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Biomedical subjects

G J Hankey

Publications and source records attributed to G J Hankey.

At least 55 records · Page 3Linked to original sources
PubMed1999

Stroke: how large a public health problem, and how can the neurologist help?

Stroke is an enormous public health problem, the magnitude of which can be reduced mainly by effective stroke prevention and less so by effective treatment of acute stroke. The greatest effect is likely to be achieved by a mass approach to prevention, which consists of modification of lifestyle behaviors (eg, less smoking and less intake of salt, alcohol, and fat) among the general population through public education and, more importantly, government legislation. The appropriate identification and treatment of high-risk individuals by neurologists is likely to have a smaller but complimentary impact on the population burden of stroke and a substantial impact on the burden of stroke among individuals. The most cost-effective interventions for patients with transient ischemic attack and ischemic stroke are organized multidisciplinary acute care and rehabilitation in a stroke unit and early secondary prevention with aspirin, blood pressure control, smoking cessation, and, in the appropriate patient, oral anticoagulant therapy and carotid endarterectomy. The cost-effectiveness of carotid endarterectomy for asymptomatic carotid stenosis is highly questionable until data from ongoing trials (eg, Asymptomatic Carotid Surgery Trial) become available. Screening for asymptomatic carotid stenosis is more likely to be harmful than helpful, except perhaps among populations with a very high prevalence (pretest probability) of severe carotid stenosis. It is essential that the impact of these strategies on the incidence, outcome, and cost of stroke is measured and monitored. Currently, this is done simply, but unreliably, by examining changes in statistics that are already being measured, such as mortality (eg, among those younger than 70 years old, for greater accuracy). A growing priority in many countries is the development and implementation of valid, reliable, practical, and inexpensive methods of routinely collecting and evaluating data on stroke incidence, outcome, and cost.

Aged↗
PubMed1999

Trends in the incidence, severity, and short-term outcome of stroke in perth, Western Australia.

BACKGROUND AND PURPOSE: This report describes trends in the key indices of cerebrovascular disease over 6 years from the end of the 1980s in a geographically defined segment of the city of Perth, Western Australia. METHODS: Identical methods were used to find and assess all cases of suspected stroke in a population of approximately 134 000 residents in a triangular area of the northern suburbs of Perth. Case fatality was measured as vital status at 28 days after the onset of symptoms. Data for first-ever strokes and for all strokes for equivalent periods of 12 months in 1989-1990 and 1995-1996 were compared by age-standardized rates and proportions and Poisson regression. RESULTS: There were 355 strokes in 328 patients and 251 first-ever strokes (71%) for 1989-1990 and 290 events in 281 patients and 213 first-ever strokes (73%) for 1995-1996. In Poisson models including age and period, overall trends in the incidence of both first-ever strokes (rate ratio=0.75; 95% confidence limits, 0.63, 0.90) and all strokes (rate ratio=0.73; 95% confidence limits, 0.62, 0.85) were obviously significant, but only the changes in men were independently significant. Case fatality did not change, and the balance between hemorrhagic and occlusive strokes in 1995-1996 was almost indistinguishable from that observed in 1989-1990. CONCLUSIONS: Our results, which are the only longitudinal population-based data available for Australia for key indices of stroke, suggest that it is a change in the frequency of stroke, rather than its outcome, that is chiefly responsible nationally for the fall in mortality from cerebrovascular disease.

Adolescent↗
PubMed1999

Swallowing function after stroke: prognosis and prognostic factors at 6 months.

BACKGROUND AND PURPOSE: Swallowing dysfunction (dysphagia) is common and disabling after acute stroke, but its impact on long-term prognosis for potential complications and the recovery from swallowing dysfunction remain uncertain. We aimed to prospectively study the prognosis of swallowing function over the first 6 months after acute stroke and to identify the important independent clinical and videofluoroscopic prognostic factors at baseline that are associated with an increased risk of swallowing dysfunction and complications. METHODS: We prospectively assembled an inception cohort of 128 hospital-referred patients with acute first stroke. We assessed swallowing function clinically and videofluoroscopically, within a median of 3 and 10 days, respectively, of stroke onset, using standardized methods and diagnostic criteria. All patients were followed up prospectively for 6 months for the occurrence of death, recurrent stroke, chest infection, recovery of swallowing function, and return to normal diet. RESULTS: At presentation, a swallowing abnormality was detected clinically in 65 patients (51%; 95% CI, 42% to 60%) and videofluoroscopically in 82 patients (64%; 95% CI, 55% to 72%). During the subsequent 6 months, 26 patients (20%; 95% CI, 14% to 28%) suffered a chest infection. At 6 months after stroke, 97 of the 112 survivors (87%; 95% CI, 79% to 92%) had returned to their prestroke diet. Clinical evidence of a swallowing abnormality was present in 56 patients (50%; 95% CI, 40% to 60%). Videofluoroscopy was performed at 6 months in 67 patients who had a swallowing abnormality at baseline; it showed penetration of the false cords in 34 patients and aspiration in another 17. The single independent baseline predictor of chest infection during the 6-month follow-up period was a delayed or absent swallowing reflex (detected by videofluoroscopy). The single independent predictor of failure to return to normal diet was delayed oral transit (detected by videofluoroscopy). Independent predictors of the combined outcome event of swallowing impairment, chest infection, or aspiration at 6 months were videofluoroscopic evidence of delayed oral transit and penetration of contrast into the laryngeal vestibule, age >70 years, and male sex. CONCLUSIONS: Swallowing function should be assessed in all acute stroke patients because swallowing dysfunction is common, it persists in many patients, and complications frequently arise. The assessment of swallowing function should be both clinical and videofluoroscopic. The clinical and videofluoroscopic features at presentation that are important predictors of subsequent swallowing abnormalities and complications are videofluoroscopic evidence of delayed oral transit, a delayed or absent swallow reflex, and penetration. These findings require validation in other studies.

Aged↗
PubMed1999

Smoking and risk of stroke.

Up to one quarter of all strokes are directly attributable to cigarette smoking, which independently increases the relative risk of stroke about three-fold. The risk is dependent upon the amount of cigarettes smoked, is consistent for all subtypes of stroke, and is strongest for subarachnoid haemorrhage and cortical ischaemic stroke caused by arterial atherothromboembolism. The relative risk of stroke is equally high among male and female smokers, and is maximal (compared with non-smokers) n middle age, declining with advancing years. Evidence is also accumulating to implicate pipe and cigar smoking as a risk factor for stroke, and passive exposure to environmental smoke as a risk factor for atherogenesis. The risk of stroke declines considerably and rapidly after stopping smoking, thus supporting a causal relationship, even though it has proved impossible to perform a satisfactory randomised controlled trial. The mechanisms by which smoking causes stroke remain uncertain, but are probably multifactorial and primarily atherogenic.

Age Factors↗
PubMed1998

Heparin in acute ischaemic stroke. The T wave is negative and it's time to stop.

The use of heparin for acute ischaemic stroke has long been controversial. Although it may have some theoretical benefits in preventing fibrin formation and thrombus propagation, data from 16 randomised controlled trials involving more than 22,000 patients show that heparin produces no significant net benefit in eventual outcome.

Acute Disease↗
PubMed1998

Dominantly inherited proximal myotonic myopathy and leukoencephalopathy in a family with an incidental CLCN1 mutation.

A two generation family of Greek origin with mild myotonia, predominantly proximal muscle weakness, and cataracts compatible with the syndrome of proximal myotonic myopathy, is reported. In addition, brain MRI showed a diffuse leukoencephalopathy in the propositus. Molecular genetic studies showed the R894X mutation in exon 23 of the muscle chloride channel gene in the propositus but in only one of her two clinically affected offspring, indicating that it is not the mutation causing disease in this family.

Abnormalities, Multiple↗
PubMed1998

One year after CAPRIE, IST and ESPS 2. Any changes in concepts?

The IST, CAPRIE and ESPS-2 have shown that large collaborative randomised trials can be conducted in stroke medicine and can provide statistically and clinically significant results. They, and other concurrent studies, have highlighted the potential hazards of early anticoagulation, and the effectiveness and safety of early (and continuous) antiplatelet therapy in limiting early stroke recurrence and its consequences. In addition, they have shown that antiplatelet agents with differing mechanisms of action can have different effects, and perhaps additive effects when combined. The ESPRIT trial should delineate the roles of oral anticoagulant therapy, and the combination of aspirin and dipyridamole, in the prevention of stroke due to arterial disease. Future trials will hopefully determine the role in secondary stroke prevention of inhibitors of the platelet GPIIb/IIIa complex (the final common pathway of platelet aggregation), the combination of anitplatelet agents with different mechanisms of action (e.g. aspirin and clopidogrel, aspirin and IIb/IIIa inhibitors), the combination of antiplatelet agents and oral anticoagulants (which may simultaneously modify platelet function and fibrin production), and the combination of antithrombotic and cholesterol-lowering (statin) medications.

Cerebrovascular Disorders↗
PubMed1998

Long-term risk of first recurrent stroke in the Perth Community Stroke Study.

BACKGROUND AND PURPOSE: Few community-based studies have examined the long-term risk of recurrent stroke after an acute first-ever stroke. This study aimed to determine the absolute and relative risks of a first recurrent stroke over the first 5 years after a first-ever stroke and the predictors of such recurrence in a population-based series of people with first-ever stroke in Perth, Western Australia. METHODS: Between February 1989 and August 1990, all people with a suspected acute stroke or transient ischemic attack of the brain who were resident in a geographically defined region of Perth, Western Australia, with a population of 138 708 people, were registered prospectively and assessed according to standardized diagnostic criteria. Patients were followed up prospectively at 4 months, 12 months, and 5 years after the index event. RESULTS: Three hundred seventy patients with a first-ever stroke were registered, of whom 351 survived >2 days. Data were available for 98% of the cohort at 5 years, by which time 199 patients (58%) had died and 52 (15%) had experienced a recurrent stroke, 12 (23%) of which were fatal within 28 days. The 5-year cumulative risk of first recurrent stroke was 22.5% (95% confidence limits [CL], 16.8%, 28.1%). The risk of recurrent stroke was greatest in the first 6 months after stroke, at 8.8% (95% CL, 5.4%, 12.1%). After adjustment for age and sex, the prognostic factors for recurrent stroke were advanced, but not extreme, age (75 to 84 years) (hazard ratio [HR], 2.6; 95% CL, 1.1, 6.2), hemorrhagic index stroke (HR, 2.1; 95% CL, 0.98, 4.4), and diabetes mellitus (HR, 2.1; 95% CL, 0.95, 4.4). CONCLUSIONS: Approximately 1 in 6 survivors (15%) of a first-ever stroke experience a recurrent stroke over the next 5 years, of which 25% are fatal within 28 days. The pathological subtype of the recurrent stroke is the same as that of the index stroke in 88% of cases. The predictors of first recurrent stroke in this study were advanced age, hemorrhagic index stroke, and diabetes mellitus, but numbers of recurrent events were modest. Because the risk of recurrent stroke is highest (8.8%) in the first 6 months after stroke, strategies for secondary prevention should be initiated as soon as possible after the index event.

Age Factors↗
PubMed1997

Thrombolytic therapy in acute ischaemic stroke: the jury needs more evidence.

Randomised controlled trials have shown that thrombolytic therapy for acute ischaemic stroke may reduce the rate of death and disability at three- or six-month follow-up, but may also increase the risk of haemorrhage and early death. Probable predictors of increased risk are severe neurological deficit and early signs of infarction on computed tomography, but these remain to be confirmed. More research is needed to determine which stroke patients will benefit from thrombolysis and the best regimen to use.

Acute Disease↗
PubMed1997

The effect of treating people with reversible ischaemic attacks of the brain and eye on the incidence of stroke in Australia.

BACKGROUND: Reversible ischaemic attacks of the brain or eye (RIA) are a risk factor for stroke. Strategies of stroke prevention include vascular risk factor control, antithrombotic therapy, and carotid surgery. AIMS: To determine the effectiveness, risks and costs of each stroke prevention strategy for patients with RIA and the Australian community, and the effect of treating people with RIA on the incidence of stroke in Australia. METHODS: Review of data from prospective community-based studies to determine the prevalence of RIA, the incidence of stroke, and the proportion of stroke patients who report a RIA before their stroke; and data from randomised trials to determine the effectiveness, risks and costs of treatments for RIA. RESULTS: About 111,000 Australians have had a prior RIA. Each year, about 37,000 Australians suffer a stroke, of whom up to 8000 (22%) have had a prior ('warning') RIA. Targeting effective stroke prevention strategies to RIA patients with relevant treatable conditions may reduce the individual's stroke risk by two-thirds (individual strategies) and possibly further (combination strategies). However, because the attributable risk of RIA for stroke is only about 22% (and may be less, given the role of other causal risk factors for stroke), strategies of stroke prevention in RIA patients can only reduce stroke incidence by up to 15% (from 22% to 7%). CONCLUSIONS: The potential benefits of the 'high risk' approach to stroke prevention appear to be less than the 'population' approach, but both approaches are necessary and complementary. Indeed, the cost of implementing the 'high risk' approach may be less than the cost of the strokes prevented ($255 million; i.e. 15% of $1.7 billion).

Anticoagulants↗
PubMed1997

Surgery for primary intracerebral hemorrhage: is it safe and effective? A systematic review of case series and randomized trials.

BACKGROUND AND PURPOSE: The surgical treatment of primary intracerebral hemorrhage (PICH) varies throughout the world, mainly because of the lack of evidence of its safety and effectiveness. This study compares the outcome of patients with PICH who are treated surgically with those who are not. METHODS: We conducted a systematic overview (meta-analysis) of all studies of the outcome of surgery for PICH by means of a Medline search of relevant randomized trials and case series published since 1966. Cited references and presentations were also reviewed. RESULTS: The 15 case series of surgery for PICH involving a total of 1524 patients (654 treated surgically) are potentially confounded and the results inconclusive. The pooled results of the three randomized controlled trials of open craniotomy and one trial of endoscopic evacuation for supratentorial PICH in a total of 349 patients (173 treated surgically) indicate a nonsignificant increase in odds of death and dependency at 6 months for patients treated surgically (odds ratio, 1.23; 95% confidence interval, 0.77 to 1.98). The odds of death or dependency at 6 months were 2.1 (1.1 to 4.1) for patients undergoing craniotomy and 0.45 (0.2 to 1.0) for endoscopic evacuation. CONCLUSIONS: There is insufficient evidence of the risks and benefits of surgery for PICH. Further randomized trials are needed to identify whether there is a favorable treatment effect of surgery, the types of PICH and patients who are likely to benefit and not benefit, and the safety and effectiveness of the different surgical interventions.

Cerebral Hemorrhage↗