bluuebunny/crossref_metadata_2025 huggingface dataset:
Management of the Hemodialysis Patient: A European Perspective
Authors: Lameire Norbert
Published: April 2003

This article explores some of the factors which may contribute to the persistence of the differences in outcome between European and US hemodialysis patients. A higher comorbidity of incident and prevalent renal replacement therapy patients, different vascular access policies with less use of arteriovenous fistulas, shorter dialysis times, and higher reutilization of dialysis membranes in the USA may, among other factors, explain the higher mortality compared to Europe and Japan. No major differences in patient referral to the nephrologist, in residual renal function at the start of dialysis, nor in the dialysis dose based on Kt/V urea data were noted.
How to Feed Patients with Renal Dysfunction
Authors: Bellomo Rinaldo
Published: April 2003

Renal dysfunction is common in critically ill patients and its presence has, in the past, posed serious challenges to nutritional support. Such challenges were due to the increased azotemia induced by protein or amino acid administration, the fluid overload caused by the administration of nutrients and the difficulties associated with the control of these complications by means of conventional dialytic techniques. The development and increasing application of continuous renal replacement therapy (CRRT) has removed such concerns, because control of azotemia and fluid balance can be predictably and reliably achieved in all patients. Accordingly, the presence of renal failure should in no way influence the amount or type of nutritional support administered to a critically ill patient. We recommend that approximately 30–35 kcal/kg/day be administered enterally and begun within the first few hours of admission to the intensive care unit and that protein intake be kept in the 1.5–2 g/kg/day range. Accumulating evidence also suggests that immune-enhancing enteral preparations decrease the duration of hospital stay, the number of infections and perhaps mortality. Such preparations should be used in these patients. Finally adequate vitamin and trace element supplementation is recommended to counterbalance the decrease in antioxidants and the loss of some vitamins during CRRT. Available evidence suggests that if these steps are applied as part of a protocol-based approach to the nutritional support of patients with renal failure, their morbidity and perhaps mortality can be significantly decreased.
Oxytocin Treatment during Early Life Influences Reproductive Performance in ad libitum Fed and Food-Restricted Female Rats
Authors: Sohlström Annica , Olausson Hanna , Brismar Kerstin , Uvnäs-Moberg Kerstin
Published: April 2003

Oxytocin treatment may permanently alter endocrine axes resulting in anti-stress and anabolic effects. However, the nutritional status influences the effects of oxytocin. The specific aims of this study were to investigate the effects of postnatal oxytocin treatment on reproductive performance in adult life, by studying maternal weight gain, adiposity, plasma levels of IGF-I as well as fetal and placental weights in the following groups of animals: (1) Ad libitum fed dams coming from ad libitum fed mothers. (2) Ad libitum fed dams coming from food-restricted mothers. (3) Food-restricted dams coming from ad libitum fed mothers. (4) Food-restricted dams coming from food-restricted mothers. Oxytocin treatment postnatally had long-term effects and increased adiposity in pregnant dams and stimulated placental and fetal growth relative to saline-treated dams. However, if the dams themselves had been exposed to food restriction during fetal life, the effect of postnatal oxytocin treatment changed. The oxytocin-treated mothers were still fatter but had smaller fetuses. In conclusion, postnatal oxytocin treatment influences reproductive performance in later life but is dependent on the mother’s previous and current nutritional experience.
Distribution and Innervation of Taste Buds in the Axolotl
Authors: Northcutt R. Glenn , Barlow Linda A. , Braun Christopher B. , Catania Kenneth C.
Published: April 2003

Adult axolotls have approximately 1,400 taste buds in the epithelium of the pharyngeal roof and floor and the medial surfaces of the visceral bars. These receptors are most dense on the lingual surfaces of the upper and lower jaws, slightly less dense throughout lateral portions of the pharyngeal roof and floor, and more sparse within medial portions of the pharyngeal roof and floor, except for a median oval patch of receptors located rostrally between the vomerine tooth fields. Each taste bud is a pear-shaped organ, situated at the center of a raised hillock and averaging 80 and 87 µm in height and width, respectively. Each comprises 50 to 80 cells, which can be classified as basal, dark fusiform, or light fusiform, based on differences in their morphology. The distal ends of the apical processes of the fusiform cells reach the surface of each hillock, forming a single taste pore with an average diameter of 15 µm. Each apical process terminates in one of three ways: as short, evenly spaced microvilli; as long clustered microvilli; or as large, stereocilia-like microvilli. The pharyngeal epithelium and associated taste buds in axolotls are innervated solely by rami of the facial, glossopharyngeal and vagal nerves. Approximately, the rostral one half of the pharyngeal roof is innervated by the palatine rami of the facial nerve, whereas the caudal one half of the pharyngeal roof is innervated by the pharyngeal rami of the glossopharyngeal and vagal nerves. The lingual surface of the lower jaw is innervated by the pretrematic (mandibular) ramus of the facial nerve. The dorsal two-thirds of the visceral arches, and the ventral one-third of the visceral arches and the pharyngeal floor, are innervated by both the pretrematic and post-trematic rami of the glossopharyngeal and vagal nerves, respectively.
Relative Volume of the Cerebellum in Dolphins and Comparison with Anthropoid Primates
Authors: Marino Lori , Rilling James K. , Lin Shinko K. , Ridgway Sam H.
Published: April 2003

According to the ‘developmental constraint hypothesis’ of comparative mammalian neuroanatomy, brain growth follows predictable allometric trends. Therefore, brain structures should scale to the entire brain in the same way across mammals. Evidence for a departure from this pattern for cerebellum volume has recently been reported among the anthropoid primates. One of the mammalian groups that has been neglected in tests of the ‘developmental constraint hypothesis’ is the cetaceans (dolphins, whales, and porpoises). Because many cetaceans possess relative brain sizes in the range of primates comparative tests of the ‘developmental constraint hypothesis’ across these two groups could help to delineate the parameters of this hypothesis. In this paper, we compare relative cerebellum volumes in two cetacean species, the bottlenose dolphin (Tursiops truncatus) and the common dolphin (Delphinus delphis), with published data from anthropoid primates. We found that relative cerebellum size is significantly greater in the two dolphin species than in any of the primates, including humans. These results suggest that there is possibly expansion of brain structures independent of strictly allometric processes.
Mammal-Like Striatal Functions in Anolis
Authors: Clark Edward C. , Baxter Jr. Lewis R. , Dure Leon S. , Ackermann Robert F. , Kemp George F. , Bachus Susan E.
Published: April 2003

We used in situ autoradiographic ligand binding methods to determine the occurrence and distribution of dopamine D1 and D2 receptor sub-types in the anole lizard, Anolis carolinensis. Both were present and exhibited pharmacological specificity characteristics similar to those described for mammals. However, unlike in mammals where in the neostriatum [outside the nucleus accumbens/olfactory tubercle complex (NA/OT)] these receptors exhibit only slight dorsolateral (D2 high, D1 low) to ventromedial (D1 high, D2 low) gradients that co mingle extensively, in the anole striatum outside the NA/OT there was a striking laminar pattern, with little if any overlap between D2 (high in a dorsal band) and D1 (high ventral to the D2 band) distributions. As D1 receptors are related to the direct and D2 to the indirect basal ganglia (BG) subsystems in mammals, we also determined anole striatal distributions of pre-proenkephalin mRNA, a marker for striatal efferents to the indirect BG subsystem in mammals. Here, too, there was a striking laminar pattern, with pre-proenkephalin mRNA in a band similar to that seen for D2 receptors. The crisp neuroanatomical separation between these classic BG subsystem markers in Anolis striatum make this species attractive for the study of such systems'' functions during behavior.
Distribution Pattern of Taste Buds along Hyoidal Barbels of Mullus barbatus and M. surmuletus
Authors: Aguirre H. , Lombarte A.
Published: April 2003

The external taste buds of bony fishes are differentiated and grouped throughout the body epithelium, concentrating in the buccopharyngeal cavity or in certain external organs such as the lips, barbels or fins. The family Mullidae (goatfishes) is characterized by having barbels covered with taste buds (TBs). However, It is not known how the TBs are distributed and how their characteristics vary along the barbels. To obtain answers to these questions, the morphological variability in taste bud density (δTB), pore area (AP) and taste bud area (ATB) was studied in Mullus barbatus (L., 1758) (red mullet) and M. surmuletus (L., 1758) (striped red mullet), for fish ranging in size from 58 to 227 and from 56 to 287 mm in total length (LT), respectively. Assuming that larger fish are older, in both species the pore area (AP) and taste bud area (ATB) increased with ontogenic development. Also, in both species clear differences were observed along the barbel. The δTB increased from the basal area to the apical area, whereas both the AP and ATB had an inverse pattern.
Acute Effects of Transdermal Estrogen in Postmenopausal Women with Coronary Artery Disease
Authors: Manhem Karin , Ahlm Helen , Dellborg Mikael , Milsom Ian
Published: April 2003

In the present study the acute anti-ischemic effect of clinically relevant doses of transdermal estradiol during concurrent antianginal therapy was investigated in 14 postmenopausal women with stable coronary artery disease. Plasma estradiol was significantly increased, but no significant effects on time to angina, time to 1 mm S–T depression, total exercise time, maximum rate-pressure product, maximum S–T depression or maximum workload were found. However, resting diastolic blood pressure was significantly decreased due to estrogen.
Helicobacter pylori Infection and Coronary Heart Disease in Japanese Patients
Authors: Osawa Hiroyuki , Kawakami Masanobu , Fujii Mikihisa , Kubo Norifumi , Iwanaka Hisakazu , Yamamoto Wari , Saitoh Muneyasu , Yaginuma Toshio , Sugano Kentaro
Published: April 2003

Although several independent studies have claimed a link between Helicobacter pylori infection and coronary heart disease (CHD), this association has not been established conclusively. The aim was to determine whether an association between H. pylori infection and CHD can be demonstrated in Japanese patients. Three-hundred and four patients who underwent consecutive coronary arteriography were investigated. Ninety-four patients had single-vessel coronary stenosis and 112 had multi-vessel stenosis. The remaining 98 patients had no significant stenosis in any coronary arteries. H. pylori infection was diagnosed serologically and the association between infection and CHD was estimated by the odds ratio. The serum pepsinogen (PG) I-II ratio was used to estimate the degree of gastric atrophy. Seropositivity for H. pylori was significantly higher in the patients with CHD (67%) than in the controls (50%; p = 0.006). The odds ratio for CHD after having H. pylori infection was estimated as 1.35 (95% confidence interval 1.03–1.78; p = 0.028), after adjustment for the common risk factors of CHD in a logistic regression analysis. The association between CHD and H. pylori infection was more significant among patients without any history of diabetes or smoking. The PG I-II ratio in H. pylori-positive patients was significantly higher in the multi-vessel group (3.46) than in the control or single-vessel group (2.86, p = 0.030; 2.78, p = 0.008; respectively). H. pylori infection was shown to be an independent risk factor for CHD in Japanese patients, especially among those who did not have a history of diabetes or smoking. These data imply that the association between H. pylori infection and CHD is clinically relevant.
Echocardiographic Evaluation of Left-Ventricular Diastolic Function in Patients with Chronic Pulmonary Hypertension
Authors: Moustapha Ali , Kaushik Vinod , Diaz Susana , Kang Seung-Ho , Barasch Eddy
Published: April 2003

Different patterns of left-ventricular (LV) diastolic dysfunction were reported in patients with pulmonary hypertension (PHT). There are no data regarding the relationship between the severity of PHT and LV diastolic dysfunction. In order to determine the severity of PHT at which LV diastolic dysfunction occurs and to identify its pattern, we studied by Doppler echocardiography 120 patients with PHT (57 with severe PHT and 63 with mild or moderate PHT) and compared them with 75 normal controls. Systolic pulmonary artery pressure (SPAP) was measured by tricuspid regurgitant jet method and the usual transmitral LV diastolic indices were recorded. LV diastolic dysfunction of impaired relaxation type is most commonly seen in patients with severe PHT. No differences were observed between patients with mild and moderate PHT regarding LV diastolic function. A SPAP ≧60 mm Hg is needed to induce changes in the LV diastolic filling pattern.
An Integrated Proposal to Explain the Epidemic of Cardiovascular Disease in a Developing Country
Authors: López-Jaramillo Patricio , Casas Juan P. , Bautista Leonelo , Serrano Norma C. , Morillo Carlos A.
Published: April 2003

An increase of coronary artery disease has been observed in developing countries during the last years. Various factors may explain this accelerated increase. We propose that inappropriate diet and inadequate sanitary infrastructure may act as triggers to create an imbalance between nitric oxide (NO) and superoxide (O–2). An increase in the concentrations of oxidizedLDL produces both decreased NO and increased O–2 endothelial synthesis, by accumulation of asymmetrical NG-NG-dimethyl-L-arginine, the endogenous inhibitor of NO, and by activation of NAD(P)H oxidase. On the other hand, high rates of chronic infection-inflammation, due to inappropriate sanitary environment stimulate higher circulating levels of proinflammatory cytokines. These cytokines also contribute to reduced NO and increased O–2 endothelial production through the same mechanisms of oxidized LDL. The net result of this imbalance is an increased generation of peroxynitrate that injures the endothelium in a proatherogenic, prothrombotic and vasoconstrictive manner.
Extracorporeal Ultrafiltration for the Treatment of Overhydration and Congestive Heart Failure
Authors: Ronco Claudio , Ricci Zaccaria , Bellomo Rinaldo , Bedogni Francesco
Published: April 2003

Fluid overload may occur in patients with congestive heart failure. Under normal conditions, this is treated with inotropic support and diuretics. However, when diuretics fail, fluid removal becomes uncontrolled and other therapeutic options must be undertaken. Extracorporeal ultrafiltration is a possible solution to restore a status of fluid balance close to normal. Several new technologies have made ultrafiltration available today in all centers and easy to be instituted. Acute isolated schedules of ultrafiltration may, however, be too aggressive and result in severe hemodynamic instability. For this reason, continuous extracorporeal techniques have been applied in such patients and the therapy is generally carried out with success. Excellent hemodynamic stability, a good cardiovascular response and often diuresis restoration are the most common effects encountered using continuous forms of extracorporeal fluid removal. The potential for a home-based application of these techniques represents a further stimulating concept to be investigated.
Long-Term Follow-Up with Stress Echocardiograms of Patients with Kawasaki’s Disease
Authors: Dunning Dennis W. , Hussey Mary E. , Riggs Thomas , Bestervelt Ronald , Goerke Cindy
Published: April 2003

Patients with a history of Kawasaki’s disease (KD), particularly those not treated with intravenous γ-globulin, are at risk of coronary artery aneurysms and later obstruction. Twenty-eight patients with a history of KD (4 had coronary artery aneurysms) were examined with stress echocardiograms. Fourteen patients received γ-globulin ≤10 days of the onset, 8 patients received γ-globulin >10 days and 6 received no γ-globulin. The mean age at diagnosis was 7.2 ± 4.1 years; the median follow-up was 8.0 ± 7.4 years. All tests were negative. Using a binomial model, a power of 0.80, a sensitivity of each test of 80% and assuming uniform risk, the individual rate of failure to detect was <7%. At least 640 patients in each group would be needed to detect a difference of 3.5% vs. 7.0% and 184 in each group would be needed to detect a difference of 1.5% vs. 7.5%. We conclude that the probability of an abnormal stress echo in asymptomatic patients with a history of KD is at most 7% and that a more precise determination of the risk of an abnormal stress echo in KD requires a much larger study.
Differences in the Salivary Glycan Pattern between Children with High and Low Caries Susceptibility
Authors: Seemann R. , Zimmer S. , Bizhang M. , Kage A.
Published: April 2003

Interactions between bacterial adhesins of lectin type and the oligosaccharide part of immobilised glycoconjugates on the tooth surface are involved in the specific colonisation of teeth. The specificity of the adhesion process is determined by the carbohydrate specificity of the bacterial lectins and the availability of the corresponding glycosylation pattern. On the other hand the same carbohydrate structures can specifically prevent the binding of bacteria by competitively blocking their adhesion, if sufficient amounts of this distinct carbohydrate structure are available in the secretion. Since carbohydrate binding receptors are also involved in the colonisation of tooth surfaces by cariogenic bacteria, it has been suggested that the architecture of the oligosaccharide portion of soluble glycoconjugates in saliva may play an important role as a constitutional host defence factor in the aetiology of dental caries. Characterising the availability of distinct carbohydrate patterns in saliva by using a pattern of well–described lectins in a competitive lectin inhibition assay we show that in children of a population–based sample a high caries susceptibility is associated with a reduced binding inhibition against the lectin peanut agglutinin (PNA). PNA is specific for the presence of terminal galactosyl residues and binds to the same O–glycan fractions as a surface lectin from Streptococcus mutans. The data suggest that a reduced availability of glycosylation patterns of galactosyl residues detected by the lectin PNA may act as an additional host–derived factor for an increased caries susceptibility.
Fluoride Concentrations of Unstimulated Whole and Labial Gland Saliva in Young Adults after Fluoride Intake with Milk
Authors: Boros I. , Keszler P. , Bánóczy J.
Published: April 2003

Following a fluoride depletion period 6 subjects repeatedly rinsed with 30–ml volumes of milk with or without added fluoride (5 ppm). Rinsing time was timed according to the measurements on how long it took to drink 200 or 500 ml milk. Rinsing with fluoridated milk for a total interval of 20 and 60 s, respectively, did not influence significantly the fluoride concentration of unstimulated centrifuged whole saliva 45 min later. Neither the urinary fluoride concentration nor the fluoride excretion were significantly affected by rinsing with fluoridated milk during the first hour. However, intake of 1 or 2.5 mg of fluoride with 200 and 500 ml milk, respectively, resulted in significant elevations in whole saliva fluoride levels 45 min later. In addition, the fluoride excretions into urine produced during 60 min after the fluoride intakes were significantly elevated and those reflected the ingested dose of fluoride. The intake of either 1 or 2.5mg fluoride with milk did not significantly influence the fluoride level of unstimulated labial gland saliva collected simultaneously with whole saliva.
Peroxidase Reaction as a Parameter for Discrimination of Streptococcus mutans and Streptococcus sobrinus
Authors: Rupf S. , Merte K. , Eschrich K. , Stösser L. , Kneist S.
Published: April 2003

425 strains of mutans streptococci and 12 reference strains were investigated by membrane fatty acid spectra (MFAS) and peroxidase reaction (PR) after aerobic and anaerobic incubation. 423 strains were identified as Streptococcus mutans. The remaining 2 strains were identified as Streptococcus sobrinus. The PR of 29 strains was doubtful; immediately after anaerobic incubation a negative PR changed into a slightly positive PR. To test the diagnostic value of PR the strains were additionally investigated by means of species–specific polymerase chain reactions (PCR). The species–specific PCRs were developed on the basis of the respective genes of 16S rRNA of the pathogens S. mutans and S. sobrinus. Specificity and sensitivity were tested on reference strains (n = 17) and negative control strains (n = 39). The results of this investigation showed that an anaerobic incubation regime could lead to false–positive (S. mutans) or false–negative (S. sobrinus) PR. The 425 MS strains were classified as either S. mutans (n = 420) or S. sobrinus (n = 5). The findings on the reference strains required a reclassification of S. mutans V 100 into S. sobrinus V 100. Summarising, it is possible now to differentiate strains of mutans streptococci by MFAS and PR after aerobic incubation.
What Questions Can Large, Simple Trials Answer?
Authors: Sandercock Peter
Published: April 2003

Large, simple trials can provide reliable evidence on the balance of risk and benefit of widely practicable treatments that have moderate effects on major clinical outcomes. Treatments for stroke will potentially be used extensively world-wide. Each year about 8,000,000 people have an acute stroke, with about 5,000,000 being ischaemic. Of these, perhaps 1,000,000 receive medical attention within the first few hours of stroke onset. If reliable decisions about the treatment of such large numbers of patients are to be made, we need to be certain about the effects of treatment on death from any cause (and on other important outcomes) and in many different types of patient. Generally, such reliable evidence on whether to treat and on whom to treat, will only come from large, randomised trials recruiting many thousands of patients. Such trials are only feasible and affordable if they are simple.
Carotid Artery Disease and the Risk of Ischaemic Stroke and Coronary Vascular Events
Authors: Rothwell P.M.
Published: April 2003

Information on the presence and extent of carotid arterial wall disease has significant prognostic value. Carotid artery stiffness, intima-media thickness, and early plaque formation are potentially useful predictors of the risk of both ischaemic stroke and coronary heart disease in asymptomatic populations. Early carotid arterial wall disease is also a useful predictor of coronary artery disease on angiography and subsequent coronary vascular events in populations at risk of coronary heart disease. More advanced carotid wall disease (carotid stenosis and plaque surface morphology) is predictive of both ischaemic stroke and coronary heart disease in high-risk populations with established cerebrovascular disease. Plaque characteristics on ultrasound, such as echolucency, may also have a prognostic value. However, in order to identify individuals with high risks of vascular events, this information must be combined with other clinical, laboratory, and imaging data. Ideally, large prospective cohort studies are required in which all these data are recorded and then combined using multivariate statistical modelling. Future studies should also determine the relationship between the various measures of carotid wall disease and the risk of stroke for the different subtypes of ischaemic stroke.
Imaging of Acute Stroke
Authors: Moonis Majaz , Fisher Marc
Published: April 2003

The utility of diagnostic imaging during the critical first few hours after stroke onset has many important applications. First and foremost, imaging technologies that can reliably detect and quantify the location of acute stroke will greatly enhance the clinician’s ability to accurately diagnose individual stroke patients. Secondly, if imaging technology could provide information about the likely severity of the ischemic injury, patient prognosis and management would be enhanced. The possibility of potentially distinguishing severely injured and likely irreversible ischemic brain tissue from ischemic tissue likely not yet irreversibly injured may soon be attainable. The ability of imaging technology to reliably distinguish the status of focally ischemic brain will presumably dramatically impact upon patient management. This information, along with the data about the severity and extent of blood flow and tissue perfusion abnormalities, will help acute stroke care evolve beyond rigid time windows to individualized, pathophysiologically based treatment decisions. Not only will decisions to treat or not be made based upon imaging-derived status, but also the most appropriate type of therapy to be employed, i.e. thrombolysis, neuroprotection, therapy to reduce secondary reperfusion-related injury or combinations of these modalities. In this brief and necessarily incomplete overview of acute stroke imaging, the focus will be on new developments in CT and MRI.
Early Diagnosis of Hemorrhagic Transformation: Diffusion/Perfusion-Weighted MRI versus CT Scan
Authors: Nighoghossian N. , Hermier M. , Berthezène Y. , Wiart M. , Derex L. , Honnorat J. , Trouillas P. , Turjman F. , Froment J.C.
Published: April 2003

Standard magnetic resonance imaging (MRI) techniques failed to image adequately acute hemorrhagic transformation (HT). Therefore, computed tomography (CT) is still needed to exclude intracerebral hemorrhage. New MRI techniques such as diffusion- and perfusion-weighted imaging (DWI and PWI) may improve the early detection of HT. The utility of this approach requires a direct comparison of the sensitivity of CT with these MRI techniques. Methods: Nine patients experienced an acute carotid artery territory ischemic stroke diagnosed on a first CT performed 3.8 ± 2 h after the onset of stroke. They underwent a second CT 12 ± 4 h after the onset of stroke, followed 35 ± 10 min later by an MRI protocol including: (1) an axial isotropic DWI SE echo-planar imaging (EPI) sequence; (2) time of flight MR angiography (TOF MRA); (3) PWI with an axial T2*-weighted gradient echo EPI sequence using 20 ml gadolinium contrast agent (Gd-DTPA); HT was characterized on DWI SE EPI as a heterogeneous area of signal loss within the ischemic area; (4) at day 7, CT was also performed in all patients who had an early suspicion of bleeding according to MRI. Results: An HT was detected exclusively with CT in 1 out of 9 patients, while an MRI pattern of HT was found in 6 out of 9 patients. In 5 of these 6 patients, the CT scan did not show an obvious pattern of HT. Day 7 CT confirmed HT in all patients who had early suspicion of bleeding according to DWI criteria. Conclusion: This study suggests that new MRI techniques may allow an early detection of HT, thus improving the management of stroke.
Validity and Reliability of Simple Questions in Assessing Short- and Long-Term Outcome in Norwegian Stroke Patients
Authors: Berge Eivind , Fjærtoft Hild , Indredavik Bent , Sandset Per Morten
Published: April 2003

The utility of simple questions for the assessment of stroke outcome in large-scale international studies has generally been approved, but their validity and reliability have not been evaluated in different cultures or at different intervals after a stroke. The study comprised 150 stroke patients who had been admitted consecutively to a stroke unit 6 weeks or 6 months earlier. Two weeks before the visit the patient received a postal questionnaire containing the simple ‘dependency’ question: ‘In the last 2 weeks, did you require help from another person for everyday activities?’ and the simple ‘recovery’ question: ‘Do you feel that you have made a complete recovery from your stroke?’. The visit was performed by trained personnel unaware of the patient’s or his carer’s replies, and comprised the same 2 questions administered by the personnel, the Barthel ADL Index (BI) and the modified Rankin Scale (mRS). The patients’ functional status was categorised as good or bad according to the chosen cutoff levels on BI and mRS. At 6 months the dependency question had an accuracy of 83 and 82% in identifying patients with good or bad outcome, defined as BI ≧95 or <95 and mRS <3 or ≧3, respectively, whereas the recovery question had an accuracy of 86% when compared with mRS = 0 or >0. There was no difference in accuracy of the simple questions at 6 weeks compared with 6 months, and there was no clinically important difference between responses from patients and carers. The agreement between the responses to the questionnaire and the interview was good to moderate (ĸ = 0.62 for the dependency question, and 0.55 for the recovery question). We conclude that the simple questions seem to be valid and reliable measures of stroke outcome when tested in Norwegian patients after 6 weeks or 6 months, which supports their continued use in large-scale multinational stroke studies at different intervals after stroke.
Diagnostic Impact of Early Transcranial Doppler Ultrasonography on the TOAST Classification Subtype in Acute Cerebral Ischemia
Authors: Wijman Christine A.C. , McBee Nichol A. , Keyl Penelope M. , Varelas Panayiotis N. , Williams Michael A. , Ulatowski John A. , Hanley Daniel F. , Wityk Robert J. , Razumovsky Alexander Y.
Published: April 2003

Objective: The impact of early transcranial Doppler ultrasonography (TCD) upon stroke subtype diagnosis is unknown and may affect therapeutic strategies. In this study, the diagnostic usefulness of TCD in stroke subtype diagnosis according to the criteria of the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) study was investigated in patients with acute cerebral ischemia. Methods: TCD examination within 24 h of symptom onset was performed in 50 consecutive patients with acute cerebral ischemia. Of these 54% were female. Sixty percent of patients were black, 36% white, and 4% Asian. Initial TOAST stroke subtype diagnosis (ITSSD) was based upon clinical presentation and initial brain imaging studies. Modified TOAST stroke subtype diagnosis was determined subsequently after additional review of the TCD examination. Final TOAST stroke subtype diagnosis was determined at hospital discharge, incorporating all diagnostic studies. Using final TOAST stroke subtype diagnosis as the ‘gold standard’ ITSSD and modified TOAST stroke subtype diagnosis were compared in order to determine additional benefit from the information obtained by TCD. Data were collected retrospectively by a single investigator. Results: ITSSD classified 23 of 50 (46%) patients correctly. After TCD, 30 of 50 (60%) patients were classified correctly, for an absolute benefit of 14% and a relative benefit of 30% (p = 0.018). Most benefit from TCD was observed in the TOAST stroke subtype category large-artery atherosclerosis, in particular in patients with intracranial vascular disease. In this category, ITSSD had a sensitivity of 27% which increased to 64% after TCD (p = 0.002). Conclusion: TCD within 24 h of symptom onset improves the accuracy of early stroke subtype diagnosis in patients with acute cerebral ischemia due to large-artery atherosclerosis. This may have clinical implications for early therapeutic interventions.
Socioeconomic Inequalities in the Incidence, Mortality and Prognosis of Subarachnoid Hemorrhage: The FINMONICA Stroke Register
Authors: Jakovljević Dimitrije , Sivenius Juhani , Sarti Cinzia , Torppa Jorma , Mähönen Markku , Immonen-Räihä Pirjo , Kaarsalo Esko , Alhainen Kari , Tuomilehto Jaakko , Puska Pekka , Salomaa Veikko
Published: April 2003

Low socioeconomic status (SES) is associated with increased mortality from stroke, but usually no distinction is made between stroke subtypes. We analyzed the relationship of SES with mortality and morbidity of subarachnoid hemorrhage (SAH). In the FINMONICA Stroke Register, 956 consecutive SAH events were recorded during 1983–1992 in patients aged 25–74 years. We used taxable income stratified into three categories, low, middle, and high, as an indicator of SES. The age-standardized incidence of SAH among men and women aged 25–44 years was approximately three times higher in the low-income group than in the high-income group. In older individuals, differences between the income groups were less pronounced. Among survivors of the acute stage, a poorer prognosis was observed in patients with low income than in those with high income. In conclusion, there is a clear excess mortality and morbidity of SAH in young individuals with low income, particularly among men.
Transcranial Doppler Detection of Cerebral Microemboli during Left Heart Catheterization
Authors: Leclercq Florence , Kassnasrallah Saad , Cesari Jean-Baptiste , Blard Jean-Marie , Macia Jean-Christophe , Messner-Pellenc Patrick , Mariottini Claude-Jean , Grolleau-Raoux Robert
Published: April 2003

The role of transcranial Doppler ultrasonography (TCD) in individual risk assessment of embolic complications and the development of prevention strategies during coronary angiography remains to be determined. The purpose of this study was to assess the prevalence, time of occurrence and potential significance of microembolic signals (MES) detected with TCD during femoral left heart catheterization. TCD monitoring of the right and left middle cerebral artery was performed in 51 consecutive patients (36 men, 15 women) who were referred for coronary angiography. Percutaneous coronary angioplasty was performed during the same procedure in 16 patients. MES were counted manually during and after (off-line analysis) the procedure. Two patients were excluded from analysis because of the absence of an adequate acoustic temporal window. No neurological event occurred within 24 h in the 49 included patients. MES were detected in all except 2 patients (mean number 17.1 ± 12.8 per patient), mainly during left ventriculography (38%) and contrast media injection into the coronary arteries (55%), suggesting their gaseous origin. There was no statistically significant association between the number of MES and patient age, cardiovascular history and risk factors, or catheterization results. The presence of coronary artery disease was inversely related to the number of MES (15.8 ± 0.3 compared to 21.8 ± 0.2 per patient when a normal angiogram was present; p < 0.05). In conclusion, although asymptomatic microemboli commonly occur during left heart catheterization, the majority of them are probably of gaseous origin, since they occurred predominantly during contrast media injection in this study, and were not related to cardiovascular history or to atheroma risk factors. Because air embolism has been reported to be harmful, attempts to reduce its occurrence during catheter-based procedures could be pertinent.
Hyperhomocyst(e)inemia Is a Risk Factor of Secondary Vascular Events in Stroke Patients
Authors: Del Ser Teodoro , Barba Raquel , Herranz Antonio Sánchez , Seijas Victoria , López-Manglano Cruz , Domingo Julio , Pondal Margarita
Published: April 2003

Objective: Moderate hyperhomocyst(e)inemia is an independent risk factor for stroke, but it is unclear whether it also would be a risk factor for secondary vascular events after stroke. Methods: Longitudinal study of 137 consecutive ischemic stroke patients (age 45–91 years) who were prospectively studied with a standard clinical protocol. Vascular events (stroke recurrence, ischemic heart disease, deep venous thrombosis or peripheral arterial disease) were identified during 2 years of follow-up. Serum homocyst(e)ine was determined 3 months after the stroke. The cumulative proportion of patients with homocyst(e)ine above or below the 75th percentile who survived free of vascular events was determined by Kaplan-Meier analysis. Cox models were used to estimate the relative risk of vascular events after controlling for other confounding factors. Results: Serum homocyst(e)ine was significantly higher in patients with vascular events (26.2 versus 19.4 µmol/l; p = 0.016). The cumulative proportion of patients with vascular events was 46.5% in the group with homocyst(e)ine over the 75th percentile (>30 µmol/l) and 20.2% in the other group (log-rank test 7.5; p = 0.0062). After adjustment for age, sex, high blood pressure, diabetes, heart disease, previous cerebrovascular disease, smoking and serum cholesterol, the relative risk of vascular event for patients above compared with those below the 75th percentile of serum homocyst(e)ine was 2.8 (CI 95% 1.3–6; p = 0.01). Conclusion: Hyperhomocyst(e)inemia is a significant risk factor for vascular events after ischemic stroke. This finding is independent of other risk factors such as hypertension, and may have therapeutic relevance in the secondary prevention of vascular diseases in stroke patients.
Lack of Evidence for a Poor Haemodynamic or Metabolic State of the Brain in Patients with Haemodynamic Clinical Features Associated with Carotid Artery Occlusion
Authors: Klijn C.J.M. , Kappelle L.J. , van der Grond J. , Visser G.H. , Algra A. , Tulleken C.A.F. , van Gijn J.
Published: April 2003

Objective: To assess whether patients with carotid artery occlusion (CAO) who have clinical features suggesting a haemodynamic origin have a poor haemodynamic or metabolic state of the brain. Methods: In 117 patients with ischaemic symptoms of the eye or brain that were transient or at most moderately disabling and associated with a CAO, we compared CO2 reactivity, quantitative flow measurement by magnetic resonance (MR) angiography, metabolic ratios measured by 1H-MR spectroscopy, collateral blood flow patterns and the presence of infarcts of the borderzone type between patients grouped by the following clinical features: (1) presence or absence of at least one of the ‘classical’ haemodynamic symptoms: limb shaking, retinal claudication, precipitation of symptoms by exercise, by rising from a sitting or lying position, by transition from a cold to a warm environment, or by documented hypotension, and (2) symptoms having occurred after demonstration of the CAO or only before the occlusion was documented. Results: Patients with (n = 16) and without (n = 101) one of the ‘classical’ haemodynamic symptoms did not differ in any of the measured indices. Patients with recurrent symptoms after documentation of the CAO (n = 56) had lower CO2 reactivity (difference 8.3%, 95% confidence interval 0.1–16.5) than those with symptoms only before documentation of the occlusion (n = 61), whereas no significant differences were found in any of the other measured indices. The difference in CO2 reactivity was no longer significant after adjustment for the interval between the patients’ last symptoms and the CO2 reactivity measurement. Conclusion: In patients with CAO we could not find an association between symptoms that have been associated with hypoperfusion and a poor haemodynamic or metabolic state of the brain.
Stroke Pattern Interpretation: The Variability of Hypertensive versus Amyloid Angiopathy Hemorrhage
Authors: Lang Erhard W. , Ren Ya Zhan , Preul Christoph , Hugo Heinz-Hermann , Hempelmann Ralf G. , Buhl Ralf , Barth Harald , Klinge Hartwig , Mehdorn H. Maximilian
Published: April 2003

Introduction: It is commonly felt that cerebral amyloid angiopathy (CAA) related intracerebral hemorrhage (ICH) can be distinguished from hypertension (HTN)-related ICH by certain typical features on computerized tomography (CT) and magnetic resonance imaging (MRI). The purpose of this study was to investigate the performance of clinicians who were asked to differentiate between CAA and HTN based on hemorrhage pattern interpretation and to assess the feasibility of such classification. Methods: The admission scans from 83 patients who were admitted to our service with an acute ICH were presented to 5 clinicians in a randomized and blinded fashion (1 junior, and 1 senior neurosurgical resident, 1 attending neurosurgeon, and 2 neurosurgeon-neuroradiologists). There were no patients who received oral anticoagulants other than low-dose aspirin, or who suffered from vascular malformations or tumors. Scans from 41 patients with a histologically proven diagnosis of CAA and from 42 patients with a clear history of HTN were investigated. Hematoma evacuation was done in all CAA patients and in 59% of HTN patients (n = 25). Results: The overall average classification accuracy was 66.8% (range: 62.7–69.9). For correct HTN classification it was 69.5% (range: 64.3–81), and 63.9% for CAA, respectively (range: 48.9–75.6). There were negligible differences in classification accuracy among all observers. Patients with a CAA-related ICH were significantly older than patients with a HTN-related ICH (74 vs. 66.5 years, p < 0.05). There was a significantly higher number of hematomas >30 ml in CAA (85.3%) when compared with HTN (59.5%). No basal ganglionic hemorrhage was seen in CAA, but in 40.5% in HTN. Intraventricular hemorrhage was seen in 24.4% in CAA, and in 26.2% in HTN. Two patients (4.9%) with CAA, and 7 patients with HTN (16.7%) presented with cerebellar hematomas. Conclusions: Three of 10 scans were not correctly diagnosed regardless of the examiner’s level of training. This calls into question the reliability of classifying the underlying pathological condition based on hemorrhage pattern interpretation on CT or MRI. The definite diagnosis of CAA- versus HTN-related hemorrhage requires a histopathological confirmation and should not be based solely on hemorrhage pattern interpretation.
The Influence of Food Ingestion on Blood Pressure in Stroke Patients
Authors: Rowat Anne M. , Wardlaw Joanna M. , Dennis Martin S. , Warlow Charles P.
Published: April 2003

We aimed to investigate whether and how often changes in blood pressure (BP) were occurring in relation to eating in a large sample of acute stroke patients. BP was measured non-invasively at 5-min intervals from 10 min before the meal, throughout the meal and for 10 min after completion of the meal while the patient was seated. Stroke patients (n = 93) had a higher BP at baseline than both elderly (n = 49) and young controls (n = 20), which was statistically significant. There were no significant differences in the magnitude of change of BP during the meal between the three groups. Compared with the average baseline BP recordings, stroke and elderly control patients, but not young healthy control subjects, had a significant fall in average BP recordings by 3–4 mm Hg. Falls of ≧10 mm Hg in systolic BP immediately after finishing the meal were observed in a similar frequency of stroke (26%) and elderly patients (22%) and in a small number of young controls (10%). These data suggest that acute stroke and elderly patients have similar changes in BP during and immediately after eating. Although reassuring, these results may have greater implications in patients with acute ischaemic stroke, although it is unclear whether changes in BP of this magnitude and duration might influence the fate of the penumbral brain tissue and thus the clinical outcome after stroke.
Transcranial Doppler Monitoring in Hypertensive Patients during Physical Exercise
Authors: Magyar Mária Tünde , Valikovics Attila , Bereczki Dániel , Ficzere Andrea , Czuriga István , Csiba László
Published: April 2003

Purpose: To evaluate the diagnostic value of a combined method, i.e. ergometer cycling with continuous bilateral transcranial Doppler monitoring (TCD) to detect cerebral hemodynamic abnormalities in recently diagnosed hypertensive patients. Methods: 30 neurologically symptom-free, nontreated patients with essential hypertension and 30 age- and sex-matched controls were studied. Carotid ultrasound, resting ECG and blood parameters were investigated. Cycling ergometry was performed according to the WHO protocol. Blood pressure, heart rate, end-tidal CO2 (etCO2) and bilateral middle cerebral artery (MCA) blood flow velocity (MV) were monitored. Results: At rest, MV in the MCA did not differ significantly between controls and hypertensive subjects. MV continuously increased in controls until the end of loading whereas a plateau was reached at 4 min in hypertensive subjects. During 6 min of cycling, the time course of absolute values of MV in the MCA and that of the changes in the ratio of mean velocity/end-tidal CO2 (ΔMV/ΔetCO2) differed significantly between hypertensive subjects and controls (p = 0.03 and p = 0.02, respectively). Conclusion: Ergometer cycling combined with TCD revealed altered vasoreactivity, therefore this may be a sensitive method for the detection of early hemodynamic impairment in nontreated hypertensive subjects.
Bleeding Risk of Tirofiban, a Nonpeptide GPIIb/IIIa Platelet Receptor Antagonist in Progressive Stroke: An Open Pilot Study
Authors: Junghans Ulrich , Seitz Rüdiger J. , Aulich Albrecht , Freund Hans-Joachim , Siebler Mario
Published: April 2003

Background:Glycoprotein (gp) IIb/IIIa-receptor antagonists are highly effective antiplatelet agents with proven efficacy in the treatment of acute coronary and experimental cerebral ischemia. In this study we examined the rate of hemorrhagic transformation and major bleedings in patients with acute stroke treated with tirofiban, a nonpeptide gpIIb/IIIa antagonist. Methods: Eighteen patients with progressively deteriorating acute ischemic stroke were treated with body-weight adjusted intravenous tirofiban for a mean period of 46 h and compared with a matched group of 17 acute ischemic clinically stable stroke patients. Cerebral hemorrhage was assessed by cranial imaging 6–10 days after symptom onset. Results: No major intracranial hemorrhage was observed in either group. Clinically asymptomatic hemorrhagic infarctions type I/II/III were detected in 4/2/0 controls and in 4/1/1 patients of the tirofiban group, respectively (OR = 0.92; 95% CI 0.4–2.5). Clinical outcome scores were not different in both groups (p = 0.18). Conclusions: Tirofiban was not associated with a significantly increased cerebral bleeding rate in acute ischemic stroke. Randomized multicenter studies are needed to further evaluate the safety and efficacy of tirofiban in the treatment of acute stroke.
Parental Causes of Death in Primary Intracerebral Haemorrhage
Authors: Starr John M. , Rush Margaret , Dennis Martin S.
Published: April 2003

There are many reports of familial aggregation in stroke. Previously, examining parental causes of death, we found no evidence for familial risk in stroke once socioeconomic and socioenvironmental factors were controlled for. However, the number of patients with primary intracerebral haemorrhage (PICH) was small in this sample and we could not exclude a moderate effect of familial factors in this important subgroup. We therefore matched all cases with PICH on the Lothian Stroke Register with 2 controls per case of the same sex, born in the same year, district, and whose fathers had the same occupation. Presence on parental death certificates of cerebrovascular disease, other vascular disease, bronchial carcinoma, hypertension, diabetes mellitus and other causes of death was recorded. No significant difference in risk was found for cases with parental cerebrovascular disease (OR 0.75, 95% CI 0.40–1.40). Other forms of vascular disease in parents were not associated with significant risk either (OR 0.93, 95% CI 0.51–1.68). We conclude that familial factors do not contribute substantially to risk in most cases of PICH.