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Most patients with suspected stroke should be transported without delay to a hospital, which has access to the required diagnostic tests and appropriate hyperacute treatments 24 h/day and 7 days/week. Once admitted, patients should be managed in a stroke unit rather than a general medical ward. There appears to be no systematic increase in length of hospital stay associated with organized (stroke unit) care. The recent development of hyperacute stroke units is not based on evaluation within RCTs but appears to improve processes of care in the acute phase. Processes of care on a stroke unit should mirror those found to be effective in RCTs. Stroke care should be specialized, organized, and multidisciplinary (i.e. provided by medical, nursing, physiotherapy, occupational therapy, speech therapy, and social work staff who are interested and trained in stroke care). The other beneficial components of organized stroke care are likely to be many, but it remains uncertain which are the most effective. Early discharge from the stroke unit with support from a domiciliary rehabilitation team (coordinated by the stroke unit) promises to reduce hospital length of stay and improve rehabilitation in the home and patient outcome.
Brain white matter changes (WMC) and depressive symptoms are linked, but the directionality of this association remains unclear.
To investigate the relationship between baseline and incident depression and progression of white matter changes.
In a longitudinal multicentre pan-European study (Leukoaraiosis and Disability in the elderly, LADIS), participants aged over 64 underwent baseline magnetic resonance imaging (MRI) and clinical assessments. Repeat scans were obtained at 3 years. Depressive outcomes were assessed in terms of depressive episodes and the Geriatric Depression Scale (GDS). Progression of WMC was measured using the modified Rotterdam Progression scale.
Progression of WMC was significantly associated with incident depression during year 3 of the study (P = 0.002) and remained significant after controlling for transition to disability, baseline WMC and baseline history of depression. There was no significant association between progression of WMC and GDS score, and no significant relationship between progression of WMC and history of depression at baseline.
Our results support the vascular depression hypothesis and implicate WMC as causal in the pathogenesis of late-life depression.
The clinical significance of low serum vitamin B12 levels in elderly people is controversial. We aimed to document the prevalence of a low serum vitamin B12 (<175pmol/l) in patients referred to a geriatric medical unit, and to determine whether haemopoiesis is commonly affected in elderly patients with low serum vitamin B12. We studied prospectively 472 consecutive referrals to a geriatric medical unit; fifty-six (13%) had a low serum vitamin B12 level, of whom nineteen (34%) of the fifty-six also had evidence of Fe deficiency (serum ferritin<45ng/ml). Low vitamin B12 was associated with a raised mean erythrocyte volume (MCV; mean 96·0 (SD 6·7) fl), compared with a control group (91·7 (SD 6·0) fl; P=0·001). However, only thirteen (23%) of the fifty-six patients with a low vitamin Blz had an MCV≥100 fl. Mean haemoglobin (Hb) levels were not significantly reduced in those with a low vitamin B12. In a subsequent study the haematological response to intramuscular hydroxocobalamin was examined in thirty-four patients with a low serum vitamin B12. Treatment resulted in a significant fall in MCV and rise in Hb; these effects could be detected both in those patients with an initially normal full blood count (change in MCV -1·2 (SD 1·2); Hb + 0·5 (SD 0·6); P<0·01) and in those with macrocytosis and/or anaemia (-9·1 (SD 11·8); + 0·8 (SD 1·2); P<0·05). A low serum vitamin B12 is common in geriatric medical patients. This is usually associated with an upset in erythropoiesis, although the abnormalities are often subtle and may not be apparent on inspection of the full blood count. Elderly patients with serum vitamin B12<175pmol/l should be assumed to have vitamin deficiency even if their full blood count is normal.
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