Lancet neurology
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Ischaemic stroke is an important cause of death and dependency in industrialised countries; it has a high incidence (affecting up to 0.2% of the population each year) and is commonly lethal or disabling. One in six patients die in the first month after ischaemic stroke, and half of survivors are permanently disabled despite best efforts to rehabilitate them and to prevent complications, recurrent stroke, and other serious vascular events. Optimisation of the early, and ongoing, management of patients with acute ischaemic stroke is pivotal to the reduction of both case fatality and long-term disability. ⋯ Guidelines for the early management of patients with ischaemic stroke have recently been published by the Stroke Council of the American Stroke Association (ASA; Adams and co-workers, Stroke 2003; 34: 1056-83) and the European Stroke Initiative (EUSI; European Stroke Initiative Executive Committee and Writing Committee, Cerebrovasc Dis 2003; 16: 311-38). Although transatlantic differences might create different interpretations, priorities, and views, the guidelines are remarkably similar, even regarding controversial issues. We believe this is not only because both groups have had the opportunity to discuss many of the controversial issues at international meetings, but also because both groups have endorsed the concept of evidence-based medicine and have based their recommendations on similar classifications of the levels of evidence for the effectiveness of interventions. This is a triumph for evidence-based medicine and a major step towards unification of acute stroke management worldwide. WHERE NEXT?: There are three main challenges in stroke management. To increase the body of reliable evidence from large randomised controlled trials (RCTs) of the safety, effectiveness, and cost of promising treatments (eg, thrombolysis, antithrombotic therapy, neuroprotection, and interventional recanalisation, alone and in combination) in a wide range of patients around the world. To facilitate the widespread development of stroke units, delivery of organised stroke care, and emergency transport of patients with stroke to appropriate stroke centres. And finally, to improve the uptake of effective therapies into clinical practice (eg, by widely disseminating the ASA and EUSI guidelines).
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Most clinical studies of pain in dementia have focused on assessment procedures that are sensitive to pain in "demented" or "cognitively impaired" elderly patients. The neuropathology of dementia has not played a major part in pain assessment. In this review, the neuropathological effects of dementia on the medial and the lateral pain systems are discussed. ⋯ The results of the studies reviewed show that, although the subtypes of dementia show common neuropathological features (such as atrophy and white-matter lesions), the degree by which they occur and affect pain-related areas determine the pattern of changes in pain experience. More specifically, in AD and even more so in frontotemporal dementia, a decrease in the motivational and affective components of pain is generally present whereas vascular dementia might be characterised by an increase in affective pain experience. Future studies should combine data from experimental pain studies and neuropathological information for pain assessment in dementia.
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Symptoms of abnormal autonomic-nervous-system function occur commonly in Parkinson's disease (PD). Orthostatic hypotension in patients with parkinsonism has been thought to be a side-effect of treatment with levodopa, a late stage in the disease progression, or, if prominent and early with respect to disordered movement, an indication of a different disease, such as multiple system atrophy. ⋯ Post-mortem studies confirm this distinction. Because PD involves postganglionic sympathetic noradrenergic lesions, the disease seems to be not only a movement disorder with dopamine loss in the nigrostriatal system of the brain, but also a dysautonomia, with norepinephrine loss in the sympathetic nervous system of the heart.