vascular events independently of traditional risk factors. Conclusions: Based on the data presented, there is clear evidence that measurement of the ankle‐brachial index identifies subjects of increased stroke risk in primary and secondary care settings as well as of stroke recurrence in acute stroke.     

Stroke prevention awareness and treatment knowledge among patients'' relatives

BACKGROUND: Recent research indicates that if a stroke can be effectively treated within three hours, prognosis is improved. Therefore, it is necessary to properly educate stroke patients' relatives about prevention and treatment. OBJECTIVE: To survey and analyze the present awareness of stroke prevention and treatment knowledge among patients' relatives. DESIGN: Cross-sectional study. SETTING: Beijing Hospital and Medical College of Shandong University and Harrison International Peace Hospital, the Affiliated Hospital of Hebei Medical University.PARTICIPANTS: From May 2005 to November 2006, a "stroke awareness" questionnaire survey was performed in four hospitals, including Harrison International Peace Hospital in Hengshui City (third class, first grade), Fucheng County People's Hospital (second class, first grade), Zaoqiang County Jiahui Countryside Hospital (first class, first grade) and Hengshui City Electricity Industry Bureau Infirmary. The participants provided confirmed consent.METHODS: The "stroke awareness" questionnaire included 10 questions: 1–8 were related to the understanding of stroke, 9 and 10 were related to behavior and attitude towards medical treatment. Demographic information was also collected on each participant, including age, education level, and occupation. Each positive answer accounted for one point. A score of 8 or higher was categorized as "good stroke awareness".MAIN OUTCOME MEASURES: Scores of stroke awareness. RESULTS: A total of 4 000 "stroke awareness" questionnaires were printed and distributed. 3 597 copies were completed and 3 468 were included in the study. ① Relative factors of stroke awareness: The survey demonstrated that the participant's age, educational level, occupation, grade of hospital, and the relationship with the patient had a significant effect on their stroke awareness (P < 0.05–0.01). ② Stroke knowledge: With regard to stroke awareness, 72% subjects did not know the signs indicating the onset of transient ischemic attack; 86%, 72%, and 51% did not know that diabetes, cardiopathy, or smoking and drinking were risk factors for cerebral thrombosis, respectively. With regard to awareness of cerebral thrombosis symptoms, almost 60% did not know the symptoms of vertebrobasilar ischemia, such as dizziness, vomiting, and impaired eyesight. With respect to cerebral thrombosis treatment, 27% reported that when a stroke occurs, they would like to see the doctor subsequent to discussion with their families, or they would even wait a few days. They did not regard their condition as an "emergency".CONCLUSION: Relatives have little knowledge about stroke, but there are significant differences in levels of awareness with respect to occupation and educational levels.     

Stroke and stroke care in China: huge burden, significant workload, and a national priority

At the same time as the world recognizes the rapid economic development in China, Chinese healthcare system has also had significant improvement. However, this nation of 1.4 billion faces tough challenges in treating stroke, the leading cause of death in China. The recently completed Chinese National Stroke Registry has provided new information on the status of stroke epidemiology, diagnosis, management, and prevention strategies in China. In this article, we summarized these new findings, described the effort of providing and improving stroke care, and illustrated the challenges in risk factor modification and secondary stroke prevention. Well-designed epidemiological surveys and clinical trials for stroke prevention and management are still urgently needed in China.     

Latest advances in intracerebral hemorrhage

Despite the fact that intracerebral hemorrhage (ICH) is the deadliest and least treatable of all stroke subtypes, historically researchers have directed most of their efforts toward ischemic strokes. However in the past few years this tendency has been changing, and several studies are showing very interesting results that allow us to believe that in the following years ICH management will change dramatically, paralleling the recent revolution that ischemic stroke treatment experienced in the past decade. Studies offering a better understanding of risk factors, pathophysiology, and treatment will help in primary and secondary prevention and also in developing therapeutic strategies to reduce brain damage. This review comments on some of the most relevant publications during the past year in any field related to ICH.     

The geographical mobility of severely mentally ill residents in London

Background: There is currently great concern over the demands on psychiatric services in metropolitan areas in most developed countries, and this is exemplified in capital cities. These greater demands were not anticipated by those planning psychiatric services and the consequences have led to insufficient beds in many areas. We investigated the geographical mobility (the number of changes of address in the past 2 years) of patients presenting to services in greater London, to determine whether this might be a possible factor in the increased demand. Method: The geographical mobility of the severely mentally ill was determined by taking a random sample of all psychiatric admissions to hospitals serving residents in the London area over the calendar year of 1994 (n=156) and an equivalent sample of patients in an established community mental health team (n=74) in one area (Paddington). The extent of geographical movement was determined for the 2 years prior to interview. Results: Greater geographical movement in the in-patient group was found for those living in inner London compared with outer London and for patients admitted to hospitals outside their catchment area. Twenty-eight percent of the in-patient sample had changed address in the year before admission (including 13% more than once) and 39% had changed address in the 2 years prior to admission. By contrast, the patients seen by the community psychiatric team were less than half as likely to have changed address over the previous year as the in-patients, and none of the community team's patients had changed address more than once over the previous year. The geographically mobile patients had significantly longer periods in hospital than geographically stable patients. Conclusion: Geographical mobility of psychiatric patients in London is high and is particularly marked for those presenting for in-patient treatment. These findings suggest that greater mobility could be one of the most important reasons for the higher than expected demands on psychiatric services and the difficulties in maintaining contact with patients in London in general and inner London in particular. More attention should be paid to geographical mobility as a predictor of psychiatric service use, and it is recommended that it is recorded regularly in information systems. Accepted: 20 January 2000     

Effect of on-admission antiplatelet treatment on patients with cerebral hemorrhage

BACKGROUND: Antiplatelet treatment remains the first choice for primary and secondary prevention of vascular diseases; even so, expected benefits may be offset by risk of bleeding, particularly cerebral hemorrhage. The aim of this study was to assess the influence of antiplatelet treatment on clinical outcome at hospital discharge. MATERIALS AND METHODS: Consecutive patients with first-ever stroke due to a primary intraparenchymal hemorrhage were prospectively identified over a 4-year period (2000-2003). Data on hemorrhage location, vascular risk factors, and antiplatelet and anticoagulant treatment were collected. At discharge, outcome was measured using the modified Rankin Scale (disabling stroke > or =3). Patients treated with anticoagulant therapy were excluded from the study. RESULTS: Of 457 consecutive patients with cerebral hemorrhage, 94 (20.5%) had been taking antiplatelet agents. The treated patients (mean age for antiplatelet group 78.9 +/- 9.0 years) were older than the nontreated patients (73.8 +/- 9.4, p = 0.02). In-hospital mortality was 23.4 and 23.1% (p = n.s.) for patients who had been taking antiplatelet agents or no treatment. Poor outcome at discharge was found in 52.1 and 59.7% (p = n.s.), respectively. Univariate analysis showed that age and coma at admission were predictors of disability at discharge, but antiplatelet treatment was not. Additionally, age and coma were shown to be determinants of disability at discharge after multivariate analysis: OR 1.03 per year (95% CI: 1.018-1.049), p < 0.001 and OR 1.68 (95% CI: 1.138-2.503), p = 0.009, respectively. CONCLUSIONS: Hemorrhagic stroke continues to be responsible for a high percentage of disability and death. Furthermore, it was seen here that functional outcome was independent of previous antiplatelet treatment.     

Standard medical management in secondary prevention of ischemic stroke in China (SMART)

BACKGROUND: Although guidelines for secondary ischemic stroke have been developed, there is a gap between guidelines and clinic practice. AIMS: This study will investigate the current status of secondary ischemic stroke prevention in China, and implement a standard medical program in ischemic stroke and/or transient ischemic attack patients, and to examine the feasibility and efficacy of the program. DESIGN: This is a multicentre, parallel, randomized, open label, controlled trial to evaluate the feasibility and efficacy of a recommended guideline based program (SMART) in secondary stroke prevention. Forty-eight sites across Mainland China will participate in the trial. The number of enrolled patients in the study will be 4074. Primary outcome includes the proportion of patients adherent to eligible measures recommend by the SMART program, which is derived from current prevention guidelines for ischemic stroke, and the proportion of the patients achieving the treatment target. Secondary outcomes include new onset ischemic stroke, hemorrhagic stroke, acute coronary syndrome and all causes of death. The study has been registered on Clinicaltrials.gov (NCT00664846); to date, 3380 patients have been enrolled.     

Latest advances in intracerebral hemorrhage

Despite the fact that intracerebral hemorrhage (ICH) is the deadliest and least treatable of all stroke subtypes, historically researchers have directed most of their efforts toward ischemic strokes. However in the past few years this tendency has been changing, and several studies are showing very interesting results that allow us to believe that in the following years ICH management will change dramatically, paralleling the recent revolution that ischemic stroke treatment experienced in the past decade. Studies offering a better understanding of risk factors, pathophysiology, and treatment will help in primary and secondary prevention and also in developing therapeutic strategies to reduce brain damage. This review comments on some of the most relevant publications during the past year in any field related to ICH.     

Preventing cancer, cardiovascular disease, and diabetes: a common agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association

Collectively, cardiovascular disease (including stroke), cancer, and diabetes account for approximately two thirds of all deaths in the United States and about 700 billion dollars in direct and indirect economic costs each year. Current approaches to health promotion and prevention of cardiovascular disease, cancer, and diabetes do not approach the potential of the existing state of knowledge. A concerted effort to increase application of public health and clinical interventions of known efficacy to reduce prevalence of tobacco use, poor diet, and insufficient physical activity-the major risk factors for these diseases-and to increase utilization of screening tests for their early detection could substantially reduce the human and economic cost of these diseases. In this article, the ACS, ADA, and AHA review strategies for the prevention and early detection of cancer, cardiovascular disease, and diabetes, as the beginning of a new collaboration among the three organizations. The goal of this joint venture is to stimulate substantial improvements in primary prevention and early detection through collaboration between key organizations, greater public awareness about healthy lifestyles, legislative action that results in more funding for and access to primary prevention programs and research, and reconsideration of the concept of the periodic medical checkup as an effective platform for prevention, early detection, and treatment.     

Regional disparities in acute and post-acute care of stroke patients in France, 2015

Objective

The aim of this study was to assess regional variations of the hospital management of stroke patients during acute and post-acute phases in France in 2015.

Incidence,risk factors and prognosis of stroke and TIA: the need for high-quality,large-scale epidemiological studies and meta-analyses

Stroke is a considerable clinical, social and economic burden. In recent clinical trials, a number of strategies have been shown to reduce the risk of stroke and transient ischaemic attack (TIA) in both primary and secondary prevention settings. Whether these treatments are leading to a significant reduction in the incidence of first and recurrent stroke in the clinic, however, remains unclear due to a paucity of high-quality epidemiological data. A similar lack of reliable epidemiological studies has undermined our understanding of the relationship between many potentially important vascular risk factors and stroke risk. Improvement in our knowledge of stroke epidemiology is a prerequisite for the planning of stroke services, the effective application of current stroke prevention strategies, the development of new strategies, and our understanding of the mechanisms of stroke. Future studies must take into account the clinical and pathological heterogeneity of TIA and stroke, and must be powered to allow subtype differences in risk factor relationships and prognosis to be determined reliably. In many cases, this will require meta-analysis of detailed individual patient data from multiple independent studies.     

Aspirin resistance in secondary stroke prevention

BACKGROUND: We investigated the platelet function in stroke patients treated with aspirin [acetylsalicylic acid (ASA)] for secondary stroke prevention during a follow-up period of 1 year. METHODS: In this prospective study 291 patients with first initiated aspirin therapy (300 mg/day) for secondary stroke prevention were included. Platelet aggregation measurements were performed 24 h, 3, 6, and 12 months after starting medication. RESULTS: Twenty-one of 291 patients (7.2%) were identified as primary ASA-non-responders (initial insufficient platelet inhibition) and 4.1% as secondary ASA-non-responders (insufficient platelet inhibition during follow-up). There were no significant differences between ASA-responders and ASA-non-responders concerning age, gender, risk factors, and stroke characteristics. CONCLUSION: Aspirin resistance in stroke patients is not uncommon. The clinical usefulness of routine platelet function tests needs to be proved by further trials.     

Stroke Unit care in Italy. Results from PROSIT (Project on Stroke Services in Italy). A nationwide study

Abstract The future challenge for improving stroke patients’ outcome will be to implement new Stroke Units (SUs) worldwide. However the best SU model remains uncertain. The aim of this study was to evaluate the number of SUs and the quality characteristics of acute stroke care in Italy. We conducted a SU survey in Italy, interviewing the directors of the hospital wards that discharged at least 50 acute stroke patients a year. A SU was defined as an acute ward area with stroke-dedicated beds and staff. To compare the quality of care provided in SUs with that in general wards (GWs) we investigated the characteristics of five domains: hospital setting, unit setting, staffing, process of care and diagnostic investigations. We identified 68 SUs and 677 GWs. Multivariate logistic regression analyses demonstrated that SUs compared to GWs had higher quality scores in unit setting (ROC area=0.9721), staffing (ROC area=0.8760) and care organisation (ROC area=0.7984). The hospital setting (ROC area=0.7033) and the availability of rapid diagnostic investigations (ROC area=0.7164) had lower power in discriminating SU from GW. In Italy in 2003/04 only 9% of the hospital services had organised SU care. The study demonstrated that SUs admitted more than 100 patients per year, had more monitoring equipment and staffing time, and practised multidisciplinary meetings and early mobilisation. The utility of these structural and performance characteristics needs validation from outcome studies.     

Secondary stroke prevention with apixaban in nonvalvular atrial fibrillation: A subgroup analysis of the STANDARD study

BackgroundData on independent risk factors for stroke recurrence in Japanese patients with nonvalvular atrial fibrillation are limited.MethodsWe performed a subgroup analysis of a postmarketing surveillance study of apixaban (STroke prevention ANticoagulant Drug Apixaban Real-world Data study) in Japanese patients with nonvalvular atrial fibrillation receiving oral apixaban (5 mg/2.5 mg twice daily) in routine clinical practice. Patients were categorized into primary and secondary prevention groups based on the absence or presence of a history of ischemic stroke/transient ischemic attack, respectively.ResultsPatients in the secondary prevention group (1101 of 6306 patients [17.5%] analyzed; mean observation period, 15.7 months) had a higher risk of ischemic stroke or hemorrhage than those in the primary prevention group. The incidence rates of major (3.92%/year vs 2.06%/year), intracranial (1.87%/year vs 0.55%/year), and cerebral (1.14%/year vs 0.37%/year) hemorrhage and effectiveness outcomes (ischemic stroke/systemic embolism/transient ischemic attack, 3.25%/year vs 0.57%/year) were significantly higher (all P < 0.001) in the secondary prevention group than in the primary prevention group. Multivariate analysis identified no independent risk factors in the secondary prevention group, while prior major bleeding, alcohol abuse, advanced age, male sex, lower body weight, higher serum creatinine, and antiplatelet drug use were identified as risk factors for major hemorrhage, and advanced age and antiplatelet drug use for effectiveness outcomes in the primary prevention group.ConclusionsAmong Japanese patients with nonvalvular atrial fibrillation who received apixaban, presence of a history of ischemic stroke/transient ischemic attack was associated with higher incidence rates of hemorrhage and thromboembolic events.     

Early detection of first-episode psychosis: the effect on 1-year outcome

Early intervention is assumed to improve outcome in first-episode psychosis, but this has not been proven. OBJECTIVE: To study whether 1-year outcome will be better in a health care sector with early detection (ED) of psychosis compared with sectors with no early detection (no-ED). DESIGN: A quasi-experimental study with ED in 2 experimental sectors and no-ED in 2 control sectors. ED was achieved through low-threshold ED teams and information campaigns about psychosis for the public, schools, and primary health care providers. The ED and no-ED health care areas offered an equivalent assessment and treatment program during the first year. Two hundred and eighty-one patients were included; 88% were reassessed after 1 year. RESULTS: The ED-area patients (N = 141) had a median duration of untreated psychosis of 5 weeks at baseline compared with 16 weeks for patients in the no-ED area (N = 140). Positive and general symptoms, global assessment of functioning, quality of life, time to remission, and course of psychosis at 1 year after the start of treatment were not different between ED and no-ED groups. Outcome was significantly better for the ED area for negative symptoms. CONCLUSIONS: The ED, no-ED differences at baseline become attenuated by 1 year but not the difference in negative symptoms, suggesting secondary prevention in this domain of psychopathology. However, this possibility requires further testing by follow-up and replication.