Determinants of depression in chronic stroke: A prospective cohort study

Purpose. The aim of the study was to identify factors that are significantly related to depression in chronic stroke patients.

Methods. Prospective cohort study of stroke patients admitted for rehabilitation. A total of 165 first ever stroke patients over 18 years of age were assessed at one and three years post stroke. Depression was determined by the Centre for Epidemiologic Studies Depression Scale (CES-D). Patients with scores ≥16 were classified as depressed. Bivariate and multivariate logistic regression analyses were used to identify prognostic factors for depression.

Results. At three years post stroke, 19% of the patients were depressed. Bivariate analysis showed significant associations between post-stroke depression and type of stroke, fatigue, motor function of the leg and arm, activities of daily living (ADL) independency and instrumental ADL. Multivariate logistic regression analysis showed that depression was predicted by one-year instrumental ADL and fatigue. Sensitivity of the model was 63%, while specificity was 85%.

Conclusions. The present prospective cohort study showed that depression three years after stroke can be predicted by instrumental ADL and fatigue one year post stroke. Recognition of prognostic factors in patients at risk may help clinicians to apply interventions aimed at preventing depression in chronic stroke.     

Pain thresholds and tenderness in neck and head following acute whiplash injury: a prospective study

OBJECTIVE OF THE INVESTIGATION: In a 6-month prospective study of 141 consecutive acute whiplash-injured participants, and 40 acute, ankle-injured controls, pain and tenderness in the neck/head, and at a distant control site, were measured. BASIC PROCEDURES: Muscle palpation and pressure algometry in five head/neck muscle-pairs were performed after 1 week and 1, 3 and 6 months after injury. Algometry was performed at a distant control site. MAIN FINDINGS: Whiplash-injured patients had lowered pressure-pain-detection thresholds and higher palpation-score initially in the neck/head, but the groups were similar after 6 months, and the control site was not sensitized. PRINCIPAL CONCLUSION: Focal, but not generalized, sensitization to musculoskeletal structure is present until 3 months, but not 6 months, after whiplash injury, and probably does not play a major role in the development of late whiplash syndrome. Pressure algometry and palpation are useful clinical tools in the evaluation of neck and jaw pain in acute whiplash injury.     

Pain and disability retirement: a prospective cohort study

This study examined the association of pain with subsequent disability retirement due to all causes as well as musculoskeletal diseases, mental disorders, and a heterogeneous group of other diseases and to study whether pain has an effect of its own after taking into account long-standing illness, physician-diagnosed diseases, working conditions, and occupational class, which are the key factors affecting disability retirement. The data consisted of the Helsinki Health Study baseline survey linked to national pension register data (n=6258). Mean follow-up time was 8.1 years. The data included 594 disability retirement events. Pain (acute or chronic) was stratified by long-standing illness (yes/no). Cox regression analysis was performed. Chronic pain without and with co-occurring long-standing illness was strongly associated with all types of disability retirement outcomes, but the associations were particularly strong for disability retirement due to musculoskeletal diseases. The associations remained even when further adjusted for physician diagnosed chronic conditions and diseases, psychosocial and physical working conditions, and occupational class. Associations for acute pain were also found, but they were clearly weaker than those of chronic pain. Chronic pain contributes to disability retirement. Prevention and effective treatment of chronic pain may help prevent early retirement due to disability.     

Pain self-efficacy beliefs and pain behaviour. A prospective study

This study examined the relationship between pain self-efficacy beliefs and a range of pain behaviours, as measured by the pain behaviour questionnaire (PBQ), using a prospective design. A heterogeneous sample of 145 chronic pain patients completed sets of questionnaires on four occasions over a nine-month period. Multiple hierarchical regression analyses revealed that the subjects' confidence in their ability to perform a range of tasks despite pain (assessed at baseline), was predictive of total pain behaviour and avoidance behaviour over the nine-month study period. This finding was particularly significant because the analyses controlled for the possible effects of pain severity (at each measurement occasion), pain chronicity, age, gender, physical disability, depression, neuroticism and catastrophising. These findings suggest that pain self-efficacy beliefs are an important determinant of pain behaviours and disability associated with pain, over and above the effects of pain, distress and personality variables. In particular, higher pain self-efficacy beliefs are predictive of reduced avoidance behaviours over an extended period.     

Outcomes following military traumatic cardiorespiratory arrest: A prospective observational study

Aim

To determine the characteristics of military traumatic cardiorespiratory arrest (TCRA), and to identify factors associated with successful resuscitation.

Methods

Data was collected prospectively for adult casualties suffering TCRA presenting to a military field hospital in Helmand Province, Afghanistan between 29 November 2009 and 13 June 2010.

Results

Data was available for 52 patients meeting the inclusion criteria. The mean age (range) was 25 (18-36) years. The principal mechanism of injury was improvised explosive device (IED) explosion, the lower limbs were the most common sites of injury and exsanguination was the most common cause of arrest. Fourteen (27%) patients exhibited ROSC and four (8%) survived to discharge. All survivors achieved a good neurological recovery by Glasgow Outcome Scale. Three survivors had arrested due to exsanguination and one had arrested due to pericardial tamponade. All survivors had arrested after commencing transport to hospital and the longest duration of arrest associated with survival was 24 min. All survivors demonstrated PEA rhythms on ECG during arrest. When performed, 6/24 patients had ultrasound evidence of cardiac activity during arrest; all six with cardiac activity subsequently exhibited ROSC and two survived to hospital discharge.

Conclusion

Overall rates of survival from military TCRA were similar to published civilian data, despite military TCRA victims presenting with high Injury Severity Scores and exsanguination due to blast and fragmentation injuries. Factors associated with successful resuscitation included arrest beginning after transport to hospital, the presence of electrical activity on ECG, and the presence of cardiac movement on ultrasound examination.     

Pain in multiple sites and sickness absence trajectories: A prospective study among Finns

We studied the number of musculoskeletal pain sites as a predictor of sickness absence during a 7-year follow-up among a nationally representative sample (the Health 2000 survey) of occupationally active Finns 30 to 55 years of age (3420 subjects who did not retire or die during the follow-up). Baseline data (questionnaire, interview, clinical examination by a physician) were gathered in 2000 to 2001 and linked with information from national registers on annual compensated sickness absence periods (?10 workdays) covering the years 2002 to 2008. Pain during the preceding month in 18 body locations was inquired and combined into 4 sites (neck, upper limbs, low back, lower limbs). Demographic factors, BMI, smoking, leisure-time physical activity, sleep disorders, physical and psychosocial workload, and chronic diseases were assessed. Four distinct sickness absence trajectories emerged, labeled as Low (59% of the subjects), Ascending (21%), Mixed (11%), and High (9%). In multinomial logistic regression, the odds ratios (ORs) for belonging to the High vs. the Low trajectory increased with the number of pain sites, being 2.1 for single-site pain, 2.6 for 2 pain sites, 2.9 for 3 pain sites, and 4.1 for 4 pain sites, after adjustment for chronic diseases, demographic and lifestyle factors, and workload. The confidence intervals of the ORs did not include unity. The adjusted ORs for belonging to the Ascending trajectory were 1.1, 1.3, 1.7, and 1.7, respectively. As the number of pain sites was a strong independent predictor of work absenteeism, early screening of workers with multisite pain and interventions to support work ability seem warranted.     

Headache following carotid endarterectomy: a prospective study

The occurrence of headache in the 28 days following surgery was studied in 50 consecutive patients (14F and 36M, mean aged 70 years) who underwent carotid endarterectomy for atheromatous carotid stenosis. Thirty-one patients (62%) reported headache. Headache occurred in the first five days after surgery in 87% of cases. Its characteristics and temporal profile were highly variable but it was mostly bilateral (74%), mild or moderate (78%), requiring no treatment (77%). No correlation was found between the occurrence of headache and degree of stenosis, intraoperative characteristics and past history of headache. In none of our patients was severe ipsilateral headache, cerebral hyperperfusion syndrome, or cluster-like hemicrania encountered and only five patients met the IHS criteria for post-endarterectomy headache. Post-endarterectomy headache is frequent when specifically looked for and is therefore not a single entity. The present IHS criteria are unsatisfactory and should be modified accordingly.     

Longitudinal robustness of variables predicting independent gait following severe middle cerebral artery stroke: a prospective cohort study

OBJECTIVE: To determine within the first 10 weeks post onset the most robust variables in the prediction of recovery of independent gait at six months post stroke. DESIGN: A prospective cohort study. SUBJECTS: One hundred and one first ever ischaemic middle cerebral artery stroke patients. None of these patients were able to walk at onset and all suffered from a marked hemiplegia. SETTING: Twenty-four determinants, possibly related to recovery of gait at six months, were measured within 14 days following stroke onset. Based on Functional Ambulation Categories (FAC) independent gait was classified into present (FAC > or = 4) or absent (FAC < 4). Bivariate logistic regression analysis was used to select determinants. Only significant determinants during the entire 10-week period were used for further weekly multivariate logistic prediction modelling of independent gait at six months post stroke. RESULTS: After six months post onset 62% (N = 63) regained independent gait. Age, Barthel Index, Trunk Control Test, Motricity Index of arm and leg, Brunnstrom Fugl-Meyer stage of leg motor recovery, and type of intervention were significant determinants in bivariate analysis, but age of patient and Barthel Index were the most robust determinants in the final prediction model. Weekly re-evaluation produced sensitivity values between 89% and 96% and specificity values between 53% and 62%. CONCLUSION: In initially non-ambulatory stroke patients age and Barthel Index were the most robust variables during the first 10-week poststroke period in the prediction of independent walking at six months. However, prediction of non-ambulation at six months proved to be less accurate.     

Determinants of depression in chronic stroke: a prospective cohort study

PURPOSE. The aim of the study was to identify factors that are significantly related to depression in chronic stroke patients. METHODS. Prospective cohort study of stroke patients admitted for rehabilitation. A total of 165 first ever stroke patients over 18 years of age were assessed at one and three years post stroke. Depression was determined by the Centre for Epidemiologic Studies Depression Scale (CES-D). Patients with scores >/=16 were classified as depressed. Bivariate and multivariate logistic regression analyses were used to identify prognostic factors for depression. RESULTS. At three years post stroke, 19% of the patients were depressed. Bivariate analysis showed significant associations between post-stroke depression and type of stroke, fatigue, motor function of the leg and arm, activities of daily living (ADL) independency and instrumental ADL. Multivariate logistic regression analysis showed that depression was predicted by one-year instrumental ADL and fatigue. Sensitivity of the model was 63%, while specificity was 85%. CONCLUSIONS. The present prospective cohort study showed that depression three years after stroke can be predicted by instrumental ADL and fatigue one year post stroke. Recognition of prognostic factors in patients at risk may help clinicians to apply interventions aimed at preventing depression in chronic stroke.     

Rehabilitation following a stroke: A participant perspective

Following a stroke in January 1996 the author, a college lecturer, kept notes of his feelings, perceived treatment, and other people's responses to him. This paper reports these especially as they relate to the experience of illness, disability and rehabilitation. Areas covered include the experience of the stroke itself, perceptions of the process, reactions to disability and therapies, and the experience of trying to return to a ‘normal’ life. No claim is made for the uniqueness or significance of this account. It is simply offered as a contribution towards a better understanding of the patient's perspective on disability and rehabilitation.     

Preload-independent mechanisms contribute to increased stroke volume following large volume saline infusion in normal volunteers: a prospective interventional study

Introduction

Resuscitation with saline is a standard initial response to hypotension or shock of almost any cause. Saline resuscitation is thought to generate an increase in cardiac output through a preload-dependent (increased end-diastolic volume) augmentation of stroke volume. We sought to confirm this to be the mechanism by which high-volume saline administration (comparable to that used in resuscitation of shock) results in improved cardiac output in normal healthy volunteers.

Methods

Using a standardized protocol, 24 healthy male (group 1) and 12 healthy mixed sex (group 2) volunteers were infused with 3 l normal (0.9%) saline over 3 hours in a prospective interventional study. Individuals were studied at baseline and following volume infusion using volumetric echocardiography (group 1) or a combination of pulmonary artery catheterization and radionuclide cineangiography (group 2).

Results

Saline infusion resulted in minor effects on heart rate and arterial pressures. Stroke volume index increased significantly (by approximately 15–25%; P < 0.0001). Biventricular end-diastolic volumes were only inconsistently increased, whereas end-systolic volumes decreased almost uniformly. Decreased end-systolic volume contributed as much as 40–90% to the stroke volume index response. Indices of ventricular contractility including ejection fraction, ventricular stroke work and peak systolic pressure/end-systolic volume index ratio all increased significantly (minimum P < 0.01).

Conclusion

The increase in stroke volume associated with high-volume saline infusion into normal individuals is not only mediated by an increase in end-diastolic volume, as standard teaching suggests, but also involves a consistent and substantial decrease in end-systolic volumes and increases in basic indices of cardiac contractility. This phenomenon may be consistent with either an increase in biventricular contractility or a decrease in afterload.