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Biomedical subjects

A Rudd

Publications and source records attributed to A Rudd.

At least 19 recordsLinked to original sources
PubMed2004

Venous thromboembolism after acute ischemic stroke: a prospective study using magnetic resonance direct thrombus imaging.

BACKGROUND AND PURPOSE: We prospectively evaluated the prevalence and clinical risk factors for venous thromboembolism (VTE) after acute ischemic stroke using magnetic resonance direct thrombus imaging, a highly accurate noninvasive technique that directly visualizes thrombus.Method-102 unselected patients with AIS receiving standard prophylaxis with aspirin and graded compression stockings (GCS) were sequentially recruited, underwent regular clinical assessments, and were screened for VTE. RESULTS: The prevalence of all VTE, proximal deep vein thrombosis (PDVT), and pulmonary embolism (PE) after 21 days were 40%, 18%, and 12%, increasing to 63%, 30%, and 20% in patients with Barthel indices (BI) of < or =9 2 days after stroke (BI-2< or =9). Clinical deep vein thrombosis and PE occurred in 3% and 5% overall; half these events were overlooked by the attending team. The true incidence of clinical events is probably higher because the natural history of subclinical PDVT was modified by screening and anticoagulation. BI-2< or =9 or nonambulatory status 2 days after stroke were the clinical factors most strongly associated with subsequent VTE on univariate analysis. Odds ratios for any VTE and PDVT for BI-2< or =9 versus >9 were 8.3 (95% CI, 2.7 to 25.2) and 8.1 (95% CI, 1.7 to 38.3) on multivariable analysis. CONCLUSIONS: BI < or =9 or nonambulatory status around the time of admission identifies a subgroup of acute ischemic stroke patients at very high risk for VTE in whom the current strategy of thromboprophylaxis may be inadequate. Future thromboprophylactic studies should focus on the patients at high risk defined in this study.

Aged↗
PubMed2004

Dehydration and venous thromboembolism after acute stroke.

BACKGROUND: Although it is widely assumed that dehydration predisposes to venous thromboembolism (VTE), there are no clinical studies to support this. AIM: To evaluate the relationship between biochemical indices of dehydration and VTE after acute ischaemic stroke (AIS). DESIGN: Prospective observational study. METHODS: Unselected AIS patients (n = 102) receiving standard thromboprophylaxis with aspirin and graded compression stockings, underwent serial measurements of serum urea, creatinine and osmolality, and were screened for VTE using magnetic resonance direct thrombus imaging. RESULTS: Serum osmolality of >297 mOsm/kg, urea >7.5 mmol/l and urea:creatinine ratio (mmol:mmol) >80 a few days post-AIS were associated with odds ratios for VTE of, respectively, 4.7, 2.8 and 3.4 (p = 0.02, 0.05, 0.02) on multivariable analysis. DISCUSSION: Dehydration after AIS is strongly independently associated with VTE, reinforcing the importance of maintaining adequate hydration in these patients.

Aged↗
PubMed2004

Screening for proximal deep vein thrombosis after acute ischemic stroke: a prospective study using clinical factors and plasma D-dimers.

Deep vein thrombosis (DVT) remains common in patients with acute ischemic stroke (AIS) receiving aspirin and graded compression stockings (considered standard thromboprophylaxis in the UK), most events occurring in patients with Barthel indices (BI) of <9 ('severe stroke') around the time of admission. In the absence of data indicating improved clinical outcomes with use of low-dose anticoagulant thromboprophylaxis, we evaluated the hypothesis that plasma D-dimers (D-d) might be a valuable initial screening test for proximal DVT (PDVT), facilitating selective use of imaging. One hundred and two unselected AIS-patients receiving aspirin/graded compression stockings thromboprophylaxis were screened for DVT using magnetic resonance direct thrombus imaging, a highly accurate non-invasive technique which directly visualizes thrombus. D-d (VIDAS and IL test D-d assays) were measured on recruitment and at weekly intervals. Median D-d were significantly higher throughout the study in patients with severe stroke who developed PDVT vs. those with severe stroke not developing PDVT, differences being most marked around day 9. Depending on the discriminatory threshold used, a single D-d measurement at this time in patients with severe-AIS allowed identification of a subgroup with ~50% prevalence of PDVT. Sensitivity of these strategies for PDVT was 67-83%, at a cost of imaging 22-30% of the entire cohort of patients. A single measurement of BI around the time of admission and D-d level at day 9 in AIS-patients receiving aspirin/graded compression stockings thromboprophylaxis allows identification of a subgroup containing a substantial proportion of all PDVTs who could be selectively imaged.

Age Factors↗
PubMed2004

Variations in care and outcome in the first year after stroke: a Western and Central European perspective.

BACKGROUND: There are significant variations in the short term patterns of care and outcome after a first stroke in Europe. OBJECTIVE: To estimate the variation in stroke care and outcome up to 1 year after a stroke in selected European centres. METHODS: Hospital based stroke registers were established in 11 hospitals in seven western and central European countries to collect demographic, clinical, and resource use data at the time of first ever stroke during 1993-4. At 3 and 12 months, details of survival, activities of daily living score, and use of services were recorded. Univariate comparisons between centres were made using the chi2 test and stepwise regression was used to identify associations between centre, case mix, therapy provision, and outcomes. RESULTS: Of the 4048 patients registered, 23% were lost to follow up and 38% had died at 1 year. The proportions of survivors who felt they needed assistance at 12 months ranged from 35% in Italy to 77% in UK2. There were comparatively high amounts of therapy provided up to 1 year in UK3, France and Germany 1, mainly at home. At 1 year, social services were still providing support in UK1, UK5 and France, with some support in Germany 1 and family support was provided in France. In multivariate analysis, after adjustment for case mix and receipt of rehabilitation, non-UK centres had improved activities of daily living (p<0.001). Older age was indicative of more need for assistance, but less likelihood of assistance from the family. Those in France were more likely to get assistance from their family than any other centre. Mainland European patients were more likely to get help from their family than those in the UK. Patients in all areas except UK2 and UK3 were more likely to be dead or dependent at 1 year than patients in UK1. CONCLUSIONS: There were significant variations in the pathways of care for stroke across European centres in the mid 1990s, which were associated with variation in outcome, and remain unexplained. Family support is more prevalent in southern Europe and service support more prevalent in the UK.

Activities of Daily Living↗
PubMed2003

Anticoagulation or inferior vena cava filter placement for patients with primary intracerebral hemorrhage developing venous thromboembolism?

BACKGROUND: Most patients with primary intracerebral hemorrhage developing clinically apparent proximal deep vein thrombosis (DVT) and/or pulmonary embolism (PE) require treatment with either anticoagulants or inferior vena cava filter insertion. Although the latter probably reduces the immediate risk of incident or recurrent PE and surmounts the undefined risk of recurrent intracranial bleeding with anticoagulation, the issue of preventing further thrombus propagation is not addressed, and there are associated short- and long-term risks, including a greater incidence of recurrent DVT. SUMMARY OF REVIEW: There are no data from randomized trials to clarify optimum treatment in these patients; indeed, the feasibility of such studies is questionable. Hence, treatment decisions continue to be made on an individualized basis and should include assimilation of information on key factors such as time elapsed post-stroke and lobar versus deep hemispheric location of the index event, natural history studies demonstrating a two-fold risk of recurrent intracerebral hemorrhage in the former subgroup. CONCLUSIONS: In patients selected for anticoagulation, data from nonstroke patients suggest that a 5- to 10-day course of full-dose low-molecular-weight heparin followed by 3 months of lower-dose low-molecular-weight heparin is at least as effective as warfarin and may be associated with fewer hemorrhagic complications.

Anticoagulants↗
PubMed2003

Variation in the management of acute physiological parameters after ischaemic stroke: a European perspective.

Studies have shown significant variation in stroke case fatality across Europe. These variations suggest the need to explore whether differences in physiological support in acute stroke exist across Europe. Data were collected in four European centres over 6 months. These included clinical status and management of acute physiology (hydration, oxygenation, nutrition, hypertension, hyperglycaemia and temperature in the first week of ischaemic stroke) and survival at 3 months. Differences in acute supportive care between centres were adjusted for case mix. Patients admitted to centres in London (n = 106), Dijon (n = 95), Erlangen (n = 91) and Warsaw (n = 72) were studied. There were significant differences in incontinence, dysphasia, dysphagia, conscious level, pyrexia, hyperglycaemia and comorbidity between centres. After adjusting for case mix, there were significant differences in intravenous fluid use (P = 0.04), enteral feeding (P = 0.003), initiation of new antihypertensive therapy (P = 0.0006) and insulin therapy (P = 0.004) between centres, with the London centre having the lowest uptake of interventions. Three-month case fatality rates varied from 10 to 28%. This pilot study shows significant variation in acute physiological support in acute stroke across four European centres, which remains unexplained by case mix. Further research is required to link variation in acute care with stroke outcome, to identify which interventions appear to be the most effective.

Acute Disease↗
PubMed2003

Management of stroke.

This article outlines the current evidenced based practice for stroke care. It outlines many of the recommendations in the National Clinical Guidelines for Stroke published by the Royal College of Physicians. It also covers all aspects of multidisciplinary stroke care from initial assessment and acute treatment to rehabilitation strategies and management of complications. The article concludes with an examination of the latest evidence for secondary prevention of cerebrovascular disease.

Delivery of Health Care↗
PubMed2001

Preventable risk factors for coronary heart disease and stroke amongst ethnic groups in London.

OBJECTIVES: People of African Caribbean descent have higher mortality rates from stroke than other ethnic groups. However, little is known about the prevalence of stroke risk factors in UK ethnic minority groups. We investigated the prevalence of these risk factors amongst African Caribbeans, black Africans and whites. DESIGN: A random sample of patients aged 45-74 registered with 16 general practices in south London was surveyed in 1995. Main outcome measures were: prevalence of hypertension, mean serum cholesterol, serum fibrinogen and glycosylated haemoglobin AIC. Logistic and linear regressions were used to determine ethnic differences in these measures. RESULTS: Hypertension was more prevalent in black Caribbeans (79.4%) and black Africans (71.6%) than in whites (54.3%) (p < 0.0001). There were ethnic group differences in mean random total cholesterol (p < 0.0001), triglycerides (p < 0.0001), fibrinogen (p = 0.03), HDL (p = 0.02) and HbAIC (p < 0.0001). Whites had higher mean random total cholesterol, triglycerides and fibrinogen than black Caribbeans but lower HDL and HbA1C. Black Africans had similar rates to black Caribbeans for these risk factors apart from lower triglvceride levels. CONCLUSION: These differences in risk factors may partially explain the high stroke mortality rates in black Caribbeans and black Africans compared to whites. There was little difference in prevalence of these risk factors between black Caribbean and black African groups. Specific strategies targeted to each ethnic group need to be developed to reduce risk factors.

Africa↗
PubMed2001

Venous thromboembolism after acute stroke.

BACKGROUND: Treatment for venous thromboembolism (VTE) is highly effective in preventing morbidity and mortality, yet pulmonary embolism (PE) accounts for up to 25% of early deaths after stroke. This is because the current diagnostic paradigm is reactive rather than proactive: the clinician responds to VTE when it becomes symptomatic, in the expectation that initiation of treatment will prevent progression to more serious manifestations. This approach is flawed, because sudden death from PE is frequently unheralded and nonfatal symptomatic pulmonary emboli are often unrecognized or misdiagnosed. SUMMARY OF COMMENT: Morbidity and mortality from PE could be reduced either by more effective thromboprophylaxis or earlier diagnosis and treatment of established VTE. The fact that early use of short-term, low-dose, unfractionated heparin (UFH) is not associated with sustained, clinically meaningful benefit suggests that a fundamental change in the diagnostic approach to VTE is needed, one which requires a greater appreciation that clinically apparent events are merely the tip of the thromboembolism iceberg. CONCLUSIONS: Research into a strategy of screening for subclinical VTE in these patients is needed, with a view to identifying a subgroup at risk of progression to symptomatic and life-threatening events, in whom outcome might be improved by anticoagulation.

Anticoagulants↗
PubMed2001

The natural history and associations of sleep disordered breathing in first ever stroke.

Although the prevalence of sleep-disordered breathing (SDB) in patients following stroke has been found to be high, there are few data about whether these changes persist in the months that follow stroke. The present study aims to confirm the prevalence of SDB following first ever stroke, to investigate an association between SDB and subtype of stroke and to determine the change in SDB three months following a first ever stroke.

Aged↗
PubMed2000

Qualitative analysis of stroke patients' motivation for rehabilitation.

OBJECTIVE: To explore the attitudes and beliefs of stroke patients identified by professionals as having either "high" or "low" motivation for rehabilitation. DESIGN: Qualitative study with semistructured interviews. SETTING: The stroke unit of an inner city teaching hospital. PARTICIPANTS: 22 patients with stroke who were undergoing rehabilitation; 14 with high motivation for rehabilitation and eight with low motivation. RESULTS: All patients thought rehabilitation was important for recovery. High motivation patients were more likely to view rehabilitation as the most important means of recovery and to accord themselves an active role in rehabilitation. These patients were also more likely to understand rehabilitation and in particular to understand the specialist role of the nursing staff. Many patients reported independence at home as a personal goal, though few low motivation patients related this goal to success in rehabilitation. Information from professionals about rehabilitation, favourable comparisons with other stroke patients, and the desire to leave hospital had a positive effect on motivation. Conversely, overprotection from family members and professionals, lack of information or the receipt of "mixed messages" from professionals, and unfavourable comparisons with other patients had a negative effect. CONCLUSIONS: There are some differences in beliefs between stroke patients identified as having low or high motivation for rehabilitation. These beliefs seem to be influenced by the environment in which the patient is rehabilitated. Professionals and carers should be made aware of the ways in which their behaviour can positively and negatively affect motivation.

Adult↗