Perception of stroke in Croatia – knowledge of stroke signs and risk factors amongst neurological outpatients

Background and purpose:  The aim of this hospital-based survey was to determine baseline stroke knowledge in Croatian population attending the outpatient services at the Department of Neurology.
Methods:  A multiple choice questionnaire was designed, divided into three sections: (i) demographic data, (ii) knowledge of stroke risk factors and stroke signs and (iii) actions the patients would undertake if confronted with risk of stroke and information resources regarding health.
Results:  The analysis included 720 respondents (54.9% women). The respondents most frequently indicated stroke symptoms as following: speech disorder 82%, paresthesiae on one side of the body 71%, weakness of arm or leg 55%, unsteady gait 55%, malaise 53%, monocular loss of vision 44%. The risk factors most frequently identified were hypertension 64%, stress 61%, smoking 59%, elevated lipids 53%, obesity 52%, coagulation disorder 47%, alcoholism 45%, low-physical activity 42%, elderly age 39%, cardiac diseases 38%, weather changes 34%, drugs 33% and diabetes 32%. If confronted with stroke signs 37% of respondents would consult the general practitioner and 31% would call 911 or go to a neurologist. Amongst patients with a risk factor, only diabetics were aware that their risk factor might cause stroke ( P  < 0.001). Respondents with lowest education had the least knowledge regarding stroke signs ( P  < 0.01).
Discussion:  The results of this study indicate that respondents showed a fair knowledge about stroke signs and risk factors for stroke. The results of our study will help to create and plan programmes for improvement of public health in Croatia.     

Impact of seizures on morbidity and mortality after stroke: a Canadian multi-centre cohort study

Introduction:  Limited information is available about the impact of seizures on stroke outcome, health care delivery and resource utilization.
Objective:  To determine whether the presence of seizures after stroke increases disability, mortality and health care utilization (length of hospital stay, ICU admission, consults, discharge to a long-term care facility).
Methods:  This cohort study included consecutive patients with acute stroke between July 2003 and June 2005 from the Registry of the Canadian Stroke Network (RCSN), the largest clinical database of patients in Canada with acute stroke seen at selected acute care hospitals. We compared clinical characteristics and outcomes amongst patients experiencing stroke without and with seizures occurring during inpatient stay. Main outcome measures included: case-fatality, disability at discharge, length-of-stay, and discharge disposition. A logistic regression analysis was used to determine whether the presence of seizures was associated with poor stroke outcomes.
Results:  Amongst 5027 patients included in the study; seizures occurred in 138 (2.7%) patients with stroke. Patients with seizures had a higher mortality at 30-day (36.2% vs. 16.8%, P  < 0.0001) and at 1-year post-stroke (48.6% vs. 27.7%, P  < 0.001), longer hospitalization, and greater disability at discharge ( P  < 0.001). Multivariate analysis revealed that stroke severity, hemorrhagic stroke, and presence of neglect were associated to occurrence of seizures after stroke.
Conclusions:  The presence of seizures after stroke was associated with increased resources utilization, length of hospital stay, whilst decreasing both 30-day and 1-year survival. Quality improvement strategies targeting patients with seizures may help optimize the management of this subgroup of more disabled patients.     

Child and Adolescent Mental Health within Primary Care: A Study of General Practitioners' Perceptions

Background:  Primary Care teams play an important role in the provision of mental health care to children and young people.
Methods:  We developed and distributed a questionnaire to all General Practitioners within one Health Authority area.
Results:  Many of the respondents rated as less than satisfactory their competence and their knowledge and skills in important areas of child and adolescent mental health practice. A significant minority expressed a high level of interest in child and adolescent mental health and most respondents reported that they would value further training.
Conclusions:  General Practitioners should be provided with more training and support in their role as providers of child and adolescent mental health care.     

An educational multimedia campaign improves stroke knowledge and risk perception in different stroke risk groups

Background and purpose:  Stroke risk factor knowledge and individual risk perception are low in the general public. Our study aimed at identifying the educational effects of a multimedia campaign on stroke knowledge and risk perception in several subgroups at increased risk of stroke.
Methods:  Telephone surveys were administered in a random sample of 500 members of the general public, before and immediately after an intense 3 months educational campaign using various mass and print media.
Results:  A total of 32.7% of respondents considered themselves as being at risk of stroke before, and 41.9% ( P  < 0.01) after the intervention. Evaluation of stroke risk increased with number of appreciated individual stroke risk factors. Knowledge of different stroke risks varied considerably and proved to be especially high in obese individuals (98.7%) and smokers (97.9%) and particularly low in patients with coronary heart disease (80.6%).
Conclusions:  Our data indicate that educational programs and the introduction of stroke risk factors can increase stroke risk perception in the public. Even though some risk groups (smokers, obese) reveal a ceiling effect, future campaigns should focus on high risk populations remarkably underrating their risk, like those with coronary heart disease or the elderly.     

Comparison of the characteristics for in-hospital and out-of-hospital ischaemic strokes

Background and purpose:  Patients who are being admitted to a hospital due to diseases other than stroke may develop a stroke (in-hospital stroke; IHS).
Methods:  We enrolled 111 consecutive patients who developed IHS outside a neurology ward during a 5-year period at a single hospital. The frequency, characteristics, and outcomes for IHS patients were compared with patients who develop ischaemic stroke outside of the hospital (out-of-hospital stroke; OHS).
Results:  Forty-six percent of IHS occurred in the department of cardiology or cardiovascular surgery and 60% were associated with surgery or procedures. In comparison with the OHS patient group, the IHS patient group showed an increased frequency of cardiac disease, leukocytosis, and anemia. Cardioembolism, stroke of other determined etiologies, and an incomplete evaluation were more common in the IHS group, whereas large artery atherosclerosis was more frequent in the OHS group. The IHS group had up to a 10-fold higher mortality than the OHS group, with sepsis being the most common cause of death in the IHS group.
Conclusions:  IHS has distinct etiologies and stroke mechanisms from OHS. The prevention and management of infection could decrease mortality in IHS patients.     

Intravenous thrombolysis in stroke patients with hyperdense middle cerebral artery sign

Background and purpose:  We assessed the safety and efficacy of intravenous thrombolysis (IVT) in acute stroke patients with hyperdense middle cerebral artery sign (HMCAS).
Patients and methods:  Data from consecutive patients with acute (within 6 h of symptom onset) ischaemic stroke admitted between January 1999 and November 2007, in whom HMCAS was diagnosed on admission CT scan was retrospectively analysed. Seventy-one patients, admitted within the 3-h window, were treated with IVT, whilst further 42, admitted 3–6 h after symptom onset, were not. At 3-month clinical follow-up, outcome, mortality at 3 months and incidence of symptomatic intracranial haemorrhage were evaluated.
Results:  The two groups were comparable concerning age, stroke risk factors, prior antithrombotic treatment and NIHSS scores on admission. Good outcome (mRS score ≤ 1) was observed in 12/71 (17%) patients who were treated with IVT and in 1/42 (2%) patients who were not ( P  = 0.02). IVT treatment was identified as independent predictor of good outcome ( P  = 0.05). Mortality was 20% in patients treated with IVT and 12% in remaining patients ( P  = 0.3). Symptomatic intracranial haemorrhage occurred in 1 patient of each group (2%).
Conclusions:  These findings suggest that IVT in patients with HMCAS results in significantly better outcome, without significantly influencing mortality.     

The last days of dying stroke patients referred to a palliative care consult team in an acute hospital

Background and purpose:  Needs of patients dying from stroke are poorly investigated. We aim to assess symptoms of these patients referred to a palliative care consult team, and to review their treatment strategies.
Methods:  All charts of patients dying from stroke in a tertiary hospital, and referred consecutively to a palliative care consultant team from 2000 to 2005, were reviewed retrospectively. Symptoms, ability to communicate, treatments, circumstances and causes of death were collected.
Results:  Forty-two patients were identified. Median NIH Stroke Scale on admission was 21. The most prevalent symptoms were dyspnoea (81%), and pain (69%). Difficulties or inability to communicate because of aphasia or altered level of consciousness were present in 93% of patients. Pharmacological respiratory treatments consisted of anti-muscarinic drugs (52%), and opioids (33%). Pain was mainly treated by opioids (69%). During the last 48 h of life, 81% of patients were free of pain and 48% of respiratory distress. The main causes of death were neurological complications in 38% of patients, multiple medical complications in 36%, and specific medical causes in 26%.
Conclusions:  Patients dying from stroke and referred to a palliative care consult team have multiple symptoms, mainly dyspnoea and pain. Studies are warranted to develop specific symptoms assessment tools in non-verbal stroke patients, to accurately assess patients' needs, and to measure effectiveness of palliative treatments.     

What Makes a Good CAMHS Primary Mental Health Worker?

Background:  The role of primary mental health worker (PMHW) in CAMHS was established in 1995 although comparatively little research has explored the attributes required to successfully undertake this role.
Method:  Qualitative interviews with PMHWs and staff working in primary care were conducted and thematic analysis was performed.
Results:  In addition to clinical skills and mental health knowledge all respondents consistently emphasised the importance of inter-personal attributes such as general accessibility, flexibility, and self-motivation.
Conclusions:  Both professional competencies and inter-personal skills are perceived as important characteristics for PMHWs. It therefore seems appropriate for these to be made more explicit in competency frameworks.     

The classic lacunar syndromes: clinical and neuroimaging correlates

Background:  Although lacunar syndromes (LSs) are aimed to be linked to lacunar infarcts, the relation between both is still not very well defined.
Purpose:  The present retrospective study tries to define more specifically the clinical and the neuroimaging characteristics of the five most classic LSs.
Patients and methods:  Out of a series of 1617 consecutive stroke patients, admitted to the Ghent University Hospital, 293 presented a classic LS. Magnetic resonance imaging (MRI) with diffusion-weighted imaging (DWI) was performed within 5 days after stroke onset in 227 patients. An acute territorial infarct was demonstrated in 54 patients. The study population finally consisted of 173 patients with a classic LS in whom the responsible lacune was demonstrated or in the absence of another type of infarct.
Results:  The responsible lacune was demonstrated with DWI in 104 patients. Pure motor stroke (MS) correlated significantly with the presence of the responsible lacune in the internal capsule ( P  = 0.000147) and with the stroke severity ( P  = 0.00724). No significant correlation was observed between the location of the lacunes and the other LS's.
Conclusion:  Pure MS has to be considered as the most specific lacunar syndrome.     

Cause of death in patients with dementia disorders

Background:  Investigations on cause of death may provide valuable information about life expectancy and on conditions of terminal dementia care, which perhaps can be ameliorated.
Methods:  The autopsy reports were studied on all patients ( n  = 524; 55.3% females; median age 80 years) with a clinically and neuropathologically diagnosed dementia disorder who underwent a complete autopsy at the University Hospital in Lund, Sweden, during 1974–2004.
Results:  The two most common causes of death were bronchopneumonia (38.4%) and ischaemic heart disease (23.1%), whilst neoplastic diseases were uncommon (3.8%). In a general population of elderly studied for comparison, bronchopneumonia accounted for 2.8%, ischaemic heart disease for 22.0%, and neoplasm for 21.3% of the deaths. Amongst the demented patients, circulatory and respiratory system diseases were the causes of death in 23.2% and 55.5% of the Alzheimer patients, respectively, whilst the corresponding figures were 54.8% and 33.1% for the patients with vascular dementia.
Conclusions:  In patients with dementia, pneumonia as the immediate cause of death may reflect a terminal stage in which patient care and feeding is difficult to manage well. Knowledge about what actually causes death is of value in the terminal care of patients with dementia disorders.     

Developing Services with Limited Resources: Establishing a CAMHS in Pakistan

Background:  There are very few mental health services in Pakistan. In 2002, the Department of Psychiatry at Aga Khan University Hospital started a separate clinic for children under the age of 15 years to meet the population needs. This service took direct referrals from other physicians as well as from parents and schools.
Method:  A DSM-IV based semi-structured interview with a uniform written format was used for an initial evaluation by a child psychiatrist. Data regarding demographic characteristics, referral source, diagnoses and treatment were collected.
Results:  A total of 290 new referrals were made to the clinic over 3 years. The most common reason for referral was aggressive behaviour, although this possibly masked other kinds of mental health problems, as indicated by the assessment. Attention deficit-hyperactivity disorder was the most frequent diagnosis, made in 25% of children.
Conclusions:  Despite the limited resources and the high level of need in developing countries, resources can be used effectively within the framework of their health and educational systems, so maximising protective factors within their communities.     

Community-based education improves stroke knowledge

BACKGROUND AND PURPOSE: Despite advances in stroke therapy, the public remains uninformed about stroke, and few stroke patients present to the hospital in time to receive treatment. Health education campaigns can increase community awareness and may decrease time to hospital presentation among stroke patients. METHODS: We conducted a community-based education campaign utilizing television and newspapers to inform the residents of King County, Wash., USA, about stroke and the need to call 911. The effectiveness of the campaign was assessed, using a pretest-posttest design, through telephone interviews with residents of King County. RESULTS: Prior to the education campaign, 59.6% of persons in King County could name a risk factor for stroke, but only 45.2% knew that the brain was the organ of injury. And while 68.2% of persons stated that they would call 911 in the event of stroke, only 38.6% could name a symptom of stroke. The knowledge deficit was greatest among Asian-Americans, men, the less educated and low-income residents. There was a significant increase in stroke knowledge following the education campaign; respondents were 52% (p = 0.005) more likely to know a risk factor for stroke and 35% (p = 0.032) more likely to know a symptom of stroke after the campaign. CONCLUSIONS: Baseline knowledge about stroke among the public is poor, but can be increased through public education campaigns.     

Public perception of stroke in Spain

BACKGROUND AND PURPOSE: Stroke is one of the leading causes of death and disability in western countries. Improving attention to stroke demands better public information about the illness. The aim of the present study was to determine the current knowledge of stroke among the Spanish population. METHODS: We conducted a population-based telephone interview in Spain. A total of 3,000 respondents were selected at random following a systematic procedure aimed at filling the sex/age community quotas. RESULTS: A total of 16,016 telephone calls were made. Three thousand respondents were eligible and 2,884 completed the telephone interview. Only 4.5% of respondents knew the term stroke, 1,719 (59.6%) participants were able to mention at least one stroke risk factor, and only 940 (32.6%) could mention at least one stroke sign without prompting. Most respondents considered stroke to be a severe and dangerous illness that can be treated, but less than half of the respondents went immediately to a hospital when faced with a stroke event. Suitable stroke knowledge was only achieved by 302 (10.5%) respondents. Those who had home-based occupations and no previous stroke experience were less likely to have suitable stroke knowledge. CONCLUSIONS: This study confirms that our community is still unfamiliar with stroke. Wide population-based educational programs are needed to increase public knowledge of stroke. Our results indicate that people with home-based occupations should be the main target of our education campaigns.     

Vascular risk factor awareness before and pharmacological treatment before and after stroke and TIA

Background and purpose:  Educating the public to screen for vascular risk factors and have them treated is a major public health issue. We assessed the vascular risk factor awareness and frequency of treatment in a cohort of patients with cerebral ischaemia.
Methods:  Data on awareness and pharmacological treatment of vascular risk factors before hospital admission of patients with confirmed ischaemic stroke/transient ischaemic attack (TIA) were analyzed. A follow-up questionnaire assessed the frequency of treatment 1 year after discharge and assessed non-adherence to antithrombotic medication.
Results:  At time of stroke/TIA, individual awareness regarding existing hypertension, diabetes, hyperlipidemia and atrial fibrillation (AF) was 83%, 87%, 73% and 69% respectively ( n  = 558). Pharmacological treatment for hypertension, diabetes, hyperlipidemia and AF was being administered in 80%, 77%, 37% and 62% of patients aware of their conditions. The follow-up was completed by 383 patients (80% recall rate): of the patients with hypertension, diabetes, hyperlipidemia and AF, 89%, 78%, 45% and 86% were receiving risk factor targeted medication. This represents a significant increase concerning AF and hyperlipidemia. Non-adherence to recommended antithrombotics (15%) was higher in patients who had had a TIA.
Conclusions:  All risk factors leave room for improvement in screening and treatment efforts. Adherence to treatment is higher for hypertension and diabetes than for hyperlipidemia. Education efforts should bear in mind less well recognized risk factors.     

Gender Differences and Mental Health: An Exploratory Study of Knowledge and Attitudes to Mental Health Among Scottish Teenagers

Method:  A cross-sectional survey of 496 teenagers was conducted in order to explore their knowledge and attitude towards mental health and people with mental health problems.
Results:  Boys reported lower levels of knowledge and different sources of stress than girls. Negative attitudes were more common among boys than girls. Boys were less likely to think that an understanding of mental health was important, less likely to want to know more about mental health issues and twice as likely to think that they had already been given enough education.
Conclusion:  Gender specific educational interventions may be more appropriate and effective than whole school approaches.     

Public Stroke Knowledge,Awareness, and Response to Acute Stroke in Isfahan Iran: What is Less or Misinterpreted in Developing Countries

BackgroundConsidering the high burden of stroke in developing countries, it is important for the community to have adequate information and awareness of this disease. In this study, the baseline knowledge of an Iranian population towards stroke has been evaluated.MethodThis study was conducted in a governmental hospital in Isfahan, Iran. The participants were selected from the companions of non-cardio-vascular hospitalized patients. A self-administered questionnaire was designed for gathering informationResultsA total of 630 questionnaires were analysed. Hypertension and stress were the most frequently identified risk factors (recognised by 83.7% and 75.8% respectively), while pregnancy, oral contraceptives, and anti-coagulants were the least (recognised by 3.5%, 14.2% and 15.8% respectively). Knowledge of other important risk factors such as cardiac diseases was also relatively low (39.4%). Sudden visual difficulties and irrelevant speech were the least identified warning signs of stroke (45.3% and 34.6% respectively), however, knowledge towards all other warning signs was moderately good (each identified by 60-70%). Importantly only 44.2% of respondents were aware that stroke treatment should be started within the first 3 hours. Participants tended to have moderately good insight of most stroke complications and rehabilitation (60-70%). Urban residence, high level of education and knowing someone with a history of stroke were significant predictors of a higher level of stroke awareness.ConclusionThe findings of this study indicate that there is a need to improve general knowledge of cardiac and hypercoagulable related risk factors. Furthermore, understanding of the importance of time critical stroke management and the ineffectiveness of traditional medicine needs to be raised in the general community.     

Stroke literacy in the population of the Eastern Province of Saudi Arabia; immediate steps are essential to bridge the gap

Background and purposeStroke is a medical emergency that demands early recognition for time sensitive acute management. Knowledge about stroke in public has not been found satisfactory in most of the studies worldwide. Studies describing the awareness of public about recognition of stroke and its treatment from Saudi Arabia (SA) are deficient. This study aimed to assess the knowledge of general population living in the Eastern Province of SA about stroke in relation to recognition of warning signs, risk factors and available acute treatment.MethodsA prospective, cross sectional study was conducted using a structured questionnaire distributed through an electronic web site over a period of six months. The data was analyzed with SPSS version 22.0.ResultsAmong a total of 1,213 respondents, 62.4% were women. Three fourth identified the affected organ correctly. Psychological stress was the most commonly identified risk factor (73.5%) followed by hypertension (63.8%). More than half of the respondents (58.5%) were not aware of diabetes mellitus as a risk factor for stroke. Speech difficulty was the most commonly identified stroke warning sign (64.4%) followed by focal weakness (62.4%). More than half (59.9%) did not recognize facial asymmetry as stroke warning sign. Nearly three fourth of the participants were unaware of t-PA (73.7%) and nearest available health care center for acute stroke management (74.9%).ConclusionOur survey found the stroke literacy in the population of the Eastern Province of SA as non- satisfactory and highlights the importance of taking immediate measure such as mass media campaign and hospital based activities to improve it.     

Sexuality and personal relationships for people with an intellectual disability. Part I: service-user perspectives

Background   Despite a recent ideological shift towards the recognition of sexual autonomy for people with an intellectual disability (ID), there are continuing social and cultural barriers to sexual expression. Part I of the current two-part study assessed the sexual knowledge, experiences and aspirations of service users through focus groups and also examined their perceptions of impediments to achieving sexual autonomy.
Method   Thirty-two participants (20 male, 12 female) attending an ID service participated in focus groups delineated by gender and age group (13–17 years; 18–30 years; 31+ years).
Results   Analysis of the focus groups showed that service users, especially those over the age of 18 years, had an understanding of their sexual rights but also identified a number of social and cultural barriers that they felt prevent them from achieving sexual autonomy. Those under the age of 18 years had only rudimentary knowledge of sexuality issues, for example pregnancy and sexual anatomy, but aspired to relationships and marriage similar to those over the age of 18 years. Family and staff attitudes appeared to be very influential in the views of respondents. All service users had received some form of sex education, although the benefits of such education appeared most enduring for those over 18 years.
Conclusion   Service users had an understanding of their sexual rights and the social and environmental barriers that prevent them from fulfilling their rights. The provision of sex education training and promotion of positive attitudes towards appropriate sexual expression is critical to the realization of sexual autonomy for people with an ID.     

Disparities in epilepsy: Report of a systematic review by the North American Commission of the International League Against Epilepsy

Purpose:   We undertook a systematic review of the evidence on disparities in epilepsy with a focus on North American data (Canada, United States, and the English-speaking Caribbean).
Methods:   We identified and evaluated: access to and outcomes following medical and surgical treatment, disability, incidence and prevalence, and knowledge and attitudes. An exhaustive search (1965–2007) was done, including: (1) disparities by socioeconomic status (SES), race/ethnicity, age, or education of subgroups of the epilepsy population; or (2) disparities between people with epilepsy (PWE) and healthy people or with other chronic illnesses.
Results:   From 1,455 citations, 278 eligible abstracts were identified and 44 articles were reviewed. Comparative research data were scarce in all areas. PWE have been shown to have lower education and employment status; among PWE, differences in access to surgery have been shown by racial/ethnic groups. Aboriginals, women, and children have been shown to differ in use of health resources. Poor compliance has been shown to be associated with lower SES, insufficient insurance, poor relationship with treating clinicians, and not having regular responsibilities.
Discussion:   Comprehensive, comparative research on all aspects of disparities in epilepsy is needed to understand the causes of disparities and the development of any policies aimed at addressing health disparities and minimizing their impact.     

Prevalence of disabling spasticity 1 year after first-ever stroke

Objective:  To estimate the prevalence of disabling spasticity (DS) 1 year after first-ever stroke.
Design:  Cross-sectional survey 1 year after first-ever stroke.
Methods:  Patients above 18 years from one county with first-ever stroke were identified by use of the national stroke registry. A representative sample of 163 patients was created and 140 of these were followed up. Assessments of motor function and ability with the modified Ashworth Scale, the modified Rankin Scale (mRS), the Barthel Index (BI) and clinical evaluation were performed in order to identify patients with spasticity-related disability.
Results:  The observed prevalence of any spasticity was 17% and of DS 4%. Patients with DS scored significantly worse than those with no DS on the mRS ( P  = 0.009) and the BI ( P  = 0.005). DS was more frequent in the upper extremity, correlated positively with other indices of motor impairment and inversely with age. There was an independent effect of severe upper extremity paresis (OR 22, CI 3.9–125) and age below 65 years (OR 9.5, CI 1.5–60).
Conclusions:  The prevalence of DS after first-ever stroke is low but corresponds to a large number of patients and deserves further attention with regards to prevention and treatment .