SUMMARY Data from 357 conscious stroke patients taking part in an acute intervention trial and assessed within 48 hours of the onset of symptoms, were used to investigate the prevalence and natural history of swallowing problems. Nearly 30% of patients with single-hemisphere strokes were initially found to have difficulty swallowing a mouthful of water, but in most of those who survived, the deficit had resolved by the end of the first week. Strong correlations were found between dysphagia and speech impairment (comprehension and expression) and with facial weakness, but there was no association with the side of the stroke. After controlling for other markers of overall stroke severity such as conscious level, urinary continence, white blood cell count and strength in the affected limbs, swallowing impairment still showed a significant inverse correlation with functional ability at 1 and 6 months. These results indicate that, even if dysphagia itself is not responsible for much excess mortality in acute stroke, it might still lead to complications which hamper functional recovery.Dysphagia is a common and serious problem after strokes involving both cerebral hemispheres or the brainstem. Because of the bilateral upper motor neuron innervation ofmost ofthe lower cranial nerves involved in swallowing, many textbooks state that the mechanism of deglutition is not significantly affected by damage to a single cerebral hemisphere. Recently, however, it has been pointed out that unilateral hemisphere strokes do affect lower cranial nerve function in general' and swallowing in particular.2-5Clearly, swallowing problems could have serious consequences, with dehydration leading to haemoconcentration, impaired cerebral perfusion and renal failure, and aspiration leading to pneumonia. Data obtained from observations on 357 conscious stroke victims taking part in a trial of beta blockers in acute stroke (the "BEST" Study67) were used to investigate this possibility and to give more detailed information on the natural history of dysphagia after stroke. The results are presented here and the relationships between swallowing problems and other neurological deficits are explored.Patients and methods Patients taking part in the BEST Study were selected from a register of all stroke admissions to the acute wards of

Mood assessments were made after six months of 149 survivors taken from a register of all patients admitted to hospital with acute stroke. Using a General Health Questionnaire score of 12 or more as a criterion of important affective illness, its prevalence was 23%. There was no difference in risk of affective illness between left and right hemisphere strokes. Affective illness was strongly associated with functional ability, with limb weakness and with longer hospital stay in those with good functional recovery. Only 15% of those with high scores were receiving antidepressant drugs. The general practitioner is in the best position to detect psychiatric illness in stroke survivors; the use of mood rating scales such as the GHQ, in conjunction with clinical assessment, may improve detection.

The β blocker stroke (“BEST”) trial was designed to see if the apparent protective effect of propranolol on cerebral function in patients with subarachnoid haemorrhage applied also to patients suffering from acute stroke. Three hundred and two conscious patients with clinically diagnosed hemispheric strokes sustained within the past 48 hours were randomly assigned to receive atenolol, propranolol, or matching placebo capsules for three weeks. More early deaths occurred among the patients allocated to receive β blockers, but this was largely explained by differences in the initial characteristics of the patients among the different treatment groups. By contrast, the outcome in a further 60 patients, who had been taking β blockers at the time of their stroke but were otherwise similar to the patients in the trial, was considerably better, suggesting that prior treatment with β blockers might be protective. The search for an effective medical treatment for acute stroke must continue. The approach used here, in which neurological outcome was assessed in a modest number of patients with a view to proceeding subsequently to a full scale trial of functional outcome, allows practical benefits of a treatment to be evaluated under realistic conditions and an ineffective treatment to be eliminated without undue cost.

one when she can legally terminate the entire pregnancy. There are, however, grounds for caution if there is a lasting effect on the surviving twin. Through the Lone Twin Network, the Multiple Births Foundation meets a large number of adults whose twin died at or before birth and who feel the loss profoundly. How far this self selected group is representative is not known. Research on the long term psychological sequelae, including their prevalence and relative seriousness, is therefore badly needed.