Treatment of acute ischemic stroke: does it impact neuropsychiatric outcome?

Stroke is a leading cause of disability globally. Although neuropsychiatric symptoms are produced by stroke and adversely effect stroke outcome, it is unclear whether neuropsychiatric outcome can be improved by acute stroke treatment. The authors reviewed published acute ischemic stroke treatment trials to determine whether neuropsychiatric outcome measures were employed. Of the 190 trials reviewed, only seven included specific measures of neuropsychiatric outcome, usually a short test of cognition or mood. Further studies are needed to determine the potential benefits of acute stroke treatment on both poststroke neuropsychiatric symptoms and the relationship between such symptoms and stroke outcome.     

Menstrual migraine: what it is and does it matter?

Journal of Neurology - The diagnostic criteria of menstrual migraine (MM), migraine related to menstruation and pure menstrual migraine, are placed in the appendix of the International...     

Policy-relevant research: When does it matter?

Evidence-based medicine is most meaningful to policy makers when research questions are clearly informed by strategic health policy questions. In Washington State workers’ compensation, key structural characteristics allow for the conduct of effective policy-relevant research. These include clear authority and a stable funding stream, a formal relationship between a policy agency and a University, development of appropriate research capacity, development of research questions related to strategic goals, and a robust data source. The research conducted relies on computerized medical bills and work disability records, medical records, structured telephone surveys to collect data on pain, functional status, quality of life, and computerized data on employment status. The types of policy-relevant research include identification of factors leading to preventable disability, outcomes research of specific procedures, technology assessment, and “real-time” research that addresses rapidly emerging questions. Health policy changes implemented from research have been substantial in Washington State workers’ compensation, including: 1) noncoverage or partial coverage decisions for emerging technologies not proven to be of value to injured workers, 2) formal treatment guidelines and utilization review criteria for invasive, expensive, or marginally effective procedures, 3) disability prevention efforts, and 4) relatively rapid changes in policy as emerging patterns suggest harmful outcomes from existing treatments (e.g., schedule II opioids). Key structural characteristics must be in place to conduct policy-relevant research effectively. The workers’ compensation system in Washington State is a single-payer system with other unique properties that have allowed the emergence of these structural characteristics and the conduct of research linked to the strategic goals of policy makers.     

Trials of thrombolysis in acute ischemic stroke: does the choice of primary outcome measure really matter?

BACKGROUND AND PURPOSE: Controversy regarding the risks and benefits of thrombolysis has not been helped by the perception that some trials were "positive" and others "negative" on their primary outcome measure of either "good" or "poor" functional outcome. We wondered whether the definition of good or poor functional outcome might have contributed to this perception, and what effect altering the definition might have on the individual trials and on the systematic review of all the trials combined. METHODS: We analyzed data on functional outcome, extracted from the randomized trials of thrombolysis in acute ischemic stroke, according to good (modified Rankin scale scores of 0 to 1 versus 2 to 6) and poor (modified Rankin 0 to 2 versus 3 to 6) functional outcome, to determine the effects of thrombolysis. RESULTS: Twelve trials (4342 patients, treated up to 6 hours after stroke) contributed to this analysis. Overall, there was no difference in the estimate of treatment effect between the 2 definitions (modified Rankin 0 to 2 versus 3 to 6, and 0 to 1 versus 2 to 6 [ORs 0.83 and 0.79, respectively]). However, the apparent "success" of several individual trials did alter. CONCLUSIONS: We should not place undue emphasis on the results of individual trials, when a change of a single point on the Rankin scale can make the difference between "success" and "failure." Overall, by either analysis, there was a significant benefit in patients treated with thrombolysis up to 6 hours after stroke.     

CT angiography in acute stroke: does it provide additional information on occurrence of infarction and functional outcome after 3 months?

OBJECTIVE: To investigate whether acute phase intracranial CT angiography (CTA) independently predicts infarction and functional outcome in ischemic stroke. METHODS: Hundred and fifty-one consecutive patients with acute (<12 h) ischemic stroke who received intracranial CTA were investigated. Stroke severity on admission was determined using the National Institute of Health Stroke Scale (NIHSS). Reconstructed CTAs were investigated for relevant pathology. Follow-up imaging was performed 24-48 h after admission. Functional outcome was assessed after 3 months using the modified Rankin scale. Single factor and multiple logistic regression analyses were performed to predict infarction and dependency (modified Rankin scale > or = 3) on follow-up. RESULTS: Median NIHSS on admission was 10 (IQR 3-14). Out of the 151 patients, 61 (40%) had pathological CTA findings. Infarction was demonstrated in 60/61 patients (98%) with and in 67/90 patients (74%) without vessel pathology. Presence of infarction on follow-up imaging and dependency at 3 months were correlated with pathological CTA findings on admission in single factor analysis (each p < 0.001). After adjustment for age (> or =/<65 years), NIHSS (> or =/<10), sex, therapy, and time to presentation (> or =/<3 h), only NIHSS > or = 10 on admission was predictive of dependency at follow-up (p < 0.001). CONCLUSIONS: Pathological CTA findings in the acute phase of ischemic stroke do not independently predict a poor outcome at 3 months after acute stroke.     

Adding consumer-providers to intensive case management: does it improve outcome?

OBJECTIVE: Over the past decade, there has been increasing interest in the employment of mental health consumers in various roles as providers of services. Although integration of consumers into case management services has been studied, the roles of consumers have been poorly defined and the benefits have not been established. The goal of this study was to evaluate whether consumers enhance case management outcome through the provision of social support. METHODS: This study compared consumer-assisted and non-consumer-assisted case management with standard clinic-based care. The consumer role focused on the development of social support by using peer staff who matched the profile of participants. A total of 203 clients with severe and persistent mental illness were randomly assigned to one of the three conditions and followed for 12 months. RESULTS: All three programs yielded the same general pattern of improvement over time for symptoms, health care satisfaction, and quality of life. Clients in the three programs also showed similar but small changes in measures of social network behavior. Consumer-assisted case management was unique in its use of peer-organized activities. Non-consumer-assisted case management made greater use of individual contacts with professional staff. Standard clinic-based care relied more on group and on individual therapy. Despite these variations in the pattern of services over a 12-month period, no one program emerged as categorically superior to the others. CONCLUSIONS: Although more research is needed to determine optimal roles for consumers in mental health service delivery, a randomized trial found no evidence that the presence of consumers enhances case management outcome.     

Female sexual dysfunction in multiple system atrophy: does it matter?

Clinical Autonomic Research -