Men 45 years or older who received pneumococcal vaccine were not less likely to have a heart attack or stroke compared to men who did not receive the vaccine, according to a study in the May 5 issue of JAMA.

Hung Fu Tseng, Ph.D., of Kaiser Permanente Southern California, Pasadena, and colleagues conducted a study to examine the association between vaccination with pneumococcal vaccine and the risk of developing acute heart attack and stroke in men, taking into account known and potentially important confounders (factors that can influence a study, leading to unexpected outcomes that improperly skew the results). The study included Kaiser Permanente Northern and Southern California health plans, with 84,170 participants ages 45 to 69 years from the California Men’s Health Study, who were recruited between January 2002 and December 2003, and followed up until December 31, 2007. The cohort was similar to the population of health plan members and men who responded to a general health survey in California on important demographic and clinical characteristics. Demographic and detailed lifestyle characteristics were collected from surveys. Vaccination records were obtained from the Kaiser Immunization Tracking System.

During follow-up, there were 1,211 first myocardial infarctions (MIs; heart attack) in vaccinated persons (rate of 10.7 per 1000 person-years) compared with 1,494 first MI events in unvaccinated individuals (6.07 per 1000 person-years). For stroke, there were 651 events in vaccinated persons (5.3 per 1000 person-years) compared with 483 events in unvaccinated persons (1.9 per 1000 person-years). After analysis of the data, the researchers found no evidence for an association between pneumococcal vaccination and reduced risk of acute MI or stroke. “In addition, association was not observed either in the current smokers, men with history of diabetes, men with history of hypertension, or men of the low-risk group.”
( JAMA. 2010;303[17]:1699-1706.)

Editorial: Preventing Myocardial Infarction With Vaccination – Myths and Realities

Mohammad Madjid, M.D., M.S., and Daniel M. Musher, M.D., of the Texas Heart Institute, St. Luke’s Episcopal Hospital, and Baylor College of Medicine, Houston, comment on the findings of this study.

“The study by Tseng et al is another important reminder of the complexities involved in evaluating observational studies examining the relationship between vaccine administration and clinical outcomes, and the need for more robust study designs. Until rigorous data from clinical trials are available to determine whether pneumonia vaccine can prevent MI, physicians should strictly adhere to available guidelines for optimizing vaccination rates in recommended target groups, because these rates are still far from optimal.”
(JAMA. 2010;303[17]:1751-1752.)

Source
American Medical Association

Many common signs of aging, such as shaking hands, stooped posture and walking slower, may be due to tiny blocked vessels in the brain that can’t be detected by current technology.

In a study reported in Stroke: Journal of the American Heart Association, researchers from Rush University Medical Center, Chicago, examined brain autopsies of older people and found:

Microscopic lesions or infarcts – too small to be detected using brain imaging – were in 30 percent of the brains of people who had no diagnosed brain disease or stroke.

Those who had the most trouble walking had multiple brain lesions. Two-thirds of the people had at least one blood vessel abnormality, suggesting a possible link between the blocked vessels and the familiar signs of aging.

“This is very surprising,” said Dr. Aron S. Buchman, lead author of the study and associate professor of neurological sciences at Rush. “The public health implications are significant because we are not identifying the 30 percent who have undiagnosed small vessel disease that is not picked up by current technology. We need additional tools in order to identify this population.”

In 1994, the researchers began conducting annual exams of 1,100 older nuns and priests for signs of aging. The participants also donated their brains for examination after death. This study provides results on the first 418 brain autopsies (61 percent women, average 88 years old at death).

Although Parkinson’s disease occurs in only 5 percent of older people, at least half of people 85 and older have mild symptoms associated with the disease.

Before the study, researchers believed that something more common, such as microscopic blocked vessels, might be causing the physical decline. The study’s autopsies found the small lesions could only be seen under a microscope after participants died. The lesions couldn’t be detected by current scans.

During the annual exams of the nuns and priests, researchers used the motor skills portion of a Parkinson’s disease survey to assess their physical abilities. Researchers observed and rated the participants’:
Balance
Ability to maintain posture
Walking speed
Ability to get in and out of chairs
Ability to make turns when walking
Sense of dizziness

“Often the mild motor symptoms are considered an expected part of aging,” said Buchman, who is also a member of the Rush Alzheimer’s Disease Center. “We should not accept this as normal aging. We should try to fix it and understand it. If there is an underlying cause, we can intervene and perhaps lessen the impact.”

Co-authors from Rush are Sue E. Leurgans, PhD; Dr. Sukriti Nag, PhD; Dr. David A. Bennett, and Dr. Julie A. Schneider, MS. The National Institutes of Health and the Illinois Department of Public Health funded the study.

The Centers for Disease Control and Prevention (CDC) have classified all children, 6-months to 24-years, one of the high risk groups for contracting the H1N1 (swine) flu, and recommend this population receive the H1N1 vaccine for immunity against the disease. But what about the millions of children who are already battling other diseases – chronic diseases including asthma, rheumatoid arthritis, HIV, irritable bowel disease (IBD) and other digestive disorders such as Crohn’s disease? Is it safe for these kids to receive the H1N1 vaccine when already taking an immunosuppressant – medication that weakens the immune system but controls their disease? Will mixing the H1N1 vaccine with these powerful medications put the patient at an even greater risk?

Doctors at Nationwide Children’s Hospital in Columbus, Ohio have been tackling this question from not just a few parents, but from a number of concerned parents. During the past five years there has been an explosion of new immunosuppressant medications, and it’s estimated that nearly 5 million children are currently taking these prescriptions to control their chronic conditions.

“It is extremely important that they [patients on immunosuppressant medication] get the H1N1 vaccine and receive it in the form of a shot, rather than in the form of a mist,” explained Dennis Cunningham, MD, an infectious disease physician and medical director of Epidemiology at Nationwide Children’s Hospital. “The reason we recommend the shot is because the mist is a live virus, and we do not want kids whose immune system is already weak to receive a live virus. Immunity to the H1N1 flu, among other diseases, is very important for kids with chronic conditions.”

Dr. Cunningham, who is leading the H1N1 efforts at Nationwide Children’s, says that it’s not an 100 percent guarantee these patients battling chronic conditions will not contract the H1N1 virus just by receiving immunization. He also suggests additional protection through what’s called ring vaccination. The idea is to make sure there is a barrier of protection for all family members that are in direct and frequent contact with children taking immunosuppressant medication.

“It’s also important for parents to put another layer of protection around their child and do so by making sure parents themselves and other children in the home receive the vaccine,” said Dr. Cunningham, also on the faculty at The Ohio State University College of Medicine.

The caveat is that there is no assurance others outside the home will be vaccinated. Important measures like washing your hands, covering your cough and sneeze with your elbow, getting adequate amounts of sleep and plenty of fluids, and staying home from work or school when sick, are stressed and should be followed. Parents should always consult their child’s pediatrician or primary care physician first for any and all questions about what’s right for the child’s health care needs.

Source
Centers for Disease Control and Prevention

A new type of laboratory mouse developed at UT Southwestern Medical Center can fight certain infections the same way humans do, making the rodents very useful for novel studies of human-pathogen interaction and developing disease therapies.

Normal mice are not susceptible to human-specific viruses, such as Epstein Barr virus and HIV, making it hard to study and craft drugs to target the viruses. Epstein Barr is a virus that causes mononucleosis.

So UT Southwestern researchers, working with University of Minnesota collaborators, generated human-mice “chimeras” – mice implanted with human tissues and human stem cells – that developed fully functional human immune systems and infection-fighting cells, such as T cells, throughout their bodies, according to a study published online in Nature Medicine.

The T cells in the mice even mounted a potent immune response to toxic shock syndrome and infection by Epstein Barr.

“These human-mice ‘chimeras’ are susceptible to a variety of human-specific viruses that couldn’t be easily studied in the past, giving scientists a new way to study, develop and implement novel vaccines and therapeutics to fight human disease like cancer and AIDS,” said Dr. J. Victor Garcia, professor of internal medicine at UT Southwestern and the study’s senior author.

Investigators have long used mouse models to study human physiology and to test new drugs, but differences in mouse and human immune systems – and the fact that normal mice can’t be infected with human-specific pathogens or produce human immune cells needed to fight them – have severely limited this line of research.

To allow these studies, researchers have developed chimeras.

In immune-deficient mice that are unable to reject human cells or tissues, researchers first implant the rodents with human tissues necessary to develop human T cells. Human blood stem cells, known as CD34+ cells, then are transplanted into the mice. CD34+ cells, which give rise to human T cells, B cells and other types of human cells that protect the body against foreign organisms and pathogens, are typically used to treat human cancer and blood and heart disorders.

In this latest study, UT Southwestern researchers and their Minnesota colleagues used this combination approach – human tissues and stem cells – to try to generate a new type of chimera that can develop T cells the same way as humans.

The resulting mice, known as Bone Marrow Liver Thymic mice (BLT mice), developed a human immune system with dramatically high human T cell and other cell counts in virtually all of their tissues, including the gut and lungs, sites of important immune response to diseases.

“The fact that virtually all human immune cells are adequately distributed in all the different mouse tissues has resulted in what is probably the most human-like immune system ever developed in mice,” Dr. Garcia said.

UT Southwestern researchers tested the immune system by inducing toxic shock syndrome in the mice or infecting them with Epstein Barr virus, both deadly diseases that are known to cause a proliferation of T cells in humans. The mice produced ample human T cells to respond to each disease.

This finding highlights the potential of BLT mice to be used to study the interactions between the human immune system and viruses that target human immune cells. These viruses include HIV, dengue hemorrhagic fever and other highly pathogenic agents such as influenza, SARS, anthrax and others that are hard to study in humans. Dr. Garcia said the availability of this mouse model should pave the way for the evaluation and testing of novel drugs and approaches to treat these diseases.

###

Other UT Southwestern researchers involved in the study were lead author and student research assistant Michael Melkus, postdoctoral researcher Dr. Anja Wege, research associate Angela Padgett-Thomas, student research assistant Paul Denton, research assistant Florence Othieno and former instructor Joel Gatlin, currently of Arena Pharmaceuticals, Inc.

The National Institutes of Health supported the study.

About UT Southwestern Medical Center

UT Southwestern Medical Center, one of the premier medical centers in the nation, integrates pioneering biomedical research with exceptional clinical care and education. Its more than 1,400 full-time faculty members – including four active Nobel prize winners, more than any other medical school in the world – are responsible for groundbreaking medical advances and are committed to translating science-driven research quickly to new clinical treatments. UT Southwestern physicians provide medical care in 40 specialties to nearly 89,000 hospitalized patients and oversee 2.1 million outpatient visits a year.

This news release is available on our World Wide Web home page or directly.

Dr. J. Victor Garcia

Contact: Cliff Despres

UT Southwestern Medical Center

A new Web site designed to emphasize smoking prevention for young girls has been launched through Children’s Hospital at Dartmouth (CHaD) and Dartmouth Medical School (DMS). The safe, online patient education site was created by Dartmouth pediatrician Henry Bernstein to help prevent smoking in young girls 8-11 years old).

Funded by Pfizer Inc. through an unrestricted educational grant, the site – No Smoking Room is designed to empower young girls to say “no” to smoking and to encourage those who are smoking to quit. Bernstein says the No Smoking Room team is looking for partners to spread the “no smoking” message to as many young girls and their health influencers, such as parents, as possible.

“Despite a national decline in smoking rates, young girls are exposed to intense social and media pressures to smoke,” said Dr. Henry (Hank) Bernstein, D.O., a physician with the Children’s Hospital at Dartmouth and a professor of pediatrics at Dartmouth Medical School. “No Smoking Room does not use a bullhorn to share information about the dangers of smoking. Instead, we rely on the savvy internet behavior of youth to easily navigate the various games and activities on the site to learn about living smoke-free. Through this experience, our users learn at a young age about being the ‘drivers’ of their own health.”

The Web site engages 8-11 year old girls through high-quality multimedia features, including “the girlz lounge” where users can send electronic cards, make their own door hangers, write in their own private journal, and build their own “girlz nite-in” room. A television in the “girlz nite-in” room has video advertisements designed by girls, for girls, that convey the consequences of smoking. Facts, quizzes and “ask the expert” questions answered by two Dartmouth pediatricians (Bernstein and Dr. Susanne Tanski, M.D., M.P.H, also a pediatrician and DMS assistant professor of pediatrics) allow girls to test what they know and share that information with friends and family members.

No Smoking Room was designed by Mind Your Mind, a Canadian-based private social service non-profit organization, in collaboration with Girls, Inc., with sites in Bowling Green, Kentucky and Bloomington, Indiana, and other community groups. The site also involved the Girl’s Advisory Group, comprised of 10 girls who helped shape the girl-centered vision for the site.

###

Source: Jason Aldous

Dartmouth Medical School

Environmental changes implemented at 12 Dow Chemical Company worksites helped employees’ there achieve modest improvements in health risks, including weight management, decreasing tobacco use and blood pressure, says Emory University public health researcher Ron Goetzel, PhD.

Goetzel and his team will present the findings from their study Oct. 29, 2008, at the annual meeting of the American Public Health Association in San Diego.

“These are early findings from a longer and larger multi-site study that examine the effects of introducing relatively low-cost environmental and ecological interventions at the workplace aimed at curbing the growth of overweight and obesity among workers,” says Goetzel, research professor of health policy and management, Rollins School of Public Health, Emory University. Goetzel is also director of Emory’s Institute for Health and Productivity Studies and vice president of consulting and applied research for Thomson Reuters.

“Several research centers across the country are testing this idea with different types of workers and in various industries,” adds Goetzel.

The study, the first large-scale study of its kind, examined the effectiveness of environmental interventions that support individual change efforts through creation of more supportive worksite health promotion environments.

Environmental weight management interventions were implemented at 12 work locations at the Dow Chemical Company. The environmental interventions, called LightenUP, aimed to decrease the number of calories employees consumed and increase the number of calories they expended.

Nine locations were designated treatment sites and three control. The control sites received only individually focused interventions via Dow’s core health promotion program that seeks to improve employees’ health behaviors through a combination of education and behavior change efforts. At treatment sites, employees were provided enhanced access to healthy foods in vending machines and cafeterias, greater access to physical activity through walking trails and pedometer programs, dissemination of multiple health education materials, leadership training, physical activity and weight management programs, health assessments and individual consultations, and online behavior change programs.

Researchers found that after one year, employees who participated in the environmental weight management interventions significantly reduced their blood pressure risk and maintained a steady weight when compared to employees at control sites who only received individual interventions.

“We continue to study the effects of environmental interventions aimed at preventing obesity in the workplace, and we are now beginning to analyze results from the second year. We expect to present updated findings at future scientific meetings,” says Goetzel.

###

In addition to Goetzel, study authors were Enid Roemer, PhD, Emory University, Rollins School of Public Health; Mark Wilson, HSD, Kristin Baker, MPH, and David DeJoy, PhD, University of Georgia; and Meghan Short, Shaohung Wang, PhD, and Jennie Dalton Bowen, of Thomson Medstat; and Ronald Ozminkowski, PhD, of Consulting Economist.

Funding support was provided by the National Heart, Lung, and Blood Institute (NHLBI), a branch of the National Institutes of Health.

Source: Ashante Dobbs

Emory University

There is an extremely high prevalence of sleep disturbances in U.S. soldiers returning from wartime deployment, according to a research abstract presented Tuesday, June 8, 2010, in San Antonio, Texas, at SLEEP 2010, the 24th annual meeting of the Associated Professional Sleep Societies LLC.

Results indicate that 86 percent of participants had sleep disturbances upon return from deployment and 45 days later even though the majority of them had no signs of post-traumatic stress disorder or depression. Soldiers were more likely to have sleep disturbances if they had a personal history of sleep problems, symptoms of physical illness or mild traumatic brain injury.

“This is the first study to describe the prevalence of sleep disturbances at two different time points in soldiers returning from deployment without any apparent physical trauma from blasts or amputation,” said principal investigator Major Betty Garner, PhD, a nurse scientist in the Nursing Research Office at Landstuhl Regional Medical Center in Landstuhl, Germany. “The most surprising finding from this small preliminary sample was the extremely high percentage of sleep disturbances in soldiers even 45 days after they returned from wartime deployment back to the United States – the safe zone.”

Major Garner conducted the study as a doctoral student at the University of Washington, where she screened 58 U.S. soldiers between the ages of 23 and 58 years. Participants were assessed immediately upon return from deployment and 45 days later using the Pittsburgh Sleep Quality Index, Post Deployment Health Assessment, Perceived Stress Scale and Combat Exposure Scale.

The U.S. has deployed more than one million soldiers in support of overseas operations in Iraq and Afghanistan since 2001. The researchers noted that the stress and uncertainty involved with deployment may have an impact on the sleep quality of soldiers.

According to Major Garner, previous research studies have shown disturbed sleep can be a symptom of existing medical conditions or a risk factor for the development of mental and physical health disorders. Therefore, the prompt treatment of sleep disturbances in soldiers returning from deployment might mitigate future physical and mental health problems.

“It is anticipated that this knowledge will facilitate the identification of those at risk for sleep disturbances and the provision of education for health care providers in the crucial role of sleep in our soldiers,” said Major Garner.

The study was supported by the U.S. Military’s TriService Nursing Research Program through the Uniformed Services University of the Health Sciences.

Source:
Kathleen McCann

American Academy of Sleep Medicine

Once a mere fantasy, the idea of growing new, healthy heart tissue to replace damaged or diseased heart muscle is inching closer to reality. Researchers are exploring several routes to grow new heart muscle, according to the January issue of the Harvard Heart Letter.

One approach uses adult stem cells found in bone marrow or the bloodstream. Injected or infused into damaged heart tissue, these stem cells can take up residence and grow into healthy heart muscle. An alternative is to use immature muscle cells taken from the thigh; when injected into the heart, they adopt the characteristics of heart cells.

Scientists are also pursuing the possibility of using growth factors, hormones, or other substances to stimulate dormant stem cells in the heart itself to multiply and grow into healthy heart tissue. And a particularly innovative self-repair strategy involves coaxing some heart cells to regress to a stem-cell-like state and then stimulating them to produce young, healthy heart cells.

The Harvard Heart Letter points out that while the field of cardiac repair is in its infancy, the long-term implications for heart disease are great, particularly for people with heart failure, a condition in which the heart is so damaged that it becomes difficult for it to deliver enough blood to meet the body’s demands. Although current therapies can ease symptoms of heart failure and lengthen life expectancy, they don’t reverse the damage. Stem cell research may also someday enable doctors to create replacement heart valves tailored to a patient’s own body or to grow new blood vessels around blocked coronary arteries.

Long-term tests are needed to determine the safety and effectiveness of these strategies, says the Harvard Heart Letter. And heart disease certainly isn’t the only condition that might benefit from these techniques, which are also being tested for treating diabetes, Parkinson’s disease, spinal cord injuries, Alzheimer’s disease, and other problems.

The Harvard Heart Letter is available from Harvard Health Publications, the publishing division of Harvard Medical School, for $28 per year. Subscribe at health.harvard.edu/heart or by calling 1-877-649-9457 (toll free).

Harvard Heart Letter
Harvard Health Publications Harvard Medical School 10 Shattuck St., Ste. 612
Cambridge, MA 02115
USA
Phone 617-432-4717
health.harvard.edu/heart

The Mailman School of Public Health received a grant to create the Manhattan Tobacco Cessation Network, a program
dedicated to reducing tobacco use through evidence-based smoking cessation treatment programs. The Manhattan Tobacco
Cessation Network is one of 19 cessation centers statewide funded by the New York State Department of Health’s Tobacco
Control Program. It will be based at the Department of Sociomedical Sciences’ Center for Applied Public Health (CAPH). The
program represents a collaboration of the Mailman School of Public Health, Columbia University Medical Center (CUMC),
NewYork-Presbyterian Hospital and many of New York City’s leading hospitals and healthcare networks.

Smoking is the number one cause of preventable deaths in the U.S. and New York City, yet a large number of smokers still do
not get the help they need to quit. The Manhattan Tobacco Cessation Network grant will link smokers to proven treatments.
“The network’s primary goal is to promote systematic screening and counseling of all tobacco users. Through partnerships with
leading healthcare providers we are implementing strategies that will decrease smoking rates, improve the health of New
Yorkers, and save lives,” says Donna Shelley, MD, MPH, principal investigator and assistant professor of clinical
Sociomedical Sciences. According to Daniel Hyman, MD, chief medical officer of the NewYork-Presbyterian Hospital Ambulatory
Care Network, “This program is a critical component of our quality improvement initiatives across healthcare settings. The
center grant provides important resources to enhance tobacco treatment by more effectively identifying and treating smokers
who wish to quit throughout NewYork-Presbyterian and Manhattan.”

Co- investigators at Columbia University Medical Center are Daniel Seidman, MD, assistant clinical professor of Psychiatry
and David Albert, associate clinical professor of Dental and Oral Surgery. Additional collaborators with the Mailman School,
NewYork-Presbyterian, and CUMC include Bellevue, Harlem, Metropolitan, Lenox Hill, and St. Luke’s Hospitals; Clinical
Directors Network; Community Premier Plus; the Health and Hospitals Corporation and Group Health Insurance; and the New York
City Department of Health and Mental Hygiene.

In addition to designing and implementing interventions to ensure that all smokers are identified and linked to effective
treatment, the program:

– Provides ongoing technical assistance to partnering sites;

– Provides healthcare provider training on evidence based treatment of tobacco use;

– Provides resources to clinicians and patients such as self-help materials and information on pharmacotherapy, smokers’
quit lines, and other cessation resources;

– Implements referral systems for other on-site and community programs including the New York State Smokers’ Quit Line;

– Advocates for written quality assurance plans that mandate practices for tobacco use screening, training and intervention;
and

– Evaluates the impact of all interventions.

Through partnerships with communities, health departments, and allied disciplines, the Mailman School’s Center for Applied
Public Health (CAPH) is at the forefront of community driven public health research and practice, and among the leaders in
developing and implementing replicable models of community-academic partnerships that address a multitude of health issues.
The Manhattan Tobacco Cessation Center grant builds on existing partnerships and tobacco related programs such as CAPH’s
Legacy Tobacco Control Evaluation Research Network and the Center for Community Health Partnership Community Voices
Anti-Tobacco Program.

CAPH’s ongoing tobacco initiatives include tobacco control in Central Harlem and determinants of smoking initiation among
post adolescent African American women. Most recently, CAPH has been studying the effect of a community-based smoking
cessation intervention among Chinese Americans in order to estimate smoking prevalence among New York City Chinese Americans.

About the Mailman School of Public Health

The only accredited school of public health in New York City, and among the first in the nation, Columbia University’s
Mailman School of Public Health provides instruction and research opportunities to more than 850 graduate students in pursuit
of masters and doctoral degrees. Its students and over 250 multi-disciplinary faculty engage in research and service in the
city, nation, and around the world, concentrating on biostatistics, environmental health sciences, epidemiology, health
policy and management, population and family health, and sociomedical sciences. (mailman.hslumbia.edu)

New York-Presbyterian Hospital is the largest not-for-profit, non-sectarian hospital in the country. It provides state-of-the
art inpatient, ambulatory and preventive care in all areas of medicine at five major centers: NewYork-Presbyterian
hospital/Columbia University Medical Center, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, Children’s Hospital
of New York-Presbyterian, the Allen Pavilion, and the Westchester Division. It consistently ranks as one of the top hospitals
in the country in U.S. News & World Report’s guide to “America’s Best Hospitals.” The NewYork-Presbyterian Healthcare System
- an affiliation of acute-care and community hospitals, long-term care facilities, ambulatory sites, and specialty institutes
-serves one in four patients in the New York metropolitan area.

Columbia University Medical Center provides international leadership in basic, pre-clinical and clinical research, medical
education, and health care. The medical center trains future leaders in health care and includes the dedicated work of many
physicians, scientists, nurses, dentists, and other health professionals at the College of Physicians & Surgeons, the School
of Dental & Oral Surgery, the School of Nursing, the Mailman School of Public Health, the biomedical departments of the
Graduate School of Arts and Sciences, and allied research centers and institutions. With a strong history of some of the most
important advances and discoveries in health care, its researchers are leading the development of novel therapies and
advances to address a wide range of health conditions.

Contact: Stephanie Berger, 212-305-5635, sb2247columbia.edu

Contact: Stephanie Berger
sb2247columbia.edu
212-305-5635
Mailman School of Public Health, Columbia University
mailman.hslumbia.edu

The focus on acute stroke in the UK government’s national stroke strategy may distract attention and resources from other important elements of stroke care, warn experts in a paper published on bmj today.

In 2005, the National Audit Office (NAO) report on stroke services outlined improvements for reducing death, disability and recurrent stroke, along with costs. Its recommendations led to the publication of the national stroke strategy in 2007.

But it has been suggested that the NAO report overemphasised the benefits and cost savings to be gained from intravenous thrombolysis (giving anti-clotting drugs within three hours of an acute stroke) and underestimated the gains from comprehensive care in a stroke unit.

Now senior doctors at the University of Edinburgh warn that the report’s strong focus on hyperacute stroke care (the first 72 hours), and on greatly increasing the proportion of patients being given intravenous thrombolysis, could mean that the many other effective components of a comprehensive stroke service might not receive as much attention.

They examined the current performance of stroke services in England, Wales and Northern Ireland against three proven interventions for acute stroke: organised stroke unit care, early administration of aspirin, and intravenous thrombolysis.

According to the 2008 national sentinel stroke audit, 68% of patients admitted to hospital with an acute stroke spent more than half of their admission on a specialist stroke unit, 85% of eligible patients received early aspirin, and 1.4% of eligible patients received intravenous thrombolysis.

Based on these figures, the authors estimate that, at present, in a notional UK population of one million people, intravenous thrombolysis is preventing two patients from having a poor outcome (death or disability) each year, while stroke unit care and aspirin are preventing 37 and 24 poor outcomes respectively.

More optimistically, if 5% of all stroke patients could be treated with intravenous thrombolysis within three hours (a greater than fivefold increase in what is currently being achieved UK-wide, and an improvement even on the highest rates in the UK), then 11 would avoid a poor outcome, while increased rates of stroke unit admission and early aspirin administration would lead to 59 and 29 patients avoiding a poor outcome respectively.

These calculations clearly show that the numbers of patients benefiting at current or realistic target levels are far larger for stroke units and aspirin than for intravenous thrombolysis, and they remain higher even at optimistic target levels, say the authors.

Achieving a higher rate of thrombolysis will also require radical changes to local systems. But they warn “we must be careful that the emphasis on developing hyperacute stroke care, mainly to allow delivery of thrombolysis to the small proportion who may benefit, does not distract attention and resources from the other proved interventions.”

They conclude: “Although it is important to give intravenous thrombolysis in an appropriate setting to as many eligible patients as possible, it is crucial that this should not be at the expense of any of the other parts of a comprehensive stroke service. All elements of effective stroke care must be properly joined up, and funded, from hyperacute care to long term community support.”

Link to paper

Source
British Medical Journal