Effect of socioeconomic status on functional and motor recovery after stroke: a European multicentre study

Background

Previous studies have shown an inverse gradient in socioeconomic status for disability after stroke. However, no distinction has been made between the period in the stroke rehabilitation unit (SRU) and the period after discharge. The purpose of this study was to examine the impact of education and equivalent income on motor and functional recovery for both periods.

Methods

419 consecutive patients were recruited from six SRUs across Europe. The Barthel Index (BI) and Rivermead Motor Assessment (RMA) were measured on admission, at discharge and 6 months after stroke. Ordinal logistic regression models were used, adjusting for case mix. Cumulative odds ratios (OR) were calculated to measure differences in recovery between educational levels and income groups with adjustments for case mix.

Results

Patients with a low educational level were less likely to improve on the BI (OR 0.53; 95% CI 0.32 to 0.87) and the RMA arm during inpatient stay (OR 0.54; 95% CI 0.31 to 0.94). For this period, no differences in recovery were found between income groups. After discharge, patients with a low equivalent income were less likely to improve on all three sections of the RMA: gross function (OR 0.20; 95% CI 0.06 to 0.66), leg and trunk (OR 0.22; 95% CI 0.09 to 0.55) and arm (OR 0.30; 95% CI 0.10 to 0.87). No differences were found for education.

Conclusions

During inpatient rehabilitation, educational level was a determinant of recovery, while after discharge, equivalent income played an important role. This study suggests that it is important to develop a better understanding of how socioeconomic factors affect the recovery of stroke patients.Socioeconomic health inequalities have been studied for a long time but the publication of the Black Report¹ in the UK provoked the attention of policy makers for the existence of important health inequalities² and resulted in an increased awareness of these issues in health care in general.³ At the end of the 20th century, some authors even considered socioeconomic health disparities as the most important public health issue.⁴Stroke is no exception to the general findings on health inequalities. The incidence of fatal and non‐fatal strokes shows an inverse gradient over socioeconomic groups. In an unselected population based sample, Thrift and colleagues⁵ found that the incidence rate of both stroke types was higher in disadvantaged areas. These disparities remain in the post‐acute period. The proportion of patients who are dependent or dead at 6 months after stroke varies between groups of different socioeconomic status (SES). Patients with a lower SES are at greater risk for stroke morbidity and stroke mortality compared with higher SES groups.^6,7 However, these associations were not confirmed by other studies.^8,9 In a recent review by Cox and colleagues¹⁰ it was concluded that the association between SES and morbidity and mortality is well known but that the reasons behind this association are far from clear.The socioeconomic gradient in disability after stroke is also observed in the chronic phase. Patients with lower SES experienced more disabilities up to 3 years post‐stroke compared with the group of patients with a higher SES.¹¹ It remains unclear whether these differences are the result of differences in stroke severity at onset or whether they become more prominent over time.Comparison of results between studies may be difficult because of the different methods used to define SES. Several indicators are used to determine SES (eg, education, income). Various models are used explaining health inequalities, and education and income reflect different dimensions of socioeconomic inequalities in health.¹² The behavioural/cultural explanation is perhaps the most widely used.¹³ This model refers to the more systematic unhealthy behaviours and lifestyle in lower socioeconomic groups, in part related to differences in knowledge or awareness of risks. In this model, distinction between SES groups is often based on educational attainment.¹³ The materialist model tries to explain differences in health between SES groups by material factors (eg, housing, work conditions), and income is mainly used as an indicator for material stratification.¹⁴Apart from the choice of SES indicator, differences in how the selected indicator is measured may hamper comparison between studies and make general conclusions more difficult. For example, the measurement of an indicator can be based on an individual level or at a more aggregated area level. Although individual based indicators are preferred,¹⁵ the availability of data is probably an underestimated factor in how indicators are measured.As most functional recovery is expected to take place in the first 5 months after stroke,¹⁶ stroke rehabilitation units (SRUs) may play an important role in minimising discrepancies between socioeconomic groups. However, the influence of SES on recovery during inpatient stay has not been studied. Moreover, illness trajectories are not often considered in the comparison of functional recovery between socioeconomic groups.¹⁷ To the best of our knowledge, no distinction has been made between recovery during stay in an inpatient SRU and after discharge for different SES groups. Therefore, the aim of this study was to assess the association of education and equivalent income with functional and motor recovery for these two periods.     

The development of the personality in childhood epilepsy with complex-partial seizures

The study presented addresses the association between severity and course of childhood epilepsy with complex-partial seizures and subsequent personality development. Participants in the study were 84 patients first seen when they were 8 years on average. A follow-up examination was conducted about 13 years thereafter. At the first examination about half of the patients showed a psychiatric disorder, another quarter showed developmental delays and 35% were mentally retarded. It could be demonstrated that a high frequency of complex-partial seizures was related to depressive symptoms. However, additional generalized seizures did not further contribute to the severity of psychiatric problems. Patients who continued to show seizures reported less life satisfaction, a more passive attitude and higher emotional instability at follow-up in comparison to patients with a complete remission of epilepsy.     

The fibrinogen gamma (FGG) 10034C>T polymorphism is associated with venous thrombosis

INTRODUCTION: Thrombin-induced conversion of fibrinogen to fibrin plays an essential role in hemostasis and results in the stabilization of thrombi. Elevated plasma fibrinogen levels have been associated with both increased plasma viscosity and platelet aggregability. Recently, a haplotype-tagging single nucleotide polymorphism characterized by a C to T substitution at nucleotide 10034 of the fibrinogen gamma gene (FGG 10034C>T, rs2066865), has been proposed as a novel risk factor for deep venous thrombosis (DVT). Aim of the present study was to provide further data on the role of the FGG 10034C>T polymorphism for DVT. MATERIALS AND METHODS: FGG genotypes were determined by 5'-exonuclease assay (TaqMan) in 358 patients with documented DVT and a total of 783 control subjects. RESULTS: In a multivariate analysis adjusting for age, sex, presence of factor V Leiden and carriage of prothrombin 20210A, homozygosity for the FGG 10034 TT genotype yielded an odds ratio of 2.01 (95% CI 1.23-3.31; p=0.006) for DVT. CONCLUSIONS: Our data confirm the primary finding that the FGG 10034C>T polymorphism is associated with DVT risk.     

If-then planning modulates the P300 in children with attention deficit hyperactivity disorder

Children with attention deficit hyperactivity disorder have difficulties with tasks that require response inhibition. We measured electroencephalographic data of nonmedicated children with attention deficit hyperactivity disorder and control children in two conditions: (a) a neutral condition without a self-regulation strategy and (b) a condition that involved the making of if-then plans (i.e. 'If situation X is encountered, then I will perform the goal-directed behavior Y'). If-then plans improved response inhibition and increased the P300 in children with attention deficit hyperactivity disorder compared with the neutral condition. The present results encourage the application of self-regulation using if-then plans in addition or as an alternative to common medical therapy.     

Prolonged in-vivo half-life of factor VIIa by fusion to albumin

For the treatment of haemophilia patients with inhibitors, recombinant factor VIIa (rFVIIa) is available as a therapeutic option to control bleeding episodes with a good balance of safety and efficacy. However, the short in-vivo half-life of approximately 2.5 hours makes multiple injections necessary, which is inconvenient for both physicians and patients. Here we describe the generation of a recombinant FVIIa molecule with an extended half-life based on genetic fusion to human albumin. The recombinant FVII albumin fusion protein (rVII-FP) was expressed in mammalian cells and upon activation displayed a FVII activity close to that of wild type FVIIa. Pharmacokinetic studies in rats demonstrated that the half-life of the activated recombinant FVII albumin fusion protein (rVIIa-FP) was extended six- to seven-fold compared with wild type rFVIIa. The in-vitro and in-vivo efficacy was evaluated and was found to be comparable to a commercially available rFVIIa (NovoSeven((R))). The results of this study demonstrate that it is feasible to develop a half-life extended FVIIa molecule with haemostatic properties very similar to the wild-type factor.