Five-year mortality and related prognostic factors after inpatient stroke rehabilitation : A European multi-centre study

Objective: To determine 5-year mortality and its association with baseline characteristics and functional status 6 months post-stroke for patients who received inpatient rehabilitation. Design: A prospective rehabilitation-based cohort study. Subjects: A total of 532 consecutive stroke patients from 4 European rehabilitation centres. Methods: Predictors were recorded on admission. Barthel Index was assessed at 6 months (BI6mths) and patients were followed for 5 years post-stroke. Survival probability was computed using Kaplan-Meier analysis and compared across 3 BI6mths-classes (0-60, 65-90, 95-100) (log-rank test). Significant independent predictors were determined using multivariate Cox regression analysis (hazard ratio (HR)). Results: Five-year cumulative risk of death was 29.12% (95% confidence interval (CI): 22.86-35.38). Age (HR = 1.06, 95% CI: 1.04-1.09), cognitive impairment (HR = 1.77, 95% CI: 1.21-2.57), diabetes mellitus (HR = 1.68, 95% CI: 1.16- 2.41) and atrial fibrillation (HR = 1.52, 95% CI: 1.08-2.14) were independent predictors of increased mortality. Hyperlipidaemia (HR = 0.66, 95% CI: 0.46-0.94), and higher BI6mths (HR = 0.98, 95% CI: 0.97-0.99) were independent predictors of decreased mortality. Five-year survival probability was 0.85 (95% CI: 0.80-0.89) for patients in BI6mthsclass: 95-100, 0.72 (95% CI: 0.63-0.79) in BI6mths-class: 65-90 and 0.50 (95% CI: 0.40-0.60) in BI6mths-class: 0-60 (p < 0.0001). Conclusion: Nearly one-third of rehabilitation patients died during the first 5 years following stroke. Functional status at 6 months was a powerful predictor of long-term mortality. Maximum functional independence at 6 months post-stroke should be promoted through medical interventions and rehabilitation. Future studies are recommended to evaluate the direct effect of rehabilitation on long-term survival

Portacaval shunt for glycogen storage disease and hyperlipidaemia.

Complete portacaval shunt was used to treat 10 patients with glycogen storage disease. A favourable effect was noted on body growth and a number of metabolic abnormalities. More recently, continous night feedings with an intermittently placed gastric tube or through a gastrostomy has been shown to be helpful either before or after portacaval shunts. Such alimentation techniques may eliminate the need for shunts in some patients and be of adjuvant benefit in others. Portacaval shunt was also used for three children who had homozygous Type II hyperlipidaemia. Substantial reductions in serum cholesterol concentration were observed, as well as resorption of xanthomas. Reversal of some cardiovascular lesions has been documented. The benefits of portacaval shunt in these disorders is probably due to the change in the hormone climate of the liver and the whole organism brought about by diversion of the hormone-rich splanchnic venous blood around the liver

The Attitudes about Complex Therapy Scale (ACTS) in Type 2 Diabetes and Cardiovascular Disease: Development, Validity and Reliability

Background: Type 2 diabetes is associated with cardiovascular disease, and patients with both conditions are prescribed complex medication regimens. Aim: The aim was to develop a reliable and valid measure of attitudes associated with the prescription and management of multiple medicines in patients with Type 2 diabetes and cardiovascular disease. Methods: Principal component analysis (PCA) and Cronbach alpha assessed the reliability of the Attitudes about Complex Therapy Scale (ACTS). Examinations of relationships with related measures inform concurrent validity. Questionnaires were sent to a cross-sectional sample of 480 people prescribed multiple medicines for co-morbid Type 2 diabetes. Results: Cronbach alpha was 0.76, indicating the scale had good internal reliability. PCA rotated a four factor model accounting for 37% of the variance. Four subscales identified; 1. Concerns about multiple medicines and increasing numbers of medicines; 2.Anxiety over missed medicines; 3. Desires to substitute medicines and reduce the number of medicines prescribed and; 4. Perceptions related to organising and managing complex therapy. The ACTS showed significant relationships with measures of anxiety, depression, general beliefs about medicines and self-efficacy. Also, the ACTS significantly correlated with adherence to medicines, showing good predictive validity. Conclusion: The ACTS was designed to assess negative attitudes towards complex therapy and multiple medication management. This tool could aid prescribing decisions and may identify people who are intentionally non-adherent to all or some of their medicines

Attenuation of oxidative stress-induced lesions in skeletal muscle in a mouse model of obesity-independent hyperlipidaemia and atherosclerosis through the inhibition of Nox2 activity

Obesity leading to hyperlipidaemia and atherosclerosis is recognised to induce morphological and metabolic changes in many tissues. However, both hyperlipidaemia and atherosclerosis can occur in the absence of obesity. The impact of the latter scenario on skeletal muscle and liver is not understood sufficiently. In this regard, we used the Apolipoprotein E-deficient (ApoE-/-) mouse model, an established model of hyperlipidaemia and atherosclerosis, that does not become obese when subjected to a high-fat diet, to determine the impact of Western-type diet (WD) and ApoE deficiency on skeletal muscle morphological, metabolic and biochemical properties. To establish the potential of therapeutic targets, we further examined the impact of Nox2 pharmacological inhibition on skeletal muscle redox biology. We found ectopic lipid accumulation in skeletal muscle and the liver, and altered skeletal muscle morphology and intramuscular triacylglycerol fatty acid composition. WD and ApoE deficiency had a detrimental impact in muscle metabolome, followed by perturbed gene expression for fatty acid uptake and oxidation. Importantly, there was enhanced oxidative stress in the skeletal muscle and development of liver steatosis, inflammation and oxidative protein modifications. Pharmacological inhibition of Nox2 decreased reactive oxygen species production and protein oxidative modifications in the muscle of ApoE-/- mice subjected to a Western-type diet. This study provides key evidence to better understand the pathophysiology of skeletal muscle in the context of hyperlipidaemia and atherosclerosis and identifies Nox2 as a potential target for attenuating oxidative stress in skeletal muscle in a mouse model of obesity-independent hyperlipidaemia

Intentional and unintentional non-adherence in community dwelling people with type 2 diabetes: the effect of varying numbers of medicines

People with type 2 diabetes are often prescribed multiple medicines which can be difficult to manage. Nonadherence to medicines can be intentional (e.g. active decision) or unintentional (e.g. forgetting). The objective of this study was to measure intentional and unintentional non-adherence to differing numbers of medicines prescribed in type 2 diabetes. A cross sectional survey using the Morisky medication adherence scale (with intentional and unintentional non-adherence subscales) was completed by 480 people prescribed oral antidiabetic drugs (OADs), antihypertensive agents and statins. A within-subject analysis of variance (ANOVA) showed that intentional non-adherence did not vary between OADs, anti-hypertensives and statins. Intentional non-adherence to statins significantly increased when the number of medicines prescribed was included as a between-subjects variable (p<0.05). Another within-subject ANOVA on unintentional non-adherence found a significant difference between OADs, anti-hypertensives and statins; unintentional non-adherence to OADs was significantly higher (p<0.05). When the number of medicines was added as a between-subject variable unintentional non-adherence was associated with higher numbers of medicines. This study shows the difference between intentional and unintentional non-adherence behaviours, and the effect that varying numbers of medicines can have on these behaviours

Comparative effectiveness of enalapril, lisinopril, and ramipril in the treatment of patients with chronic heart failure: a propensity score-matched cohort study

Background: Angiotensin converting enzyme inhibitors (ACEIs) are recommended as first-line therapy in patients with heart failure with reduced ejection fraction (HFrEF). The comparative effectiveness of different ACEIs is not known. Methods and results: 4,723 out-patients with stable HFrEF prescribed either enalapril, lisinopril, or ramipril were identified from three registries in Norway, England, and Germany. In three separate matching procedures, patients were individually matched with respect to both dose equivalents and their respective propensity scores for ACEI treatment. During a follow-up of 21,939 patient-years, 360 (49.5%), 337 (52.4%), and 1,119 (33.4%) patients died amongst those prescribed enalapril, lisinopril, and ramipril, respectively. In univariable analysis of the general sample, enalapril and lisinopril were both associated with higher mortality as compared with ramipril treatment (HR 1.46, 95% CI 1.30-1.65, p &lt; 0.001, and HR 1.38, CI 1.22-1.56, p &lt; 0.001, respectively). Patients prescribed enalapril or lisinopril had similar mortality (HR 1.06, 95% CI 0.92-1.24, p = 0.41). However, there was no significant association between ACEI choice and all-cause mortality in any of the matched samples (HR 1.07, 95% CI 0.91-1.25, p = 0.40; HR 1.12, 95% CI 0.96-1.32, p = 0.16; and HR 1.08, HR 1.10, 95% CI 0.93-1.31, p = 0.25 for enalapril vs. ramipril, lisinopril vs. ramipril, and enalapril vs. lisinopril, respectively). Results were confirmed in subgroup analyses with respect to age, sex, left ventricular ejection fraction, NYHA functional class, cause of HFrEF, rhythm, and systolic blood pressure. Conclusion: Our results suggest that enalapril, lisinopril and ramipril are equally effective in the treatment of patients with HFrEF when given at equivalent doses

Is clopidogrel better than aspirin following breakthrough strokes while on aspirin? A retrospective cohort study.

ObjectiveThere is insufficient evidence on which to base a recommendation for optimal antiplatelet therapy following a stroke while on aspirin. The objective was to compare clopidogrel initiation vs aspirin reinitiation for vascular risk reduction among patients with ischaemic stroke on aspirin at the time of their index stroke.DesignRetrospective.SettingWe conducted a nationwide cohort study by retrieving all hospitalised patients (≥18 years) with a primary diagnosis of ischaemic stroke between 2003 and 2009 from Taiwan National Health Insurance Research Database.ParticipantsAmong 3862 patients receiving aspirin before the index ischaemic stroke and receiving either aspirin or clopidogrel after index stroke during follow-up period, 1623 were excluded due to a medication possession ratio &lt;80%. Also, 355 were excluded due to history of atrial fibrillation, valvular heart disease or coagulopathy. Therefore, 1884 patients were included in our final analysis.InterventionsPatients were categorised into two groups based on whether clopidogrel or aspirin was prescribed during the follow-up period. Follow-up was from time of the index stroke to admission for recurrent stroke or myocardial infarction, death or the end of 2010.Primary and secondary outcome measuresThe primary end point was hospitalisation due to a new-onset major adverse cardiovascular event (MACE: composite of any stroke or myocardial infarction). The leading secondary end point was any recurrent stroke.ResultsCompared to aspirin, clopidogrel was associated with a lower occurrence of future MACE (HR=0.54, 95% CI 0.43 to 0.68, p&lt;0.001, number needed to treat: 8) and recurrent stroke (HR=0.54, 95% CI 0.42 to 0.69, p&lt;0.001, number needed to treat: 9) after adjustment of relevant covariates.ConclusionsAmong patients with an ischaemic stroke while taking aspirin, clopidogrel initiation was associated with fewer recurrent vascular events than aspirin reinitiation

LIVER TRANSPLANTATION FOR TYPE I GLYCOGEN STORAGE DISEASE

A 16½-year-old girl with type I glycogen storage disease was treated by orthotopic liver transplantation under cyclosporin/steroid immunosuppression. All metabolic stigmata of the disease were relieved and 1 year postoperatively she follows a normal diet and lifestyle