***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background and Purpose — Several stroke scales are available for estimation of the severity of stroke , but none of them provides information regarding the relative weights of the observed variables . To define an integrated severity of stroke , we developed a quantifiable stroke scale with weighted variables that apply conjoint analysis to calculate the relative weight of each item . Methods — We selected 10 variables ( consciousness , language , neglect , hemianopsia , gaze , pupillary abnormality , facial palsy , plantar reflex , sensation , and weakness ) based on the multivariate analysis of the Keio Stroke Patient Data base Battery . The variables were categorized and evaluated for their distribution and sensitivity . The categorizations were then modified and rechecked . The procedure was repeated until the appropriate categorization was obtained from 198 patients . A temporary stroke scale without weight was then formulated , and the reliability of the scale was examined and revised with 80 new stroke patients . As a next step , 150 neurologists were asked to rank a set of 27 virtual patients , each with a different combination of variables , according to severity . From these rankings , conjoint analysis was used to derive utility scores ( weights ) for each factor level . Results — The relative weights of each of the factors were as follows : consciousness 49.8 % , language 9.9 % , weakness of lower extremity 7.3 % , pupillary abnormality 6.8 % , gaze palsy 5.6 % , weakness of arm 4.3 % , weakness of h and 3.7 % , neglect 3.7 % , facial palsy 2.4 % , plantar reflex 2.2 % , hemianopsia 2.2 % , and sensory impairment 2.1 % . The total score for a patient could be calculated from the sum of the scores for each of the variables ranging from −0.38 to 27.86 . Scoring of 100 patients with acute stroke was carried out , and the changes in scores were followed for validation . Longitudinal clinical monitoring of the patients correlated well with the scores in each patient . The interrater and intrarater reliabilities of the scale were excellent ( weighted & kgr ; 0.83 ; Cronbach ’s & agr ; 0.998 ) . Conclusions — The Japan Stroke Scale is a parametric stroke scale that provides a quantitative measure of the severity of stroke . Each of the variables of the scale has a relative weight according to the severity of stroke . Reliability and responsiveness were proved to be excellent . The present data revealed a potentiality for the Japan Stroke Scale to be a universally accepted and reliable st and ardized system from the clinimetrical point of view Background and Purpose — The  NIH Stroke Scale ( NIHSS ) and the Canadian Neurological Scale ( CNS ) have been reported to be useful for the retrospective assessment of initial stroke severity . However , unlike the CNS , the NIHSS requires detailed neurological assessment s that may not be reflected in all patient records , potentially limiting its applicability . We assessed the reliability of the retrospective algorithms and the proportions of missing items for the NIHSS and CNS in stroke patients admitted to an academic medical center ( AMC ) and 2 community hospitals . Methods — R and omly selected records of patients with ischemic stroke admitted to an AMC ( n=20 ) and community hospitals with ( CH1 , n=19 ) and without ( CH2 , n=20 ) acute neurological consultative services were review ed .  NIHSS and CNS scores  were assigned independently by 2 neurologists using published algorithms . Interrater reliability of the scores was determined with the intraclass correlation coefficient , and the numbers of missing items were tabulated . Results — The intraclass correlation coefficient for NIHSS and CNS , respectively , were 0.93 ( 95 % CI , 0.82 to 1.00 ) and 0.97 ( 95 % CI , 0.90 to 1.00 ) for the AMC , 0.89 ( 95 % CI , 0.75 to 1.00 ) and 0.88 ( 95 % , 0.73 to 1.00 ) for the CH1 , and 0.48 ( 95 % CI , 0.26 to 0.70 ) and 0.78 ( 95 % CI , 0.60 to 0.96 ) for the CH2 . More NIHSS items were missing at the CH2 ( 62 % ) versus the AMC ( 27 % ) and the CH1 ( 23 % , P = 0.0001 ) . In comparison , 33 % , 0 % , and 8 % of CNS items were missing from records from CH2 , AMC , and CH1 , respectively ( P = 0.0001 ) . Conclusions — The levels of interrater agreement were almost perfect for retrospectively assigned NIHSS and CNS scores for patients initially evaluated by a neurologist at both an AMC and a CH . Levels of agreement for the CNS were substantial at a CH2 , but interrater agreement for the NIHSS was only moderate in this setting . The proportions of missing items are higher for the NIHSS than the CNS in each setting , particularly limiting its application in the hospital without acute neurological consultative services Background Stroke is a major cause of death and leading cause of disability in the United States . To maximize a stroke patient 's chances of receiving thrombolytic treatment for acute ischemic stroke , it is important to improve prehospital recognition of stroke . However , it is known from published reports that emergency medical dispatchers ( EMDs ) using Card 28 of the Medical Priority Dispatch System protocol s recognize stroke poorly . Therefore , to improve EMD 's recognition of stroke , the National Association of Emergency Medical Dispatchers recently design ed a new diagnostic stroke tool ( Cincinnati Stroke Scale -CSS ) to be used with Card 28 . The objective of this study is to determine whether the addition of CSS improves diagnostic accuracy of stroke triage . Methods / Design This prospect i ve experimental study will be conducted during a one-year period in the 911 call center of Santa Clara County , CA . We will include callers aged ≥ 18 years with a chief complaint suggestive of stroke and second party callers ( by-st and er or family who are in close proximity to the patient and can administer the tool ) ≥ 18 years of age . Life threatening calls will be excluded from the study . Card 28 questions will be administered to subjects who meet study criteria . After completion of Card 28 , CSS tool will be administered to all calls . EMDs will record their initial assessment of a cerebro-vascular accident ( stroke ) after completion of Card 28 and their final assessment after completion of CSS . These assessment s will be compared with the hospital discharge diagnosis ( ICD-9 codes ) recorded in the Office of Statewide Health Planning and Development ( OSHPD ) data base after linking the EMD data base and OSHPD data base using probabilistic linkage . The primary analysis will compare the sensitivity of the two stroke protocol s using logistic regression and generalizing estimating equations to account for clustering by EMDs . To detect a 15 % difference in sensitivity between the two groups with 80 % power , we will enroll a total of 370 subjects in this trial . Discussion A three week pilot study was performed which demonstrated the feasibility of implementation of the study protocol BACKGROUND Trials of beta blockers in patients undergoing non-cardiac surgery have reported conflicting results . This r and omised controlled trial , done in 190 hospitals in 23 countries , was design ed to investigate the effects of perioperative beta blockers . METHODS We r and omly assigned 8351 patients with , or at risk of , atherosclerotic disease who were undergoing non-cardiac surgery to receive extended-release metoprolol succinate ( n=4174 ) or placebo ( n=4177 ) , by a computerised r and omisation phone service . Study treatment was started 2 - 4 h before surgery and continued for 30 days . Patients , health-care providers , data collectors , and outcome adjudicators were masked to treatment allocation . The primary endpoint was a composite of cardiovascular death , non-fatal myocardial infa rct ion , and non-fatal cardiac arrest . Analyses were by intention to treat . This trial is registered with Clinical Trials.gov , number NCT00182039 . FINDINGS All 8351 patients were included in analyses ; 8331 ( 99.8 % ) patients completed the 30-day follow-up . Fewer patients in the metoprolol group than in the placebo group reached the primary endpoint ( 244 [ 5.8 % ] patients in the metoprolol group vs 290 [ 6.9 % ] in the placebo group ; hazard ratio 0.84 , 95 % CI 0.70 - 0.99 ; p=0.0399 ) . Fewer patients in the metoprolol group than in the placebo group had a myocardial infa rct ion ( 176 [ 4.2 % ] vs 239 [ 5.7 % ] patients ; 0.73 , 0.60 - 0.89 ; p=0.0017 ) . However , there were more deaths in the metoprolol group than in the placebo group ( 129 [ 3.1 % ] vs 97 [ 2.3 % ] patients ; 1.33 , 1.03 - 1.74 ; p=0.0317 ) . More patients in the metoprolol group than in the placebo group had a stroke ( 41 [ 1.0 % ] vs 19 [ 0.5 % ] patients ; 2.17 , 1.26 - 3.74 ; p=0.0053 ) . INTERPRETATION Our results highlight the risk in assuming a perioperative beta-blocker regimen has benefit without substantial harm , and the importance and need for large r and omised trials in the perioperative setting . Patients are unlikely to accept the risks associated with perioperative extended-release metoprolol BACKGROUND In patients with acute stroke , rapid intervention is crucial to maximise early treatment benefits . Stroke patients commonly have their first contact with medical staff in the emergency room ( ER ) . We design ed and vali date d a stroke recognition tool-the Recognition of Stroke in the Emergency Room ( ROSIER ) scale-for use by ER physicians . METHODS We prospect ively collected data for 1 year ( development phase ) on the clinical characteristics of patients with suspected acute stroke who were admitted to hospital from the ER . We used logistic regression analysis and clinical reasoning to develop a  stroke recognition instrument  for application in this setting . Patients with suspected transient ischaemic attack ( TIA ) with no symptoms or signs when assessed in the ER were excluded from the analysis . The instrument was assessed using the baseline 1-year data set and then prospect ively vali date d in a new cohort of ER patients admitted over a 9-month period . FINDINGS In the development phase , 343 suspected stroke patients were assessed ( 159 stroke , 167 non-stroke , 32 with TIA [ 17 with symptoms when seen in ER ] ) . Common stroke mimics were seizures ( 23 % ) , syncope ( 23 % ) , and sepsis ( 10 % ) . A seven-item ( total score from -2 to + 5 ) stroke recognition instrument  was constructed on the basis of clinical history ( loss of consciousness , convulsive fits ) and neurological signs ( face , arm , or leg weakness , speech disturbance , visual field defect ) . When internally vali date d at a cut-off score greater than zero , the instrument showed a diagnostic sensitivity of 92 % , specificity of 86 % , positive predictive value ( PPV ) of 88 % , and negative predictive value ( NPV ) of 91 % . Prospect i ve validation in 173 consecutive suspected stroke referrals ( 88 stroke , 59 non-stroke , 26 with TIA [ 13 with symptoms ] ) showed sensitivity of 93 % ( 95 % CI 89 - 97 ) , specificity 83 % ( 77 - 89 ) , PPV 90 % ( 85 - 95 ) , and NPV 88 % ( 83 - 93 ) . The ROSIER scale had greater sensitivity than existing stroke recognition instruments in this population . INTERPRETATION The ROSIER scale was effective in the initial differentiation of acute stroke from stroke mimics in the ER . Introduction of the instrument improved the appropriateness of referrals to the stroke team BACKGROUND AND PURPOSE Early thrombolytic therapy with recombinant tissue-type plasminogen activator is a theoretically attractive approach to the treatment of acute focal cerebral ischemia . In preparation for a larger multicenter trial , three centers piloted a protocol for a r and omized , double-blind , placebo-controlled trial of intravenous recombinant tissue-type plasminogen activator begun within 3 hours of the onset of symptoms of acute stroke to test its feasibility and to explore trends . METHODS Eligible patients had pretreatment computed tomographic scanning , gave informed consent , and began treatment with either 0.85 mg/kg recombinant tissue-type plasminogen activator or placebo as soon as possible , but no later than 180 minutes after stroke onset . Patients were stratified by whether treatment was begun within 90 minutes or 91 to 180 minutes from onset . The primary end point was the proportion of patients in each group who improved by 4 or more points on the National Institutes of Health Stroke Scale at 24 hours , as determined by a separate blinded evaluator . RESULTS Twenty-seven patients were r and omized : 20 ( 10 recombinant tissue-type plasminogen activator , 10 placebo ) within 90 minutes , and 7 ( 4 recombinant tissue-type plasminogen activator , 3 placebo ) from 91 to 180 minutes . Median baseline Stroke Scale scores 
    Output:
    
The modified National Institutes of Health Stroke Scale appears to be useful in detecting new subtle neurological deficits in critical care , or high dependency units after surgery .
However , in the general postsurgical wards , given the concern about the workload required , abbreviated stroke tests  may be more appropriate for routine regular stroke surveillance .
It is hoped that these tests will provide rapid assessment of global neurological function to facilitate timely diagnosis and treatment of perioperative stroke