bluuebunny/crossref_metadata_2025 huggingface dataset:
Plasma Homocysteine Levels and Atherosclerosis in Japan
Authors: Adachi Hisashi , Hirai Yuji , Fujiura Yoshihisa , Matsuoka Hidehiro , Satoh Akira , Imaizumi Tsutomu
Published: September 2002

Background and Purpose—

We examined whether hyperhomocysteinemia is an independent risk factor for increased carotid artery intimal-medial wall thickness (IMT) in a large, randomly selected community in Japan where the dietary habit is different and the incidence of coronary artery disease is lower compared with those of western countries.

Methods—

In 1111 cases (452 men, 659 women) aged 63±10 years old (range, 40 to 94 years) recruited from a population-based survey performed in 1999, we measured fasting plasma total homocysteine levels and performed bilateral carotid B-mode ultrasound. The participants underwent measurements of other blood chemistries (total cholesterol, HDL cholesterol, glycosylated hemoglobin A
1c
, and creatinine).

Results—

For the total population, the mean total homocysteine level was 10.9 μmol/L. Total homocysteine levels were higher in men than in women and increased with aging. With multiple linear regression analysis after adjustments for age and sex, the most powerful determinant of total homocysteine levels was serum creatinine (
P
<0.001). With multiple stepwise regression analysis after adjustments for age, sex, and other confounding factors, total homocysteine was significantly (
P
<0.05) related to IMT. Furthermore, when mean values of IMT adjusted for age, sex, and other related factors were analyzed across total homocysteine quartiles, IMT (
P
<0.05) showed a significant trend as total homocysteine level increased.

Conclusions—

Plasma total homocysteine levels in Japan are similar to those reported in western countries. Mild hyperhomocysteinemia is an independent risk factor for increased carotid artery wall thickness in Japan as well.
Ultrastructural Connective Tissue Aberrations in Patients With Intracranial Aneurysms
Authors: Grond-Ginsbach Caspar , Schnippering Holger , Hausser Ingrid , Weber Ralf , Werner Inge , Steiner Hans H. , Lüttgen Nina , Busse Otto , Grau Armin , Brandt Tobias
Published: September 2002

Background and Purpose—

An unknown connective tissue defect might predispose for the development and rupture of intracranial aneurysms in some patients. This study of connective tissue samples of a series of patients with intracranial aneurysms investigates the morphology of the extracellular matrix with methods that are currently used in the routine diagnosis of inherited connective tissue disorders.

Methods—

Skin biopsies from 21 patients with intracranial aneurysms, many with multiple aneurysms, were studied by electron microscopy. None of the patients included in this study showed clinical signs of a known connective tissue disorder.

Results—

In 7 patients (33%), we observed repetitive aberrations in the morphology of collagen fibrils and elastic fibers of the reticular dermis. The observed ultrastructural findings were somewhat similar to those typically observed in patients with Ehlers-Danlos syndrome (EDS) and in a subgroup of patients with spontaneous cervical artery dissections. The patterns of abnormalities fell into 2 classes: 4 patients displayed abnormalities that resembled those found in patients with EDS type III, and the electron microscopic findings in the skin biopsies from 3 patients resembled those of EDS type IV patients. The sequence of the COL3A1 gene from the patients with EDS type IV–like alterations of the connective tissue morphology was analyzed. No mutation was detected.

Conclusions—

Connective tissue alterations were found in skin biopsies from a minority of patients with intracranial aneurysms. Electron microscopic investigation of skin biopsies from patients and their relatives might become valuable for clinical diagnostics, identification of persons at risk, and basic studies of the pathogenesis of this vascular disease.
Attenuation of Cerebral Vasospasm After Subarachnoid Hemorrhage in Mice Overexpressing Extracellular Superoxide Dismutase
Authors: McGirt Matthew J. , Parra Augusto , Sheng Huaxin , Higuchi Yoshinori , Oury Tim D. , Laskowitz Daniel T. , Pearlstein Robert D. , Warner David S.
Published: September 2002

Background and Purpose—

Subarachnoid hemorrhage (SAH) increases production of vascular extracellular superoxide anion (·O
2
−
). We examined whether overexpression of murine extracellular superoxide dismutase (EC-SOD) alters SAH-induced cerebral vasospasm, oxidative stress, and neurological outcome.

Methods—

Mice exhibiting a 2-fold increase in vascular EC-SOD and wild-type (WT) littermates were subjected to sham surgery or SAH by perforation of the right anterior cerebral artery. Neurological deficits were scored 72 hours later. Middle cerebral artery (MCA) diameter was measured or immunohistochemically stained for nitrotyrosine.

Results—

MCA diameter (mean±SD) was greater in EC-SOD versus WT mice after SAH but not sham surgery (EC-SOD SAH=56±10 μm; WT SAH=38±13 μm [
P
<0.01]; EC-SOD sham=99±16 μm; WT sham=100±15 μm). SAH decreased median (range) neurological score (scoring scale, 9 to 39; no deficit=39) versus shams, but there was no difference between EC-SOD and WT groups (EC-SOD SAH=26 [23 to 30]; WT SAH=23 [19 to 29] [
P
=0.27]; EC-SOD sham=39 [39]; WT sham=39 [39]). Sensory-motor deficits correlated with MCA diameter (
P
<0.001) but worsened primarily between 60 and 50 μm, plateauing below this threshold. The percentage of mice with MCA nitrotyrosine staining increased after SAH in WT (sham=29%; SAH=100% [
P
<0.05]) but not EC-SOD (sham=33%; SAH=44% [
P
=0.80]) mice.

Conclusions—

Endogenous overexpression of EC-SOD attenuated vasospasm and oxidative stress but failed to reduce neurological deficits after SAH. Extracellular ·O
2
−
likely plays a direct role in the etiology of vasospasm.
Active and Passive Smoking, Chronic Infections, and the Risk of Carotid Atherosclerosis
Authors: Kiechl Stefan , Werner Philipp , Egger Georg , Oberhollenzer Friedrich , Mayr Manuel , Xu Qingbo , Poewe Werner , Willeit Johann
Published: September 2002

Background and Purpose—

Susceptibility of the vasculature to the injurious effects of smoking varies substantially, with some smokers developing severe premature atherosclerosis and others remaining free of advanced atheroma until high ages. The present study sought to estimate the contribution of chronic infections to the variability of atherosclerosis severity among smokers.

Methods—

In the community-based Bruneck Study, 5-year changes in carotid atherosclerosis were assessed by high-resolution ultrasound. Early atherogenesis was defined by the development of nonstenotic plaques and advanced atherogenesis by the development/progression of vessel stenosis >40%.

Results—

The risk of early atherogenesis strongly relied on lifetime smoking exposure and remained elevated long-term after cessation of smoking. Remarkably, current and ex-smokers faced an increased atherosclerosis risk only in the presence of chronic infections (odds ratios [95% CIs], 3.3 [1.8 to 6.2] and 3.4 [1.8 to 6.3];
P
<0.001 each), whereas current, past, and nonsmokers without infections did not differ substantially in their estimated risk burden (odds ratios [95% CIs], 1.4 [0.8 to 2.4], 0.9 [0.6 to 1.6], and 1.0 [reference group]). In analogy to first-hand smoking, subjects exposed to environmental tobacco smoke were found to be vulnerable to the manifestation of chronic infection, and only those infected experienced a high atherosclerosis risk. The risk of advanced atherogenesis showed a dose-response relation with the number of daily cigarettes, returned to normal shortly after cessation of smoking, and emerged as independent of infectious illness.

Conclusions—

Our study provides the first epidemiological evidence that the proatherogenic effects of cigarette smoking are mediated in part by the chronic infections found in smokers. A better understanding of the vascular pathogenetic mechanisms of smoking may offer novel clues for disease prevention supplementary to the primary goal of achieving long-term abstinence.
Cessation of Smoking After First-Ever Stroke
Authors: Bak Søren , Sindrup Søren Hein , Alslev Torben , Kristensen Ole , Christensen Kaare , Gaist David
Published: September 2002

Background and Purpose—

Cessation of smoking is widely recommended in patients with stroke to reduce the risk of myocardial infarction and recurrent stroke, but little is known regarding how patients modify their smoking habits after a stroke. We used data from a prospective follow-up study to assess modification of smoking habits and to identify predictors of persistent smoking after first-ever stroke.

Methods—

All patients admitted to the only neurology department of Funen County (465 000 inhabitants) with first-ever stroke from August 1, 1999, to January 31, 2001, were prospectively identified. A comprehensive structured interview was completed both during hospitalization and at 6-month follow-up. The interview comprised questions on education, occupation, marital status, lifestyle, concomitant diseases, and functional disability. We estimated the relative risk of persistent smoking at follow-up using unconditional logistic regression.

Results—

We identified 734 patients with a first-ever stroke in the study period. One hundred three patients (14%) died in the 6-month period after their admission. A total of 511 patients (81%) who participated in the interview both on admission and at follow-up were included in the present study. Among 198 patients (38.7%) who were current smokers on admission, 43 patients (21.7%) gave up smoking within 6 months of suffering a stroke. Sex, functional status, and sociodemographic characteristics were independently associated with persistent smoking.

Conclusions—

Our results suggest that more efficient antismoking counseling is required to reduce the proportion of persistent smokers after stroke. This counseling should take into account the increased risk of persistent smoking in men, patients with no disability, blue-collar workers, and patients living alone.
Intracerebral Hemorrhage Triggers Interleukin-6 and Interleukin-10 Release in Blood
Authors: Dziedzic Tomasz , Bartus Stanislaw , Klimkowicz Aleksandra , Motyl Maciej , Slowik Agnieszka , Szczudlik Andrzej
Published: September 2002

Background and Purpose—

Acute brain insult can cause systemic anti-inflammatory response, including anti-inflammatory cytokine release. The goal of this study was to determine the serum level of interleukin-6, interleukin-10, and interleukin-13 in patients with intracerebral hemorrhage and to correlate cytokine concentrations with stroke severity.

Methods—

Thirty patients with intraparenchymal hemorrhage and 16 control subjects were included. Serum samples were collected on the second day of hemorrhagic stroke. Cytokine level was measured with the enzyme-linked immunosorbent assay method.

Results—

Increased serum levels of interleukin-6 and interleukin-10 were detected in stroke patients. Interleukin-6 and interleukin-10 levels were significantly correlated with Glasgow Coma Scale score. In addition, interleukin-6 level correlated with blood volume and mass effect.

Conclusions—

Intracerebral hemorrhage is associated with systemic release of anti-inflammatory cytokines.
Perception of Verticality After Recent Cerebral Hemispheric Stroke
Authors: Yelnik Alain P. , Lebreton Frederique O. , Bonan Isabelle V. , Colle Florence M.C. , Meurin Francesca A. , Guichard Jean Pierre , Vicaut Eric
Published: September 2002

Background and Purpose—

Perception of the subjective visual vertical (SVV) is affected by cerebral hemispheric lesions. Knowledge of this disturbance is of interest for the study of its possible relation to balance disturbances. There is still uncertainty about the possible effects of a visual field defect and of the side and site of the lesion. This study was conducted to assess SVV with the head upright or tilted and to explore its relation to a visual field defect, visuospatial neglect, and the site of lesion.

Methods—

Forty patients with hemiplegia after a recent hemispheric stroke (20 with left and 20 with right stroke) were studied. The site of the lesion was determined on CT scan, with special attention focused on the vestibular cortex. A neurological examination with determination of the visual field and visual neglect was conducted before SVV was tested. Subjects sat in a dark room and adjusted a luminous rod to the vertical position. Measures were repeated with binocular and monocular vision and with the head upright or tilted to the right or left.

Results—

SVV was abnormally deviated in 23 of 40 patients (57%). The deviation was significantly greater among patients with a right or left hemispheric lesion than among healthy controls (−2.2° and 1.5° versus 0.2°); the same applied to the range of uncertainty (7.6° and 4.7° versus 1.9°). SVV deviation was not significantly related to the location of the lesion but was closely related to visuospatial neglect. The “E” effect observed in controls with the head tilted, ie, an SVV shift in the direction opposite to the head tilt, was not observed in hemiplegic patients with the head tilted toward the nonparetic side.

Conclusions—

Recent hemispheric stroke affects SVV perception, which is closely correlated to visuospatial neglect. It is suggested that the E effect might be mediated by the stretching of the somatosensory structure of the neck.
Protection Against Ischemia and Improvement of Cerebral Blood Flow in Genetically Hypertensive Rats by Chronic Pretreatment With an Angiotensin II AT
1
Antagonist
Authors: Ito Takeshi , Yamakawa Haruki , Bregonzio Claudia , Terrón José A. , Falcón-Neri Alicia , Saavedra Juan M.
Published: September 2002

Background and Purpose—

Pretreatment with angiotensin II AT
1
receptor antagonists protects against cerebral ischemia. We studied whether modulation of cerebral blood flow (CBF) and morphometric changes in brain arteries participated in this protective mechanism.

Methods—

We pretreated adult spontaneously hypertensive rats with equally antihypertensive doses of candesartan (0.1 or 0.3 mg/kg per day), nicardipine (0.1 mg/kg per day), or captopril (3.0 mg/kg per day) for 3 or 28 days via subcutaneous osmotic minipumps followed by permanent left middle cerebral artery (MCA) occlusion distal to the origin of the lenticulostriate arteries. We measured CBF by autoradiography with 4-iodo-[
N
-methyl-
14
C]antipyrine 3 hours after operation and the areas of infarct and tissue swelling 24 hours after operation. Morphometric changes in the MCA were studied after antihypertensive treatment.

Results—

Twenty-eight days of candesartan pretreatment decreased the infarct area by 31%; reduced the CBF decrease at the peripheral area of ischemia and the cortical volume of severe ischemic lesion, where CBF was <0.50 mL/g per minute; increased the MCA external diameter by 16%; and reduced the media thickness of the MCA by 23%. Captopril pretreatment for 28 days decreased the infarct area by 25%. Pretreatment with candesartan for 3 days or nicardipine for 28 days was ineffective.

Conclusions—

Angiotensin II system inhibition protects against neuronal injury more effectively than calcium channel blockade. Protection after AT
1
receptor blockade is not directly correlated with blood pressure reduction but with normalization of MCA media thickness, leading to increased arterial compliance and reduced CBF decrease during ischemia at the periphery of the lesion.
New Method of Embolus Preparation for Standardized Embolic Stroke in Rabbits
Authors: Kirchhof Klaus , Welzel Thomas , Zoubaa Saida , Lichy Christoph , Sikinger Marcus , de Ruiz Hildegard Lorbacher , Sartor Klaus
Published: September 2002

Background and Purpose—

Although thromboembolic stroke is caused by red, white, or mixed clots, the emboli previously used in animal studies on thrombolysis were more often red than white. Because this might be one of the reasons why thrombolysis is less effective in patients than in experimental stroke, we developed a new method of preparing highly standardized red and fibrin-rich white emboli.

Methods—

The middle cerebral artery of 20 rabbits was embolized with either red or fibrin-rich white autologous emboli. Cerebral perfusion was monitored by MRI.

Results—

Red emboli consisted of closely packed erythrocytes within a sparse fibrin net and white emboli of a dense mass of fibrin with only few other blood cells. Infarct volumes were 26±4% (mean±SD) of the ischemic hemisphere with red and 27±6% with white emboli. The relative regional cerebral blood volume dropped below 50% 90 minutes after vascular occlusion with either type of embolus. Late spontaneous lysis and hemorrhagic complications occurred in 37.5% of red but not in white embolus cases.

Conclusions—

Emboli prepared by our technique result in standardized cerebral infarctions. Size and composition of the emboli continuously can be adjusted according to the experimental requirements.
Improving the Assessment of Outcomes in Stroke
Authors: Wilson J.T. Lindsay , Hareendran Asha , Grant Marie , Baird Tracey , Schulz Ursula G.R. , Muir Keith W. , Bone Ian
Published: September 2002

Background and Purpose—

The modified Rankin Scale is widely used to assess changes in activity and lifestyle after stroke, but it has been criticized for its subjectivity. The purpose of the present study was to compare conventional assessment on the modified Rankin Scale with assessment through a structured interview.

Methods—

Sixty-three patients with stroke 6 to 24 months previously were interviewed and graded independently on the modified Rankin Scale by 2 observers. These observers then underwent training in use of a structured interview for the scale that covered 5 areas of everyday function. Eight weeks after the first assessment, the same observers reassessed 58 of these patients using the structured interview.

Results—

Interrater reliability was measured with the κ statistic (weighted with quadratic weights). For the scale applied conventionally, overall agreement between the 2 raters was 57% (κ
w
=0.78); 1 rater assigned significantly lower grades than the other (
P
=0.048). On the structured interview, the overall agreement between raters was 78% (κ
w
=0.93), and there was no overall difference between raters in grades assigned (
P
=0.17). Rankin grades from the conventional assessment and the structured interview were highly correlated, but there was significantly less disagreement between raters when the structured interview was used (
P
=0.004).

Conclusions—

Variability and bias between raters in assigning patients to Rankin grades may be reduced by use of a structured interview. Use of a structured interview for the scale could potentially improve the quality of results from clinical studies in stroke.
Detection of Misery Perfusion With Split-Dose
123
I-Iodoamphetamine Single-Photon Emission Computed Tomography in Patients With Carotid Occlusive Diseases
Authors: Imaizumi Masao , Kitagawa Kazuo , Hashikawa Kazuo , Oku Naohiko , Teratani Tadamasa , Takasawa Masashi , Yoshikawa Takuya , Rishu Piao , Ohtsuki Toshiho , Hori Masatsugu , Matsumoto Masayasu , Nishimura Tsunehiko
Published: September 2002

Background and Purpose—

Patients with carotid occlusive disease and stage 2 cerebral hemodynamic failure, characterized by an increased oxygen extraction fraction (OEF) as measured by positron emission tomography (PET) and otherwise known as misery perfusion, have a high risk of cerebral ischemia and subsequent stroke. In clinical practice, the detection of patients with misery perfusion through the use of widely available, noninvasive, and cost-effective modalities such as single-photon emission computed tomography (SPECT) is extremely important.

Methods—

We evaluated the relationships between the regional hemodynamic status of cerebral circulation, measured with split-dose [
123
I]
N
-isopropyl-p-iodoamphetamine SPECT (
123
I-IMP SPECT) and an acetazolamide challenge, and hemodynamic parameters, including OEF measured with PET, in 27 patients with both unilateral and bilateral carotid occlusive diseases.

Results—

A significant negative correlation was found between the SPECT-measured cerebrovascular reserve after acetazolamide administration and both the PET-measured OEF and cerebral blood volume. Neither the cerebrovascular reserve nor the cerebral blood flow index, when expressed as a SPECT-measured cerebrum-to-cerebellum ratio, was useful for detecting lesions with an elevated OEF. However, a combination of the cerebrovascular reserve and cerebral blood flow index showed high sensitivity, specificity, and positive predictive value for the detection of misery perfusion.

Conclusions—

Our study suggests that split-dose
123
I-IMP SPECT with an acetazolamide challenge could be useful for screening patients with misery perfusion in carotid occlusive diseases.
Effects of Implantation Site of Stem Cell Grafts on Behavioral Recovery From Stroke Damage
Authors: Modo Michel , Stroemer R. Paul , Tang Ellen , Patel Sara , Hodges Helen
Published: September 2002

Background and Purpose—

Findings that MHP36 stem cells grafted into intact parenchyma contralateral to the lesion induced by middle cerebral artery occlusion promoted recovery from stroke deficits led us to investigate whether implantation site of stem cells affects the functional efficacy of MHP36 grafts.

Methods—

MHP36 cells (200 000/8 μL) were implanted in the left (n=8) or right (n=9) parenchyma or infused into the right ventricle (intraventricular; n=7) 2 to 3 weeks after stroke induced by 60 minutes of intraluminal right middle cerebral artery occlusion. Additionally, intact (n=11) and stroke (n=7) control groups were tested for 14 weeks in bilateral asymmetry, rotation bias, and spatial learning tasks before histological investigation of cell distribution and differentiation.

Results—

Rats with left and right parenchymal grafts showed reduced bilateral asymmetry but no improvement in spatial learning. Conversely, spatial learning improved in rats with intraventricular grafts, but marked asymmetry persisted. No grafted group showed reduced amphetamine-induced rotation bias or reduced lesion volume relative to stroke controls. In all grafted groups, cells occupied both sides of the brain. A third of cells grafted in the striatum crossed the midline to occupy homologous regions in intact and lesioned hemispheres and differentiated into site-appropriate phenotypes.

Conclusions—

After stroke, both the intact and lesioned hemispheres attract grafted stem cells, suggesting repair processes that utilize cells both for local repair and to augment plastic changes in contralateral motor pathways. However, differential effects of parenchymal and intraventricular grafts suggest that different mechanisms are implicated in recovery from cognitive and sensorimotor deficits induced by stroke.
Baseline Blood Pressure but Not Early Computed Tomography Changes Predicts Major Hemorrhage After Streptokinase in Acute Ischemic Stroke
Authors: Gilligan A.K. , Markus R. , Read S. , Srikanth V. , Hirano T. , Fitt G. , Arends M. , Chambers B.R. , Davis S.M. , Donnan G.A.
Published: September 2002

Background and Purpose—

Intracerebral hemorrhage is the most serious complication of thrombolytic therapy for stroke. We explored factors associated with this complication in the Australian Streptokinase Trial.

Methods—

The initial CT scans (≤4 hours after stroke) of 270 patients were reviewed retrospectively by an expert panel for early signs of ischemia and classified into the following 3 categories: no signs or ≤1/3 or >1/3 of the vascular territory. Hemorrhage on late CT scans was categorized as major or minor on the basis of location and mass effect. Stepwise, backward elimination, multivariate logistic regression analysis was used to identify risk factors for each hemorrhage category.

Results—

Major hemorrhage occurred in 21% of streptokinase (SK) and 4% of placebo patients. Predictors of major hemorrhage were SK treatment (odds ratio [OR], 6.40; 95% CI, 2.50 to 16.36) and elevated systolic blood pressure before therapy (OR, 1.03; 95% CI, 1.01 to 1.05). Baseline systolic blood pressure >165 mm Hg in SK-treated patients resulted in a >25% risk of major secondary hemorrhage. Early ischemic CT changes, either ≤1/3 or >1/3, were not associated with major hemorrhage (OR, 1.58; 95% CI, 0.65 to 3.83; and OR, 1.11; 95% CI, 0.45 to 2.76, respectively). Minor hemorrhage occurred in 30% of the SK and 26% of the placebo group. Predictors of minor hemorrhage were male sex, severe stroke, early CT changes, and SK treatment. Ninety-one percent of patients with major hemorrhage deteriorated clinically compared with 23% with minor hemorrhage.

Conclusions—

SK increased the risk of both minor and major hemorrhage. Major hemorrhage was also more likely in patients with elevated baseline systolic blood pressure. However, early CT changes did not predict major hemorrhage. Results from this study highlight the importance of baseline systolic blood pressure as a potential cause of hemorrhage in patients undergoing thrombolysis.
Prediction of Early Neurological Deterioration Using Diffusion- and Perfusion-Weighted Imaging in Hyperacute Middle Cerebral Artery Ischemic Stroke
Authors: Arenillas Juan F. , Rovira Álex , Molina Carlos A. , Grivé Elisenda , Montaner Joan , Álvarez-Sabín José
Published: September 2002

Background and Purpose—

Early neurological deterioration (END) occurs in approximately one third of all ischemic stroke patients and is associated with a poor outcome. Our study sought to assess the value of ultra-early MRI in the prediction of END in stroke patients.

Methods—

Between August 1999 and November 2001, 38 stroke patients with a proven middle cerebral artery (MCA) or intracranial internal carotid artery (ICA) occlusion on MR angiography underwent perfusion-weighted imaging (PWI) and diffusion-weighted imaging (DWI) within 6 hours after onset, and 30 fulfilled all inclusion criteria. Control DWI and MR angiography were performed between days 3 and 5. Cranial CT was performed to rule out hemorrhagic transformation. Vascular risk factors, temperature, blood pressure, glycemia, and blood count were assessed on admission. National Institutes of Health Stroke Scale (NIHSS) scores were obtained at baseline and at 6, 12, 24, and 48 hours. At the same time points, transcranial Doppler (TCD) examinations were conducted to assess arterial recanalization. END was defined as an increase in the NIHSS score >4. A logistic regression model was applied to detect independent predictors of END. The Kruskal-Wallis test was used to evaluate the relationship between infarct growth and duration of vessel occlusion.

Results—

Initial MR angiography showed an occlusion of intracranial ICA in 7 patients (23.3%), of proximal MCA in 14 (46.6%), and of distal MCA in the remaining 9 (30%). A PWI-DWI mismatch >20% was observed in 28 patients (93.3%). END occurred in 7 patients (23.3%). Baseline NIHSS score (
P
=0.05), proximal site of occlusion (
P
=0.002), initial DWI (
P
=0.002) and PWI (
P
=0.003) volumes, and reduced PWI-DWI mismatch (
P
=0.038) were associated with END in the univariate analysis. Only hyperacute DWI volume remained as a predictor of END when a logistic regression model was applied (odds ratio, 11.5; 95% CI, 2.31 to 57.10;
P
=0.0028). A receiver operator characteristic curve identified a cutoff point of DWI >89 cm
3
(sensitivity, 85.7%; specificity, 95.7%) to predict END. A graded response was seen in DWI lesion expansion in relation to duration of arterial occlusion (
P
=0.017).

Conclusions—

Ultra-early DWI is a powerful predictor of END after MCA or intracranial ICA occlusion.
Optimizing the Technique of Contrast Transcranial Doppler Ultrasound in the Detection of Right-to-Left Shunts
Authors: Droste Dirk W. , Lakemeier Stefan , Wichter Thomas , Stypmann Jörg , Dittrich Ralf , Ritter Martin , Moeller Martin , Freund Michael , Ringelstein E. Bernd
Published: September 2002

Background and Purpose—

A cardiac right-to-left shunt (RLS) can be identified by transesophageal echocardiography and transcranial Doppler ultrasound (TCD) with contrast agents and a Valsalva maneuver (VM) as a provocation procedure. This article applies the modalities of these tests detailed in previous studies to a large patient cohort and compares 2 contrast agents (saline and Echovist-300).

Methods—

Eighty-one patients were investigated by both transesophageal echocardiography and bilateral TCD of the middle cerebral arteries. The following protocol with injections of 10 mL agitated saline was applied in a randomized way: (1) no VM, (2) VM for 5 seconds starting 5 seconds after the beginning of contrast injection, and (3) repetition of the test with VM if the first test with VM was negative. The VM was performed for 5 seconds starting exactly 5 seconds after the beginning of saline injection. Thereafter, the same protocol was repeated with 10 mL Echovist-300 instead of saline.

Results—

Thirty-one patients had a cardiac RLS. The Echovist-300 investigation disclosed all these 31 shunts, but saline disclosed only 29 of them. Twenty-two had an RLS only in at least 1 of the above TCD tests, some of them even with a considerable shunt volume.

Conclusions—

Contrast TCD performed with Echovist-300 but not with saline yields a 100% sensitivity to identify transesophageal echocardiography-proven cardiac RLSs. The TCD test should be repeated if negative the first time. This article gives detailed information for the optimization of the contrast TCD technique. Extracardiac shunts detected only during contrast TCD can have a considerable shunt volume and may allow for paradoxical embolism.
Soluble Intercellular Adhesion Molecule-1 and Risk of Future Ischemic Stroke
Authors: Tanne David , Haim Moti , Boyko Valentina , Goldbourt Uri , Reshef Tamar , Matetzky Shlomo , Adler Yehuda , Mekori Yoseph A. , Behar Solomon
Published: September 2002

Background and Purpose—

Inflammation is considered to be involved in the pathogenesis of ischemic stroke. Our purpose was to assess the role of soluble intercellular adhesion molecule-1 (sICAM-1) concentration, a marker of inflammation, in predicting future ischemic stroke among patients at risk because of chronic coronary heart disease.

Methods—

We obtained baseline serum samples from patients with chronic coronary heart disease enrolled in the Bezafibrate Infarction Prevention trial (n=3090), which assessed the efficacy of bezafibrate in secondary prevention. Using a prospective nested case-control design, we measured baseline sICAM-1 concentration in sera of patients who developed ischemic stroke during a mean follow-up of 8.2 years (cases, n=134) and in age- and sex-matched controls without any subsequent cardiovascular events (n=134).

Results—

Baseline serum concentrations of sICAM-1 were significantly higher in cases compared with controls (379 versus 350 ng/mL,
P
<0.05). sICAM-1 concentration at the highest quartile (>394 ng/mL) was associated with significantly higher relative odds of ischemic stroke compared with the lower concentrations after adjustment for potential confounding variables (relative odds, 2.1; 95% CI, 1.1 to 4.3). After fibrinogen and total white blood cell count were added to the multivariable model, the relative odds were 2.1 (95% CI, 1.1 to 4.2) and 2.2 (95% CI, 1.1 to 4.8), respectively. The risk associated with raised concentrations of sICAM-1 seemed to be highest for large disabling strokes of cardioembolic origin.

Conclusions—

Elevated concentrations of sICAM-1, a marker of inflammation, are associated with increased risk of ischemic stroke, independent of other traditional cerebrovascular risk factors and of plasma fibrinogen, among patients at increased risk because of manifest coronary heart disease.
Induction of Mucosal Tolerance to E-Selectin Prevents Ischemic and Hemorrhagic Stroke in Spontaneously Hypertensive Genetically Stroke-Prone Rats
Authors: Takeda Hidetaka , Spatz Maria , Ruetzler Christl , McCarron Richard , Becker Kyra , Hallenbeck John
Published: September 2002

Background and Purpose—

Inflammatory and immune mechanisms can precipitate cerebrovascular thrombosis and hemorrhage. Immunologic tolerance can be induced to a specific antigen by intranasal instillation of that antigen. Lymphocytes tolerized in this way provide local immunosuppression on restimulation with the same antigen. This study tests whether tolerization of lymphocytes to E-selectin can suppress local vessel activation and prevent stroke.

Methods—

Spontaneously hypertensive genetically stroke-prone rats (n=113) were distributed among the following studies: comparison of ischemic infarcts/intraparenchymal hemorrhages after single or repetitive tolerization schedules with ovalbumin, E-selectin, or PBS; comparison of E-selectin tolerization– and PBS tolerization–induced suppression of delayed-type hypersensitivity in animals subsequently sensitized to E-selectin; and comparison of PBS–, ovalbumin–, and E-selectin–tolerized groups (after intravenous lipopolysaccharide to activate vessels) regarding transforming growth factor-β1–positive splenocyte counts, plasma interferon-γ levels, anti-human E-selectin antibodies, endothelial intercellular adhesion molecule-1, and anti–endothelial cell antibodies.

Results—

Nasal instillation of E-selectin, which is specifically expressed on activated endothelium, potently inhibited the development of ischemic and hemorrhagic strokes in spontaneously hypertensive stroke-prone rats with untreated hypertension. Repeated schedules of tolerization were required to maintain the resistance to stroke. Suppression of delayed-type hypersensitivity to E-selectin and increased numbers of transforming growth factor-β1–positive splenocytes showed that intranasal exposure to E-selectin induced immunologic tolerance. E-selectin tolerization also reduced endothelial activation and immune responses after intravenous lipopolysaccharide, as shown by marked suppression of intercellular adhesion molecule-1 expression, anti–endothelial cell antibodies on luminal endothelium, and plasma interferon-γ levels compared with the control condition.

Conclusions—

The novel findings in this study support further investigation of immunologic tolerance as applied to the prevention of stroke.
Psychiatry at 2000
Authors: Rollin Henry R.
Published: September 2002

To cram 2000 years of the history of psychiatry into the space allowed me in this paper is like attempting to transcribe the Lord's Prayer onto the back of a postage stamp. It's well-nigh impossible, but it can be done. Fortunately for me, the task has been made infinitely less difficult by the fact that psychiatry as an organised, independent discipline dates back only as recently as the last decades of the 18th century and its history is, therefore, correspondingly short. So, I'll begin there.
Psychiatry in the new millennium
Authors: Persaud Raj
Published: September 2002

Of all the medical specialities, psychiatry seems the most resistant to change in the face of rapidly evolving technology. Yet psychiatry could become the speciality most revolutionised by advanced technology in the new millennium. If the following predictions for psychiatry in the next 1000 years appear difficult to believe, imagine what might have been the reaction of those living in 999 to being told what would happen by 1999. Back then the profession of medicine as we understand it did not even exist, neither did there appear to be any institutions devoted to the care of the mentally ill. Indeed, in 1000 years' time from now, we might yet return to a similar situation in both these respects!
Psychiatric trainees' experiences of, and reactions to, patient suicide
Authors: Dewar Ian , Eagles John , Klein Susan , Gray Nicola , Alexander David
Published: September 2002

Aims and Method

This survey is the first UK study of trainee psychiatrists' experiences of patient suicide. One hundred and three senior and specialist registrars in psychiatry working in Scotland completed the questionnaire, representing an 81% response rate.

Results

Almost half (47%) had experienced suicide of a patient in their care or otherwise known to them (e.g. through on-call experiences). Although only 28% recalled previous training on issues to consider following a suicide, all of these doctors found this to be of value. Many reported that patient suicide had a deleterious impact on their personal and professional lives. The most valuable supports were informal, and the trainees' consultants appeared particularly well placed to offer support and advice.

Clinical Implications

Many trainee psychiatrists experience the suicide of a patient. Such experiences have potential for adverse effects on doctors' professional practice and personal life. Greater availability of training in this area would allow trainees to be better prepared for such an event. Trainees' consultants have a pivotal role to play in providing appropriate advice and support after a patient suicide.
Size does matter
Authors: Carson Alan J. , Shah Prem
Published: September 2002

Aims and Methods

To examine antidepressant prescribing in a general medical hospital in the UK. The data used were extracted from a prescription database prospectively maintained by the hospital pharmacy. All prescriptions of antidepressants over a five-year period, both new and continuation, were recorded.

Results

During the study period there were 2037 prescriptions of tricyclic antidepressants. Only 18% of these prescriptions were at conventional therapeutic doses. This compared with 773 prescriptions of selective serotonin reuptake inhibitors, 70% of which were at conventional therapeutic doses. It is shown that antidepressants were prescribed at a dose in accordance with the smallest tablet size available.

Clinical Implications

We suggest that reformulation of tablets to allow one tablet daily prescribing may lead to improved antidepressant prescribing.
Lunch times eaten?
Authors: Hardwick Peter J.
Published: September 2002

At a recent regional meeting of consultant psychiatrists I did something rather irregular. I admitted I frequently take a lunch break. It felt like a confession having just heard dedicated colleague after colleague describe forgoing their lunch breaks in order to pack more and more into their overloaded days. Afterwards at the bar someone asked me if I felt guilty. My immediate response was “no”. After all I have been brought up to believe that the hallmark of a civilised professional life is having time to think. However the question intrigued me – should I feel guilty? Or, more to the point, maybe I had revealed too much by making my psychopathy apparent especially as I often follow lunch with a stroll by the sea.
Homicide inquiries
Authors: Szmukler George
Published: September 2002

We recently had a homicide inquiry in our trust. The events around the release of the report made for a demoralising experience. The visible pain in the families of the victim and the perpetrator caused by the tragedy was heart-rending. As Medical Director, I also saw at first hand the powerful impact on the members of the team involved, my colleagues in general, the trust management and the health authority, all of whom strive to provide effective mental health services in one of the most deprived areas in the country. There were also political influences, especially the need to be seen not to tolerate poor performance. Allusions to disciplinary issues were not infrequent. We all found it very disturbing. I was forced to think a lot about homicide inquiries and became increasingly struck by a growing number of internal contradictions. I started making notes to help order my thoughts. I offer for discussion some conclusions using this inquiry (Scotland et al, 1998) as an example.
Who can best protect patients' rights?
Authors: Gregory Patricia
Published: September 2002

The Mental Health Act (MHA) 1983 created three tiers: national, regional and local, for protecting the rights of patients under section, the Mental Health Act Commission (MHAC), the mental health review tribunals (MHRTs) and the hospital managers. Although the Act was in many ways revolutionary, there have been a number of criticisms about the structures it created.
What trainees and trainers think about supervision
Authors: Sembhi Sati , Livingston Gill
Published: September 2002

Aims and Method

A confidential questionnaire was mailed to all trainers and trainees on the UCL/North London rotation (n=127), asking about the content and ways of improving supervision.

Results

Seventy-six per cent of trainees received regular, timetabled supervision. Ninety-four per cent of trainees felt it was a good idea, but identified improvements, including more planning, setting an agenda and flexibility. There were differences between reports from trainers and trainees regarding the content of supervision. Respondents' comments are included.

Clinical Implications

Although supervision is popular and widely practised, this survey suggests that it is still not universally practised despite College stipulations. The content of supervision could be broadened to include more non-clinical matters such as teaching and careers guidance.
Towards the development of a reciprocal liaison service
Authors: Davies Mark
Published: September 2002

Aims and Method

The aim of this survey was to determine attitudes among consultants in different specialities towards the development of a reciprocal liaison service providing access for psychiatric patients to medical and surgical liaison services equal to the access of medical and surgical patients to psychiatric liaison services. All medical, surgical and psychiatric consultants in a district health service were surveyed, with a total response rate of 48%.

Results

The mean number of medical and surgical patients requiring a psychiatric liaison service was 6%. The mean number of psychiatric patients requiring medical and surgical liaison services was 11%. Ratings overall for various components of the two types of liaison service were generally similar, with acute assessments and follow-up being given a high priority for both types.

Clinical Implications

As liaison services are developed, the notion of equity of access for all patients is paramount. Commissioning of such services should thereby specify the reciprocal nature of development. This survey shows that generally there is a positive attitude to the development of such a service.
Forget Me Not: Mental Health Services for Older People
Authors: Benbow Susan M. , Lennon Sean P.
Published: September 2002

The exclusion of services for older people from the Mental Health National Service Framework and the delays in publication of the National Service Framework for the elderly have caused many old age psychiatrists to be concerned that, as in many other areas of health service planning and provision, the needs of older people are not being adequately addressed by Government and health service planners. The recent Audit Commission Report, entitled Forget Me Not: Mental Health Services for Older People†, gives us much encouragement that the needs of older adults have not been forgotten. Its recent publication should provide an authoritative focus, which will help old age psychiatrists, their multi-disciplinary and management colleagues and commissioners of services to push forward improvements in services for older people with mental illnesses.
Off-label prescribing by psychiatrists
Authors: Lowe-Ponsford Francesca L. , Baldwin David S.
Published: September 2002

A questionnaire was sent to 200 psychiatrists asking them about their off-label prescribing in the preceding month. One hundred and sixteen replies (58%) were obtained. Seventy-six (65%) respondents had prescribed medication off-label within the past month. Only 5 (4%) had ever received a complaint from patients related to their off-label prescribing. If this region is typical, off-label prescribing is common amongst psychiatrists. No formal guidelines exist except for the use of high dose neuroleptics. A suggested guideline is given in this article.
New Mental Health Information Strategy
Authors: Elphick Martin
Published: September 2002

What follows is an attempt to summarise the current national approach to the management of information in mental health services. There are many different perspectives – mine is that of a member of the College Informatics Sub-Committee and lead psychiatrist for the NHS Information Authority.
Preparing for a consultant post in child and adolescent psychiatry: a practical guide for specialist registrars
Authors: McKenzie Immanuel , Wurr Catherine , Cottrell David
Published: September 2002

The prospect of looking for a consultant post in child and adolescent psychiatry can be anxiety provoking. The ideal job should be balanced and fulfilling, with scope for personal and service development, and should minimise the likelihood of frustration and burn-out. It is not uncommon for newly appointed consultants to become dispirited by the discrepancy between the job description and the reality of the post.
Psychotherapy patients' views of treatment: on learning from the patient
Authors: Bende Brigitta , Crossley David
Published: September 2002

Aims and Method

Psychotherapy patients' views of treatment received from two senior registrars were obtained by questionnaire. The aim of the study was to give patients an opportunity to reflect on therapy and help trainees evaluate their therapeutic style and the therapy they provided.

Results

The response rate was 86% (25/29). All patients recalled key issues covered in therapy, 96% (24/25) found therapy valuable. Seventy-two per cent (18/25) made comments about therapists' style and 20% (5/25) made suggestions for improvement of the service.

Clinical Implications

Clinical, service and training implications are discussed and it is suggested that this form of patient survey is a useful adjunct in outcome evaluation of treatments and of training.
Child and adolescent mental health services liaison with Tier 1 services: a consultation exercise with school nurses
Authors: Richardson Greg , Partridge Ian
Published: September 2002

Consultation with Tier 1 professionals is an integral part of comprehensive child and adolescent mental health services (CAMHS) (NHS Health Advisory Service, 1995; Audit Commission, 1999). Despite enthusiasm for consultative approaches and clearly described advantages (Steinberg, 1993), the evidence base for consultation work is thin. In schools, the consultation intervention has been found to be the least effective of four interventions (Kolvin et al, 1981). Consultation enables the development of an integrated tiered system, improves communication, provides a greater understanding of the roles of CAMHS by Tier 1 professionals and fosters more relevant referral patterns.
Cubiculum squalidum (ICD–10: F91.9)
Authors: Pease James J.
Published: September 2002

All adolescent psychiatrists will know untidy bedrooms to be part of the day-to-day currency of parent–child frustration. Is it too universal to achieve caseness and a place in ICD–11? Nowadays, when an adolescent is described as having a tidy bedroom, my mind starts reviewing their other symptoms to check for a developmental disorder. Universality has not, however, generated many helpful therapy strategies in psychiatric textbooks.
Drayton Park, an alternative to hospital admission for women in acute mental health crisis
Authors: Killaspy Helen , Dalton Joy , McNicholas Shirley , Johnson Sonia
Published: September 2002

Aims and Method

To describe Drayton Park, the first women-only residential mental health crisis facility in the UK and to investigate whether it is succeeding in its remit of providing a viable alternative to hospital admission. We randomly selected case files from 100 women admitted to Drayton Park since its opening and examined variables including demographic details, the reasons for referral, diagnosis and the source of referral.

Results

Our findings show that the service is able to respond quickly to referrals and appears to be functioning safely. The women admitted have a relatively short length of stay, half suffer from depressive episodes and one-third have a relapse of schizophrenia or bipolar disorder.

Clinical Implications

This project appears to be succeeding in providing a safe alternative to hospital admission for women with severe and enduring mental health problems.