Pan-London tuberculosis services: a service evaluation

Background

London has the largest proportion of tuberculosis (TB) cases of any western European capital, with almost half of new cases drug-resistant. Prevalence varies considerably between and within boroughs with research suggesting inadequate control of TB transmission in London. Economic pressures may exacerbate the already considerable challenges for service organisation and delivery within this context. This paper presents selected findings from an evaluation of London’s TB services’ organisation, delivery, professional workforce and skill mix, intended to support development of a strategic framework for a pan-London TB service. These may also interest health service professionals and managers in TB services in the UK, other European cities and countries and in services currently delivered by multiple providers operating independently.

Methods

Objectives were: 1) To establish how London’s TB services are structured and delivered in relation to leadership, management, organisation and delivery, coordination, staffing and support; 2) To identify tools/models for calculating skill mix as a basis for identifying skill mix requirements in delivering TB services across London; 3) To inform a strategic framework for the delivery of a pan-London TB service, which may be applicable to other European cities. The multi-method service audit evaluation comprised documentary analysis, semi-structured interviews with TB service users (n = 10), lead TB health professionals and managers (n = 13) representing London’s five sectors and focus groups with TB nurses (n = 8) and non-London network professionals (n = 2).

Results

Findings showed TB services to be mainly hospital-based, with fewer community-based services. Documentary analysis and professionals’ interviews suggested difficulties with early access to services, low suspicion index amongst some GPs and restricted referral routes. Interviews indicated lack of managed accommodation for difficult to treat patients, professional workforce shortages, a need for strategic leadership, nurse-led clinics and structured career paths for TB nurses and few social care/outreach workers to support patients with complex needs.

Conclusions

This paper has identified key issues relating to London’s TB services’ organisation, delivery, professional workforce and skill mix. The majority of these present challenges which need to be addressed as part of the future development of a strategic framework for a pan-London TB service. More consistent strategic planning/co-ordination and sharing of best practice is needed, together with a review of pan-London TB workforce development strategy, encompassing changing professional roles, skills development needs and patient pathways. These findings may be relevant with the development of TB services in other European cities.

Somatic SF3B1 mutation in myelodysplasia with ring sideroblasts

BACKGROUND

Myelodysplastic syndromes are a diverse and common group of chronic hematologic cancers. The identification of new genetic lesions could facilitate new diagnostic and therapeutic strategies.

METHODS

We used massively parallel sequencing technology to identify somatically acquired point mutations across all protein-coding exons in the genome in 9 patients with low-grade myelodysplasia. Targeted resequencing of the gene encoding RNA splicing factor 3B, subunit 1 (SF3B1), was also performed in a cohort of 2087 patients with myeloid or other cancers.

RESULTS

We identified 64 point mutations in the 9 patients. Recurrent somatically acquired mutations were identified in SF3B1. Follow-up revealed SF3B1 mutations in 72 of 354 patients (20%) with myelodysplastic syndromes, with particularly high frequency among patients whose disease was characterized by ring sideroblasts (53 of 82 [65%]). The gene was also mutated in 1 to 5% of patients with a variety of other tumor types. The observed mutations were less deleterious than was expected on the basis of chance, suggesting that the mutated protein retains structural integrity with altered function. SF3B1 mutations were associated with down-regulation of key gene networks, including core mitochondrial pathways. Clinically, patients with SF3B1 mutations had fewer cytopenias and longer event-free survival than patients without SF3B1 mutations.

CONCLUSIONS

Mutations in SF3B1 implicate abnormalities of messenger RNA splicing in the pathogenesis of myelodysplastic syndromes. (Funded by the Wellcome Trust and others.).

Economic impact of a Medicaid population health management program

A population health management program was implemented to assess growth in health care expenditures for the disabled segment of Georgia's Medicaid population before and during the first year of a population health outcomes management program, and to compare those expenditures with projected costs based on various cost inflation trend assumptions. A retrospective, nonexperimental approach was used to analyze claims data from Georgia Medicaid claims files for all program-eligible persons for each relevant time period (intent-to-treat basis). These included all non-Medicare, noninstitutionalized Medicaid aged-blind-disabled adults older than 18 years of age. Comparisons of health care expenditures and utilization were made between base year (2003-2004) and performance year one (2006-2007), and of the difference between actual expenditures incurred in the performance year vs. projected expenditures based on various cost inflation assumptions. Demographic characteristics and clinical complexity of the population (as measured by the Chronic Illness and Disability Payment System risk score) actually increased from baseline to implementation. Actual expenditures were less than projected expenditures using any relevant medical inflation assumption. Actual expenditures were less than projected expenditures by $9.82 million when using a conservative US general medical inflation rate, by $43.6 million using national Medicaid cost trends, and by $106 million using Georgia Medicaid's own cost projections for the non-dually eligible disabled segment of Medicaid enrollees. Quadratic growth curve modeling also demonstrated a lower rate of increase in total expenditures. The rate of increase in expenditures was lower over the first year of program implementation compared with baseline. Weighted utilization rates were also lower in high-cost categories, such as inpatient days, despite increases in the risk profile of the population. Varying levels of cost avoidance could be inferred from differences between actual and projected expenditures using each of the health-related inflation assumptions.

Achieving continuity of care: facilitators and barriers in community mental health teams

Background

The integration of mental health and social services for people diagnosed with severe mental illness (SMI) has been a key aspect of attempts to reform mental health services in the UK and aims to minimise user and carer distress and confusion arising from service discontinuities. Community mental health teams (CMHTs) are a key component of UK policy for integrated service delivery, but implementing this policy has raised considerable organisational challenges. The aim of this study was to identify and explore facilitators and barriers perceived to influence continuity of care by health and social care professionals working in and closely associated with CMHTs.

Methods

This study employed a survey design utilising in-depth, semi-structured interviews with a proportionate, random sample of 113 health and social care professionals and representatives of voluntary organisations. Participants worked in two NHS Mental Health Trusts in greater London within eight adult CMHTs and their associated acute in-patient wards, six local general practices, and two voluntary organisations.

Results

Team leadership, decision making, and experiences of teamwork support were facilitators for cross boundary and team continuity; face-to-face communication between teams, managers, general practitioners, and the voluntary sector were facilitators for information continuity. Relational, personal, and longitudinal continuity were facilitated in some local areas by workforce stability. Barriers for cross boundary and team continuity were specific leadership styles and models of decision making, blurred professional role boundaries, generic working, and lack of training for role development. Barriers for relational, personal, and longitudinal continuity were created by inadequate staffing levels, high caseloads, and administrative duties that could limit time spent with users. Incompatibility of information technology systems hindered information continuity. Flexible continuity was challenged by the increasingly complex needs of service users.

Conclusions

Substantive challenges exist in harnessing the benefits of integrated CMHT working to deliver continuity of care. Team support should be prioritised in terms of IT provision linked to a review of current models of administrative support. Investment in education and training for role development, leadership, workforce retention, and skills to meet service users' complex needs are recommended.

Listening to those on the frontline: service users' experiences of London tuberculosis services

AIM

To explore tuberculosis (TB) service users' experiences and satisfaction with care provision.

BACKGROUND

Thirty-nine percent of all new UK TB cases occur in London. Prevalence varies considerably between and within boroughs. Overall, research suggests inadequate control of London's TB transmission; TB has become a health care priority for all London Primary Care Trusts. Service users' experiences and satisfaction with care provision have not been explored adequately previously.

METHODS

A qualitative research design, using semi-structured face-to-face interviews was used. Ten service users, purposively selected in key risk groups across London, were interviewed. All interviews were digitally recorded with users' permission, transcribed verbatim, and analyzed thematically.

RESULTS

Participants were treated in local hospitals for 6-12 months. Treatment was administered by TB nurses to inpatients and outpatients receiving directly observed therapy in consultation with medical staff and home visits for complex cases. Two participants did not realize the importance of compliance. Overall, they were satisfied with many TB services' aspects, communication, and service organization. Early access, low suspicion index amongst some GPs, and restricted referral routes were identified as service barriers. Other improvement areas were information provision on drug side effects, diet, nutritional status, and a few health professionals' attitudes. The effects on people varied enormously from minimal impact to psychological shock; TB also affected social and personal aspects of their life. With regard to further support facilities, some positive views on managed accommodation by TB-aware professionals for those with accommodation problems were identified.

CONCLUSION

This first in-depth study of TB service users' experiences across London offers valuable insights into service users' experiences, providing information and recommendations for a strategic framework for TB service organization and delivery. Overall, further research is needed; TB services - local, national, and international - need to be more closely aligned with service users' complex needs.

Electric acoustic stimulation of the auditory system: experience and results of ten patients using MED-EL's M and FlexEAS electrodes

OBJECTIVE

To evaluate the hearing preservation rate and speech perception scores in patients with profound high frequency hearing loss and acoustically aidable low frequency hearing, managed with the MED-EL electric acoustic stimulation system referenced to the insertion depth of the electrode array.

STUDY DESIGN

Retrospective data analysis.

PARTICIPANTS AND SETTING

Ten patients implanted at the Auditory Implant Centre, Guy's and St Thomas's Hospital, London, UK.

MAIN OUTCOME MEASURES

Pure tone audiometry, speech perception tests and electrode insertion depth angle.

RESULTS

Postoperatively, functional hearing preservation allowing electric acoustic stimulation was achieved in eight patients and total preservation of residual hearing in five patients with follow-up periods of more than 12 months. Three of four (75%) patients with an insertion depth of >360 degrees had a threshold shift of >25 dB, and all four patients had a threshold shift of >10 dB. All patients with total hearing preservation had the electrode inserted up to 360 degrees at maximum. Overall, speech perception outcomes increased significantly and hearing impairment was significantly reduced after electric acoustic stimulation or electric stimulation alone as compared with the preoperative scores.

CONCLUSION

Electric acoustic stimulation provides significant benefit to individuals with profound high frequency hearing loss. Studies with larger number of patients are needed to establish the optimal electrode insertion angle as well as to further analyse the benefit of electric acoustic stimulation.

Process, outcome and experience of transition from child to adult mental healthcare: multiperspective study

BACKGROUND

Many adolescents with mental health problems experience transition of care from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS).

AIMS

As part of the TRACK study we evaluated the process, outcomes and user and carer experience of transition from CAMHS to AMHS.

METHOD

We identified a cohort of service users crossing the CAMHS/AMHS boundary over 1 year across six mental health trusts in England. We tracked their journey to determine predictors of optimal transition and conducted qualitative interviews with a subsample of users, their carers and clinicians on how transition was experienced.

RESULTS

Of 154 individuals who crossed the transition boundary in 1 year, 90 were actual referrals (i.e. they made a transition to AMHS), and 64 were potential referrals (i.e. were either not referred to AMHS or not accepted by AMHS). Individuals with a history of severe mental illness, being on medication or having been admitted were more likely to make a transition than those with neurodevelopmental disorders, emotional/neurotic disorders and emerging personality disorder. Optimal transition, defined as adequate transition planning, good information transfer across teams, joint working between teams and continuity of care following transition, was experienced by less than 5% of those who made a transition. Following transition, most service users stayed engaged with AMHS and reported improvement in their mental health.

CONCLUSIONS

For the vast majority of service users, transition from CAMHS to AMHS is poorly planned, poorly executed and poorly experienced. The transition process accentuates pre-existing barriers between CAMHS and AMHS.

Specialist nursing interventions for inflammatory bowel disease

BACKGROUND

The number, type and roles of specialist nurses dedicated to the care and management of patients with inflammatory bowel disease is increasing. Despite this increase, there has been little evidence to date to demonstrate the effectiveness of specialist nursing interventions. This review aims to identify and evaluate the impact of specialist nursing interventions on management of inflammatory bowel disease, access to treatment, remission, morbidity and quality of life.

OBJECTIVES

To identify and evaluate the impact of specialist nursing interventions for improving the care and management of patients with inflammatory bowel disease (IBD).

SEARCH STRATEGY

A comprehensive search of databases including the Cochrane Library, MEDLINE, and British Nursing Index was carried out to identify trials. References from relevant papers were searched and hand searching was undertaken of relevant publications including gastroenterology conference proceedings to identify additional trials (date of last search 30 September 2008).

SELECTION CRITERIA

Randomised controlled trials, controlled before and after studies and interrupted time series studies of gastroenterology and IBD specialist nurses intending to improve access and outcomes for patients with ulcerative colitis and Crohn's disease were considered for inclusion.

DATA COLLECTION AND ANALYSIS

Two investigators independently extracted data and assessed trial quality. Any discrepancies were resolved by consensus.

MAIN RESULTS

One randomised controlled trial of 100 IBD patients receiving a specialist nurse delivered counselling package (n = 50) or routine outpatient clinic follow-up (n = 50), with assessments at entry and six and 12 months, was included in this review. This study was of low methodological quality. Disease remission, patient compliance, clinical improvement, utilisation of nurse-led services, patient satisfaction, hospital admission, outpatient attendance, progression to surgery, length of hospital stay and cost effectiveness data were not reported. Pooled mean mental health scores at 6 months were higher in patients who received nurse-led counselling compared to patients who received routine follow-up. However, this difference was not statistically significant (WMD 3.67; 95% CI -0.44 to 7.77; P = 0.08). Other pooled assessments of physical and psychological well-being showed no statistically significant differences.

AUTHORS' CONCLUSIONS

Although specialist nurse counselling interventions might provide benefit for IBD patients the one included study was of low quality and the results of this study should be interpreted with caution. Higher quality trials of gastroenterology and IBD specialist nursing interventions are needed to assess the impact of specialist nursing interventions on the care and management of patients with inflammatory bowel disease.

Continuity of care in mental health: understanding and measuring a complex phenomenon

BACKGROUND

Continuity of care is considered by patients and clinicians an essential feature of good quality care in long-term disorders, yet there is general agreement that it is a complex concept. Most policies emphasize it and encourage systems to promote it. Despite this, there is no accepted definition or measure against which to test policies or interventions designed to improve continuity. We aimed to operationalize a multi-axial model of continuity of care and to use factor analysis to determine its validity for severe mental illness.

METHOD

A multi-axial model of continuity of care comprising eight facets was operationalized for quantitative data collection from mental health service users using 32 variables. Of these variables, 22 were subsequently entered into a factor analysis as independent components, using data from a clinical population considered to require long-term consistent care.

RESULTS

Factor analysis produced seven independent continuity factors accounting for 62.5% of the total variance. These factors, Experience and Relationship, Regularity, Meeting Needs, Consolidation, Managed Transitions, Care Coordination and Supported Living, were close but not identical to the original theoretical model.

CONCLUSIONS

We confirmed that continuity of care is multi-factorial. Our seven factors are intuitively meaningful and appear to work in mental health. These factors should be used as a starting-point in research into the determinants and outcomes of continuity of care in long-term disorders.

Does appraisal enhance learning, improve practice and encourage continuing professional development? A survey of general practitioners' experiences of appraisal

BACKGROUND

Revalidation of the medical profession is under review and a system has been proposed to ensure doctors meet standards of practice and professionalism. The current appraisal system allows clinicians to chart their progress and identify developmental needs in order to improve performance. Appraisal is now an annual compulsory requirement for all doctors.

AIM AND OBJECTIVES

The aim of the study was to investigate the experiences of general practitioners (GPs) of the current appraisal process. The specific objectives were to consider the impact the appraisal process had exerted on their learning, practice and individual continuing professional development (CPD).

METHODS

We employed a cross-sectional design using a postal questionnaire sent to all doctors who work as GPs (n = 385) in West Kent.

MAIN RESULTS

Questionnaires were returned from 71.7% of doctors (n = 276). The key findings obtained were that 47.5% (n = 131) of doctors stated that taking part in the appraisal process had enhanced their learning, 40.2% (n = 111) felt that the appraisal process had improved their practice and 55.8% (n = 154) stated that the appraisal process had encouraged their CPD. Qualitative findings derived from thematic analysis of open questions revealed that participants viewed the role of the appraiser as respected peer to be vital and there was a need for independence in the appraiser's appointment. The time-consuming nature of the appraisal process was emphasised, with little protected time for preparation of documentation and engagement in CPD. Concerns were expressed about links between appraisal and revalidation.

CONCLUSIONS

Many doctors considered that the appraisal process had enhanced their learning, improved their practice and encouraged their CPD. A vital, independent role for the appraiser was emphasised as was a need to review the time-consuming nature of the current appraisal process, together with identifying protected time to complete this and CPD engagement. As the role of appraisal within the revalidation process changes it is recognised that ensuring the quality, consistency and nature of appraisal will be essential to maintain the confidence of patients and doctors.

Implementing a strategy to promote lifelong learning in the primary care workforce: an evaluation of leadership roles, change management approaches, interim challenges and achievements

OBJECTIVES

To identify and explore leadership roles and responsibilities for implementing the workforce development strategy; to identify approaches used to implement and disseminate the strategy; and to identify and explore challenges and achievements in the first 18 months following implementation.

DESIGN

A formative evaluation with qualitative methods was used. Documentary analysis, interviews (n = 29) and two focus groups (n = 12) were conducted with a purposive sample of individuals responsible for strategy implementation. Data were transcribed and analysed thematically using framework analysis.

SETTING

Regional health area in Kent, Surrey and Sussex: 24 primary care trusts (PCTs) and 900 general practices.

RESULTS

Primary care workforce tutors, lifelong learning advisors, GP tutors, patch associate GP deans and chairs of PCT education committees all had vital leadership roles, some existing and others newly developed. Approaches used to implement the strategy encompassed working within and across organisational boundaries, communication and dissemination of information. Challenges encountered by implementers were resistance to change - evident in some negative attitudes to uptake of training and development opportunities - and role diversity and influence. Achievements included successes in embedding appraisal and protected learning time, and changes in educational practices and services.

CONCLUSIONS

The use of key leadership roles and change-management approaches had brought about early indications of positive transition in lifelong learning cultures.

Detection of mucosal abnormalities in patients with oral cancer using a photodynamic technique: A pilot study

Patients who have had one oral cancer are at increased risk of developing a further malignant tumour, the detection of which is made difficult (and is often delayed) by the innocuous appearance of the early oral lesion. A technique that could reliably detect early cancers would be useful to both oral and dental health specialists. We describe a pilot study in which we used a compact spectroscopic instrument designed to excite and measure fluorescence in the oral cavity. The data were processed using principal components analysis, and the results suggest that the technique might be valuable for detecting early oral cancers. Further work should be performed to investigate some unusual characteristics observed within our data to ascertain if these are significant, simply due to errors made due data collection, or are due to other lifestyle factors. Such work could also verify that the data are due to detection of ALA metabolite in cancer and not some other systemic effect.

Assessing organisational readiness for change: use of diagnostic analysis prior to the implementation of a multidisciplinary assessment for acute stroke care

BACKGROUND

Achieving evidence-based practice in health care is integral to the drive for quality improvement in the National Health Service in the UK. Encapsulated within this policy agenda are challenges inherent in leading and managing organisational change. Not least of these is the need to change the behaviours of individuals and groups in order to embed new practices. Such changes are set within a context of organisational culture that can present a number of barriers and facilitators to change. Diagnostic analysis has been recommended as a precursor to the implementation of change to enable such barriers and facilitators to be identified and a targeted implementation strategy developed. Although diagnostic analysis is recommended, there is a paucity of advice on appropriate methods to use. This paper addresses the paucity and builds on previous work by recommending a mixed method approach to diagnostic analysis comprising both quantitative and qualitative data.

METHODS

Twenty staff members with strategic accountability for stroke care were purposively sampled to take part in semi-structured interviews. Six recently discharged patients were also interviewed. Focus groups were conducted with one group of registered ward-based nurses (n = 5) and three specialist registrars (n = 3) purposively selected for their interest in stroke care. All professional staff on the study wards were sent the Team Climate Inventory questionnaire (n = 206). This elicited a response rate of 72% (n = 148).

RESULTS

A number of facilitators for change were identified, including stakeholder support, organisational commitment to education, strong team climate in some teams, exemplars of past successful organisational change, and positive working environments. A number of barriers were also identified, including: unidisciplinary assessment/recording practices, varying in structure and evidence-base; weak team climate in some teams; negative exemplars of organisational change; and uncertainty created by impending organisational merger.

CONCLUSION

This study built on previous research by proposing a mixed method approach for diagnostic analysis. The combination of qualitative and quantitative data were able to capture multiple perspectives on barriers and facilitators to change. These data informed the tailoring of the implementation strategy to the specific needs of the Trust.

The DNA sequence and biological annotation of human chromosome 1

The reference sequence for each human chromosome provides the framework for understanding genome function, variation and evolution. Here we report the finished sequence and biological annotation of human chromosome 1. Chromosome 1 is gene-dense, with 3,141 genes and 991 pseudogenes, and many coding sequences overlap. Rearrangements and mutations of chromosome 1 are prevalent in cancer and many other diseases. Patterns of sequence variation reveal signals of recent selection in specific genes that may contribute to human fitness, and also in regions where no function is evident. Fine-scale recombination occurs in hotspots of varying intensity along the sequence, and is enriched near genes. These and other studies of human biology and disease encoded within chromosome 1 are made possible with the highly accurate annotated sequence, as part of the completed set of chromosome sequences that comprise the reference human genome.

Social relationships as predictors of depression and suicidal ideation in older adults

The prevalence of depression and suicidal ideation among older adults is considered to be a major mental health concern among this age group. The present study investigated the human relatedness variables of marital status, social support resources and sense of belonging as predictors of depression and suicidal ideation in older adults. A community sample of 110 older adults (M age 76.67 years, SD = 8.11) completed the Social Support Subscale of the Coping Resources Inventory, the Sense of Belonging Instrument, the Zung Depression Inventory and the Suicide Subscale of the General Health Questionnaire. Results indicated that fewer social support resources were associated with higher levels of depression and suicidal ideation. Sense of belonging to the community was not an additional predictor of mental health. The results of the present study suggest that enhancing social support resources in older adults could reduce depression and suicidal ideation.

Physical activity alone and with others as predictors of sense of belonging and mental health in retirees

A high sense of belonging to the community and physical activity are associated with improved mental health in older people. The present study tested a model incorporating physical activities performed alone and with others as predictors of sense of belonging, depression and suicide ideation. One hundred and ninety four retired adults (87 males, 107 females, mean age 68 years) completed the Yale Physical Activity Survey, the Sense of Belonging Instrument, the Suicide Subscale of the General Health Questionnaire and the Zung Depression Inventory. Within the context of the model, neither participating in physical activities alone, nor with at least one other person, predicted sense of belonging, depression or suicide ideation. Having the abilities and motivation to belong was a predictor of participating in physical activities with others and actual feelings of belonging and contributed to predicting mental health in retirees. It was concluded that simply performing activities with others was not associated with a sense of belonging or mental health. Rather, sense of belonging may need to be facilitated in order for mental health to be enhanced.

003.Expression of secreted frizzled related protein-4 (sFRP-4) and associated Wnt signalling in cancer and apoptosis

We examined the interplay between Wnt and secreted frizzled related protein-4 (sFRP4) in estradiol induced cell growth in breast cancer cells (MCF-7), and also determined the in vivo distribution of sFRP-4 in human breast cancer. MCF-7 cells were treated with estradiol, sFRP-4 conditioned media and a combination of the two. Real-time RT-PCR and Western blot analysis were used to determine the expression of the sFRP-4 and its associated Wnt signalling molecules following treatment. Immunohistochemistry was performed to examine sFRP-4 expression patterns in human breast cancers. Estradiol treatment up-regulated the expression of the Wnt signalling genes Wnt-10b, beta-catenin and fz-4 (P < 0.001 for all genes). This up-regulation was not associated with an increase in the Wnt signalling pathway as measured by the levels of active beta-catenin. sFRP-4 conditioned media reduced MCF-7 cell proliferation, down-regulated the Wnt signalling genes beta-catenin and fz-4 as well as down-regulating wnt signalling activity. sFRP-4 was able to reduce the proliferation of estradiol stimulated MCF-7 cells. Cytoplasmic sFRP-4 protein was expressed in all breast tumours examined, with intense staining evident in the lobular carcinoma in situ and the ductal carcinoma. These data demonstrate that sFRP-4 is a potent inhibitor of the Wnt signalling pathway in MCF-7 cells, acting not only to down-regulate the activity of the wnt signalling pathway, but also down-regulate the transcription of Wnt signalling genes. The results of these in vitro and immunohistochemical experiments warrant further investigation as to whether sFRP-4 expression can be indicative of prognosis in human breast cancer. In addition to breast cancer, we have also examined the role of sFRP-4 in other cancers such as ovarian and prostate.

An exploration of nutrition and eating disabilities in relation to quality of life at 6 months post-stroke

Quality of life (QoL) is increasingly recognised as an important healthcare outcome, especially for those living with enduring disability. Stroke is a major source of long-term disablement and many aspects of life after stroke have been explored. Little attention has been paid to nutritional issues despite the cultural and hedonistic importance of food and eating, and the deleterious effects of malnutrition. The present study employed an epidemiological survey to investigate the contribution of dietary and nutritional factors in relation to QoL after stroke. The participants were 206 survivors of a cohort of acute stroke patients consecutively admitted to a National Health Service trust hospital in South London, UK, between March 1998 and April 1999. They were interviewed in their homes at 6 months post-stroke. Cognitively or communication-impaired patients were precluded from interview except where a live-in carer participated as a proxy (n = 10). The participation rate for those who were eligible and could be contacted was 206 out of 218 (94%). Participants were assessed using standardised, validated tools for functional abilities in activities of daily living and eating, cognition and mood state, social support and economic indices, nutritional status, dietary intake, and QoL. Overall group scores demonstrated relatively minor degrees of physical disablement; exclusion of those with limited cognition and communication precluded assessment of a small subgroup with greater disablement at hospital discharge. Nonetheless, the overall assessment results were not dissimilar to other reported groups. Indices of poor nutritional status and substantial dietary inadequacy were revealed, linked with reduced appetite and depression. Multiple regression analyses revealed the dominant impact of mood state in relation to QoL scores; additional significant effects were identified for social support, eating-related disabilities and age. The effects of mood and social support are well-recognised, whilst nutrition-related effects have previously received little attention. Intervention in these areas might achieve improvements in survivors' perceived QoL.