Results of an international survey on the status of prehospital care

BACKGROUND

Prehospital care including recognition of stroke symptoms by the public and professionals combined with an efficient and effective emergency medical service (EMS) is essential to increase access to effective acute stroke care. We undertook a survey to document the status of stroke prehospital care globally.

METHODS

A survey was distributed via email to the World Stroke Organization (WSO) members. Information was sought on the current status of stroke prehospital delay globally, including (1) ambulance availability and whether payment for use is required, (2) ambulance response times and the proportion of patients arriving at hospital by ambulance, (3) the proportion of patients arriving within 3 h and more than 24 h after symptom, (4) whether stroke care training of paramedics, call handlers, and primary care staff, (5) availability of specialist centers, and (6) the proportion of patients taken to specialist centers. Respondents were also asked to identify the top three changes in prehospital care that would benefit their population. Data were analyzed descriptively at both country and continent level.

RESULTS

Responses were received from 116 individuals in 43 countries, with a response rate of 4.7%. Most respondents (90%) reported access to ambulances, but 40% of respondents reported payment was required by the patient. Where an ambulance service was available (105 respondents) 37% of respondents reported that less than 50% of patients used an ambulance and 12% less than 20% of patients used an ambulance. Large variations in ambulance response times were reported both within and between countries. Most of the participating high-income countries (HIC) offered a service used by patients, but this was rarely the case for the low- and middle-income countries (LMIC). Time to admission was often much longer in LMIC, and there was less access to stroke training for EMS and primary care staff.

CONCLUSIONS

Significant deficiencies in stroke prehospital care exist globally especially in LMIC. In all countries, there are opportunities to improve the quality of the service in ways that would likely result in improved outcomes after acute stroke.

Effects of oral anticoagulation for atrial fibrillation after spontaneous intracranial haemorrhage in the UK: a randomised, open-label, assessor-masked, pilot-phase, non-inferiority trial

BACKGROUND

Oral anticoagulation reduces the rate of systemic embolism for patients with atrial fibrillation by two-thirds, but its benefits for patients with previous intracranial haemorrhage are uncertain. In the Start or STop Anticoagulants Randomised Trial (SoSTART), we aimed to establish whether starting is non-inferior to avoiding oral anticoagulation for survivors of intracranial haemorrhage who have atrial fibrillation.

METHODS

SoSTART was a prospective, randomised, open-label, assessor-masked, parallel-group, pilot phase trial done at 67 hospitals in the UK. We recruited adults (aged ≥18 years) who had survived at least 24 h after symptomatic spontaneous intracranial haemorrhage, had atrial fibrillation, and had a CHA2DS2-VASc score of at least 2. Web-based computerised randomisation incorporating a minimisation algorithm allocated participants (1:1) to start or avoid long-term (≥1 year) full treatment dose open-label oral anticoagulation. The participants assigned to start oral anticoagulation received either a direct oral anticoagulant or vitamin K antagonist, and the group assigned to avoid oral anticoagulation received standard clinical practice (antiplatelet agent or no antithrombotic agent). The primary outcome was recurrent symptomatic spontaneous intracranial haemorrhage, and was adjudicated by an individual masked to treatment allocation. All outcomes were ascertained for at least 1 year after randomisation and assessed in the intention-to-treat population of all randomly assigned participants, using Cox proportional hazards regression adjusted for minimisation covariates. We planned a sample size of 190 participants (one-sided p=0·025, power 90%, allowing for non-adherence) based on a non-inferiority margin of 12% (or adjusted hazard ratio [HR] of 3·2). This trial is registered with ClinicalTrials.gov (NCT03153150) and is complete.

FINDINGS

Between March 29, 2018, and Feb 27, 2020, consent was obtained at 61 sites for 218 participants, of whom 203 were randomly assigned at a median of 115 days (IQR 49-265) after intracranial haemorrhage onset. 101 were assigned to start and 102 to avoid oral anticoagulation. Participants were followed up for median of 1·2 years (IQR 0·97-1·95; completeness 97·2%). Starting oral anticoagulation was not non-inferior to avoiding oral anticoagulation: eight (8%) of 101 in the start group versus four (4%) of 102 in the avoid group had intracranial haemorrhage recurrences (adjusted HR 2·42 [95% CI 0·72-8·09]; p=0·152). Serious adverse events occurred in 17 (17%) participants in the start group and 15 (15%) in the avoid group. 22 (22%) patients in the start group and 11 (11%) patients in the avoid group died during the study.

INTERPRETATION

Whether starting oral anticoagulation was non-inferior to avoiding it for people with atrial fibrillation after intracranial haemorrhage was inconclusive, although rates of recurrent intracranial haemorrhage were lower than expected. In view of weak evidence from analyses of three composite secondary outcomes, the possibility that oral anticoagulation might be superior for preventing symptomatic major vascular events should be investigated in adequately powered randomised trials.

FUNDING

British Heart Foundation, Medical Research Council, Chest Heart & Stroke Scotland.

Economic evaluation of robot-assisted training versus an enhanced upper limb therapy programme or usual care for patients with moderate or severe upper limb functional limitation due to stroke: results from the RATULS randomised controlled trial

OBJECTIVE

To determine whether robot-assisted training is cost-effective compared with an enhanced upper limb therapy (EULT) programme or usual care.

DESIGN

Economic evaluation within a randomised controlled trial.

SETTING

Four National Health Service (NHS) centres in the UK: Queen's Hospital, Barking, Havering and Redbridge University Hospitals NHS Trust; Northwick Park Hospital, London Northwest Healthcare NHS Trust; Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde; and North Tyneside General Hospital, Northumbria Healthcare NHS Foundation Trust.

PARTICIPANTS

770 participants aged 18 years or older with moderate or severe upper limb functional limitation from first-ever stroke.

INTERVENTIONS

Participants randomised to one of three programmes provided over a 12-week period: robot-assisted training plus usual care; the EULT programme plus usual care or usual care.

MAIN ECONOMIC OUTCOME MEASURES

Mean healthcare resource use; costs to the NHS and personal social services in 2018 pounds; utility scores based on EQ-5D-5L responses and quality-adjusted life years (QALYs). Cost-effectiveness reported as incremental cost per QALY and cost-effectiveness acceptability curves.

RESULTS

At 6 months, on average usual care was the least costly option (£3785) followed by EULT (£4451) with robot-assisted training being the most costly (£5387). The mean difference in total costs between the usual care and robot-assisted training groups (£1601) was statistically significant (p<0.001). Mean QALYs were highest for the EULT group (0.23) but no evidence of a difference (p=0.995) was observed between the robot-assisted training (0.21) and usual care groups (0.21). The incremental cost per QALY at 6 months for participants randomised to EULT compared with usual care was £74 100. Cost-effectiveness acceptability curves showed that robot-assisted training was unlikely to be cost-effective and that EULT had a 19% chance of being cost-effective at the £20 000 willingness to pay (WTP) threshold. Usual care was most likely to be cost-effective at all the WTP values considered in the analysis.

CONCLUSIONS

The cost-effectiveness analysis suggested that neither robot-assisted training nor EULT, as delivered in this trial, were likely to be cost-effective at any of the cost per QALY thresholds considered.

TRIAL REGISTRATION NUMBER

ISRCTN69371850.

Effective detection and identification of sheath-tailed bats of Australian forests and woodlands

Assessing the risk to threatened species of population decline from anthropogenic disturbances is challenging when there are issues with species identification, and little is known of their biology, distribution, population size, and habitat preference. The bare-rumped sheath-tailed bat (Saccolaimus saccolaimus) is one such species that has a poorly defined distribution over two broad areas of northern Australia. Environmental impact assessments are expected to consider the possibility of its presence in intervening areas outside the known distributions. Our study presents new empirical data that can assist with detection of S. saccolaimus across the entire expanse of northern Australia, provides a critical analysis of acoustics-based identification of the species, and assessed presence within the potentially high value habitat of tall Eucalyptus tetrodonta-dominated forest on the western side of Cape York Peninsula using a combination of trapping and acoustic recordings. Capture of other Saccolaimus species was the greatest of any survey conducted to date in Australia, demonstrating that the capture of these high-flying bat species in tall forest habitats can be relatively effective with mist net arrays hoisted into the tree canopy. In addition, reference echolocation call collections from the focal trapping area plus other locations across northern Australia allowed characterisation and comparison of the calls of most low-frequency-emitting (LFE) echolocating bat species of northern Australia. In addition to separation of species-specific search phase call types using multivariate statistics, a compilation of features from search phase, approach phase and feeding buzz echolocation calls will help distinguish S. saccolaimus from most other LFE species. However, the similarity of the echolocation calls of S. mixtus and S. saccolaimus prevented them from being distinguished from one another. A multi-method approach that emulates the present study and incorporates our recommendations and cautions will lead to robustness in ecological studies and greater clarity in environmental impact assessments.

P2649Do these data apply to me? Examining the applicability of trials assessing strategies for optimal management of blood pressure to older patients in UK primary care

Background

There is debate as to what extent older patients (≥80 years) should be treated for high blood pressure. Existing trials show that blood pressure lowering in this population is effective at preventing stroke and heart failure but also results in an increased risk of adverse events. However, it has been suggested that these studies enrolled healthier patients, who are less representative of the general population and more likely to benefit from treatment.

Purpose

This study aimed to compare the characteristics of patients eligible for three blood pressure management trials and assess the likelihood of eligibility for each trial based on common characteristics of older patients.

Methods

Cross-sectional study of data extracted from the medical records of 15,376 patients aged ≥80 years, registered to 24 general practices in the south of England. Anonymised patient data relating to the eligibility criteria for two previous medication intensification trials (HYVET, SPRINT) and one medication reduction trial (OPTiMISE) were extracted. Patients eligible for each trial were defined according to criteria specified in each trial protocol. Descriptive statistics were used to define the characteristics of each trial population. A logistic regression model was constructed to estimate predictors of eligibility for each trial, with practice included as a random effect.

Results

Approximately 268 (1.7%), 5,290 (34.4%) and 3,940 (25.6%) patients were eligible for HYVET, SPRINT and OPTiMISE trials respectively. There was little overlap in eligibility for each trial (1.0% were eligible for HYVET and SPRINT; 0% were eligible for HYVET and OPTiMISE; 10.2% were eligible for SPRINT and OPTiMISE). Patients eligible for OPTiMISE were comparable to the general population in terms of frailty (eFI 0.12 [OPTiMISE] vs 0.11 [general population]), but had more morbidities (4 vs 3) and cardiovascular medications prescribed (4 vs 2). Patients in HYVET and SPRINT were less frail, multi-morbid and prescribed less cardiovascular medications. Overall, increasing frailty and a history of cardiovascular disease reduced the likelihood of being eligible for any trial.

Conclusions

Patients eligible for OPTiMISE appear to best represent the population aged ≥80 years attending UK primary care. Increasing frailty and/or multi-morbidity reduce the likelihood of eligibility for all three blood pressure trials. Caution should be exercised when applying the results from randomised controlled trials to management of blood pressure in frail and multi-morbid patients.

Acknowledgement/Funding

This study was funded by the National Institute for Health Research (NIHR) SPCR and Oxford CLAHRC

Abstract TMP92: Pioglitazone for Secondary Stroke Prevention in Pre-diabetes: Implications for Real-world Practice

Pioglitazone reduces insulin resistance and cardiovascular risk among patients with type 2 diabetes. The Insulin Resistance Intervention after Stroke (IRIS) trial randomized 3876 non-diabetic participants with recent stroke/TIA and insulin resistance based on the Homeostasis Model of Insulin Resistance (HOMA-IR) score to pioglitazone (PIO) vs. placebo (PLA). Over 4.8 years, the relative risk reduction (RRR) with PIO was 27% for stroke/myocardial infarction, 25% for stroke, 29% for acute coronary syndrome (ACS), and 52% for new-onset diabetes. PIO could therefore be considered a new therapy for secondary stroke prevention before diabetes onset. However, it is not in widespread use, not only because of increased fracture risk, but perhaps also because HOMA-IR is not commonly assessed in clinical practice. In contrast, the presence of prediabetes is often identified in this population. We therefore analyzed the intention-to-treat (ITT) and the on-treatment effect of PIO (defined as adherence of > 80%) in IRIS participants with prediabetes by the American Diabetes Association criteria: HbA1C 5.7%-6.4%, or fasting glucose 100-125 mg/dL (n=2885; PIO 1456, PLA 1429). By ITT, for pioglitazone the hazard ratio and 95% confidence interval in Cox regression for stroke/MI was 0.70 (0.56-0.88, p=0.002), for stroke 0.72 (0.56-0.93, p=0.013), for ACS 0.72 (0.52-1.00, p = 0.052), for stroke/MI/hospitalized heart failure (HHF) 0.78 (0.63-0.96, p=0.02), and for new-onset diabetes HR 0.46 (0.34-0.61, p <0.0001). Among participants with good adherence, pioglitazone participants (n=644) were more likely to be men (76.2% vs 70.6%, p=0.02) and more likely to be smokers (15.9% vs. 11.7%, p=0.02) compared to PLA participants (n=810). In this subgroup, the HR for stroke/MI was 0.57 (0.39-0.84, p=0.004), for stroke 0.64 (0.42-0.99, p=0.04), for ACS 0.47 (0.26-0.85, p=0.01), for stroke/MI/HHF 0.61 (0.42-0.88, p=0.008), and for new-onset diabetes HR 0.18 (0.10-0.33, p<0.0001)

Conclusion: Pioglitazone should be considered efficacious for secondary prevention in stroke/TIA participants with prediabetes, simply assessed by fasting plasma glucose or A1C.

Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial

BACKGROUND

Results of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects.

METHODS

FOCUS was a pragmatic, multicentre, parallel group, double-blind, randomised, placebo-controlled trial done at 103 hospitals in the UK. Patients were eligible if they were aged 18 years or older, had a clinical stroke diagnosis, were enrolled and randomly assigned between 2 days and 15 days after onset, and had focal neurological deficits. Patients were randomly allocated fluoxetine 20 mg or matching placebo orally once daily for 6 months via a web-based system by use of a minimisation algorithm. The primary outcome was functional status, measured with the modified Rankin Scale (mRS), at 6 months. Patients, carers, health-care staff, and the trial team were masked to treatment allocation. Functional status was assessed at 6 months and 12 months after randomisation. Patients were analysed according to their treatment allocation. This trial is registered with the ISRCTN registry, number ISRCTN83290762.

FINDINGS

Between Sept 10, 2012, and March 31, 2017, 3127 patients were recruited. 1564 patients were allocated fluoxetine and 1563 allocated placebo. mRS data at 6 months were available for 1553 (99·3%) patients in each treatment group. The distribution across mRS categories at 6 months was similar in the fluoxetine and placebo groups (common odds ratio adjusted for minimisation variables 0·951 [95% CI 0·839-1·079]; p=0·439). Patients allocated fluoxetine were less likely than those allocated placebo to develop new depression by 6 months (210 [13·43%] patients vs 269 [17·21%]; difference 3·78% [95% CI 1·26-6·30]; p=0·0033), but they had more bone fractures (45 [2·88%] vs 23 [1·47%]; difference 1·41% [95% CI 0·38-2·43]; p=0·0070). There were no significant differences in any other event at 6 or 12 months.

INTERPRETATION

Fluoxetine 20 mg given daily for 6 months after acute stroke does not seem to improve functional outcomes. Although the treatment reduced the occurrence of depression, it increased the frequency of bone fractures. These results do not support the routine use of fluoxetine either for the prevention of post-stroke depression or to promote recovery of function.

FUNDING

UK Stroke Association and NIHR Health Technology Assessment Programme.

PP28 Tia prehospital referral feasibility trial (TIER): recruitment and intervention usage

Background

Early specialist assessment of Transient Ischaemic Attack (TIA) can reduce the risk of stroke and death. This study assessed feasibility of undertaking a multi-centre randomised trial to evaluate clinical and cost effectiveness of referral of patients attended by emergency ambulance paramedic with low-risk TIA directly to specialist TIA clinic for early review.

Methods

We developed a protocol and referral pathway for paramedics to assess and refer patients directly to TIA clinic, including provision of aspirin. We randomly allocated volunteer paramedics to intervention or control group. Intervention paramedics were trained to deliver the intervention during the patient recruitment period. Control paramedics continued to deliver care as usual. Patients with TIA were identified from hospital records. We aimed to recruit 86 patients and pre-defined progression criteria related to feasibility of intervention delivery and trial methods.

Results

Development and recruitment phases are complete, with outcome follow up ongoing. Eighty nine of 134 (66%) paramedics participated in TIER. Of 1377 patients attended by trial paramedics during the patient recruitment period, 53 (3.8%) were identified as eligible for trial inclusion. Three of 36 (8%) patients attended by intervention paramedics were referred to the TIA clinic. Of the others, only one appeared to be a missed referral; in one case there was no prehospital record of TIA; one was attended by a paramedic who was not TIER trained; one patient record was missing; all others were recorded with contraindications: FAST positive (n=13); ABCD2 score >3 (n=5); already taking warfarin (n=2); crescendo TIA (n=1) other clinical factors (n=8).

Conclusions

Preliminary Results indicate challenges in recruitment and low referral rates. The low-risk 999 TIA population suitable for Emergency Department avoidance may be smaller than previously thought. Further analyses will focus on whether progression criteria for a definitive trial were met, and clinical outcomes from this feasibility trial.

Abstract TMP24: Alteplase-Tenecteplase Trial Evaluation for Stroke Thrombolysis (ATTEST 2)

Background: IV thrombolysis with alteplase, the only medical treatment currently approved for acute ischaemic stroke, significantly increases the probability of excellent recovery. A recent trial has demonstrated that the modified tissue plasminogen activator tenecteplase at a dose of 0.4mg/kg is of similar safety and efficacy to alteplase in acute stroke. In addition to having simpler administration, tenecteplase 0.25mg/kg is also potentially superior to alteplase with respect to efficacy, based on meta-analysis of small trials. More data are required to establish the true risk-benefit profile compared with alteplase.

Objectives & Methods: ATTEST-2 will establish whether tenecteplase is superior to alteplase by undertaking a prospective randomised open blinded end-point (PROBE) trial in patients eligible for IV thrombolysis based on non-contrast CT imaging. The study opened to recruitment in Dec 2016. 60 UK centres will recruit 1870 patients.

Outcome: Primary outcome is the distribution of modified Rankin Scale (mRS) outcomes at day 90, determined by the Rankin Focused Assessment method, analysed by ordinal distribution ("shift") analysis of the of scores in intervention and control groups.

Conclusion: An agent with superior risk:benefit ratio to alteplase would potentially extend thrombolytic treatment a greater proportion of patients than at present and reduce the need for mechanical thrombectomy. This trial will contribute to the optimisation of reperfusion strategies.

Biological Effects of Mount Saint Helens Volcanic Ash on Cultured Human Alveolar Macrophages

Free alveolar macrophages (FAMs) obtained by bronchoalveolar lavage from healthy nonsmoking volunteers were incubated with varying concentrations (0–300 μg/ml) of Mt. Saint Helens volcanic ash obtained from either Portland, Oregon, or Pullman, Washington, to assess the cytotoxic effects of the ash on human lung cells. Trypan dye exclusion techniques were employed for assessment of cell viability. Following the initial 24 hour culture with the Portland ash samples, decreased viability was observed at all ash concentrations (P < 0.001 in all instances), and further decreases in viability were noted at 48 and 72 hours for all concentrations of ash tested (P < 0.001 in all instances). When the Pullman, Washington, ash sample was evaluated, a decrease in cell viability was noted for the 300 μg/ml concentration (P < 0.017) after the initial 24 hours in culture. Further decreases in cell viability were noted only when cells were cultured for longer time intervals (48 and 72 hours) (P < 0.05 in all instances). Differences in cellular response to the 2 ash samples were further investigated by exposing FAMs from a single individual to the 2 different types of ash. These studies demonstrated similar cytotoxic effects of the 2 ash samples at all concentrations and times tested (P < 0.30 in all instances) with the exception of the 100 μg/ml concentrations at 72 hours (P < 0.020). These data suggest that the differences observed between the 2 types of ash in the independent studies are probably related to interindividual variation in FAM response to the ash rather than to differences in the cytotoxicities of the 2 ash samples. Cytotoxicity of the volcanic ash was also compared with other environmentally relevant airborne particulates, such as amosite and chrysotile asbestos, as well as amorphous and crystalline silica. These results demonstrated an intermediate cytotoxic effect of the ash between innocuous amorphous silica and the very cytotoxic chrysotile asbestos. The affinity for volcanic ash to adsorb tritiated benzo(a)pyrene (3H-BaP) was also compared with that of amorphous silica and amosite asbestos. These studies demonstrate that volcanic ash has intermediate adsorption qualities (4.3 ± 0.1; pmoles 3H-BaP adsorbed/μg particulate ± SD) between those of amorphous silica (1.9 ± 1.0) and amosite asbestos (7.8 ± 1.2) (P < 0.05 in all instances). These data suggest volcanic ash exhibits moderate biological properties compared with those of other environmentally important airborne particulates. Whether in vitro studies reflect in vivo response of human lung cells to the ash cannot be determined at this time, and follow-up of assessment of individuals exposed to the ash will be required to assess its long-term effects on pulmonary tissue.

Abstract W P369: International Variability in Stroke Preventive Care

Introduction: Research protocols for stroke prevention trials commonly specify goals for preventive care. We report variability in goal achievement between 3 countries participating in an on-going stroke secondary prevention trial.

Methods: The Insulin Resistance Intervention after Stroke (IRIS) trial is testing pioglitazone, compared with placebo, for prevention of stroke and myocardial infarction among non-diabetic patients with a recent ischemic stroke/TIA. Preventive care is provided by personal physicians, although achievement of prevention goals is monitored and reported to participants and their physicians annually. Goals are from the American Heart Association guidelines: blood pressure (BP) <140/90 mmHg, statin therapy, and anti-platelet or anticoagulation depending on clinical indications. At baseline and year 1, we compared the proportions of participants meeting these goals in the largest enrolling countries: Canada (CA), United Kingdom (UK) and United States (US).

Results: Participant characteristics were similar across countries, except the proportions of women and blacks were lower in the UK and CA than the US, and self-reported hypertension was more common in US than CA or UK. At baseline, achievement of BP goal was lower in the UK (53%) compared with the US (66%) and CA (75%) (Chi 2 p<0.0001). Statin therapy was used more commonly in the UK (91%) and CA (88%) compared with the US (80%) (Chi 2 p<0.0001). Differences persisted at year 1. At baseline, use of antithrombotic therapy was high (99%) in all countries. However, at year 1, use fell in US (96%) compared to CA and UK (p=0.02).

Conclusions: Secondary preventive care for stroke varied among 3 countries for BP, statin therapy and antithrombotic therapies despite the IRIS protocol specifying uniform goals. These findings may be the result of disagreement among practitioners in the 3 countries for secondary prevention goals, variability in care delivery, or variability in research implementation. Understanding and resolving variability may lead to more efficient research and improved care for patients.

Abstract W P281: Inter-Rater Reliability of Clinical Decision Making Based on Recorded Telemedicine Assessments and Case Histories

Background: Patient outcomes are improved by reducing time, and increasing access, to stroke-specialist consultation and treatment. Telemedicine may ensure earlier and wider access to stroke-specialist consultation. However, reliable and accurate decision making is necessary by various professional groups in the emergency department in order for the telemedicine assessment to be initiated.

Aim: To explore the inter-rater reliability of clinical decision making by various health professionals, when using telemedicine assessments in acute stroke.

Method: Twenty-six telemedicine assessments in patients with suspected stroke (final/gold standard diagnosis: 16 strokes and 10 non-strokes) were recorded, edited and then presented with case histories. Health professionals viewed 6, randomly selected assessments and rated: whether ‘stroke or not’; level of confidence with their diagnosis. Data were analysed using Cohen’s kappa (K) with 95% confidence interval (CI) calculated using bias-corrected bootstrapping in STATA with 10000 replicates. Sensitivity and specificity were estimated.

Results: Forty raters: 13 stroke physicians, 15 stroke nurses, 12 non-stroke specific staff (NSS) (including 3 ED consultants, 8 registrars and 1 neurologist). Median of 8 raters per assessment.

For ‘stroke or not’, agreement between all health professions was fair (K=0.36, CI 0.22-0.54); correctly diagnosing whether the patient was ‘stroke or not’ on 8 occasions, Sensitivity 77% (98/128), Specificity 67% (45/67).

Agreement within each health professional group ranged from K=0.37 (stroke physicians and nurses) to K=0.43 (NSS group), although CIs were wide. Sensitivity ranged from 74% (stroke physicians) to 81% (NSS group); specificity from 58% (stroke physicians) to 74% (NSS group).

Median confidence was highest in 4 of the 8 on which all raters agreed the ‘stroke or not’ diagnosis.

Conclusion: Agreement was ‘fair’ overall and was similar for all groups, although CIs were wide. Nurses’ agreement or diagnostic accuracy were similar to stroke physicians and NSS doctors when rating telemedicine consultations.

The challenges of implementing a telestroke network: a systematic review and case study

Background

The use of telemedicine in acute stroke care can facilitate rapid access to treatment, but the work required to embed any new technology into routine practice is often hidden, and can be challenging. We aimed to collate recommendations and resources to support telestroke implementation.

Methods

Systematic search of healthcare databases and the Internet to identify descriptions of the implementation of telestroke projects; interviews with key stakeholders during the development of one UK telestroke network. Supporting documentation from existing projects was analysed to construct a framework of implementation stages and tasks, and a toolkit of documents. Interviews and literature were analysed with other data sources using Normalisation Process Theory as described in the e-Health Implementation Toolkit.

Results

61 telestroke projects were identified and contacted. Twenty projects provided documents, 13 with published research detailing four stages of telestroke system development, implementation, use, and evaluation. Interviewees identified four main challenges: engaging and maintaining the commitment of a wide range of stakeholders across multiple organisations; addressing clinicians perceptions of evidence, workload, and payback; managing clinical and technical workability across diverse settings; and monitoring how the system is used and reconfigured by users.

Conclusions

Information to guide telestroke implementation is sparse, but available. By using multiple sources of data, sufficient information was collated to construct a web-based toolkit detailing implementation tasks, resources and challenges in the development of a telestroke system for assessment and thrombolysis delivery in acute care. The toolkit is freely available online.

Extending the clinical research network approach to all of healthcare

The development of Clinical Research Networks (CRN) has been central to the work conducted by Health Departments and research funders to promote and support clinical research within the NHS in the UK. In England, the National Institute for Health Research has supported the delivery of clinical research within the NHS primarily through CRN. CRN provide the essential infrastructure within the NHS for the set up and delivery of clinical research within a high-quality peer-reviewed portfolio of studies. The success of the National Cancer Research Network is summarized in Chapter 5. In this chapter progress in five other topics, and more recently in primary care and comprehensively across the NHS, is summarized. In each of the 'topic-specific' networks (Dementias and Neurodegenerative Diseases, Diabetes, Medicines for Children, Mental Health, Stroke) there has been a rapid and substantial increase in portfolios and in the recruitment of patients into studies in these portfolios. The processes and the key success factors are described. The CRN have worked to support research supported by pharmaceutical, biotechnology and medical device companies and there has been substantial progress in improving the speed, cost and delivery of these 'industry' studies. In particular, work to support the increased speed of set up and delivery of industry studies, and to embed this firmly in the NHS, was explored in the North West of England in an Exemplar Programme which showed substantial reductions in study set-up times and improved recruitment into studies and showed how healthcare (NHS) organizations can overcome delays in set up times when they actively manage the process. Seven out of 20 international studies reported that the first patient to be entered anywhere in the world was from the UK. In addition, the CRN have supported research management and governance, workforce development and clinical trials unit collaboration and coordination. International peer reviews of all of the CRN have been positive and resulted in the continuation of the system for a further 5 years in all cases.

Protocol for Past BP: a randomised controlled trial of different blood pressure targets for people with a history of stroke of transient ischaemic attack (TIA) in primary care

Background

Blood pressure (BP) lowering in people who have had a stroke or transient ischaemic attack (TIA) leads to reduced risk of further stroke. However, it is not clear what the target BP should be, since intensification of therapy may lead to additional adverse effects. PAST BP will determine whether more intensive BP targets can be achieved in a primary care setting, and whether more intensive therapy is associated with adverse effects on quality of life.

Methods/Design

This is a randomised controlled trial (RCT) in patients with a past history of stroke or TIA. Patients will be randomised to two groups and will either have their blood pressure (BP) lowered intensively to a target of 130 mmHg systolic, (or by 10 mmHg if the baseline systolic pressure is between 125 and 140 mmHg) compared to a standard group where the BP will be reduced to a target of 140 mmHg systolic. Patients will be managed by their practice at 1-3 month intervals depending on level of BP and followed-up by the research team at six monthly intervals for 12 months.

610 patients will be recruited from approximately 50 general practices. The following exclusion criteria will be applied: systolic BP <125 mmHg at baseline, 3 or more anti-hypertensive agents, orthostatic hypotension, diabetes mellitus with microalbuminuria or other condition requiring a lower treatment target or terminal illness.

The primary outcome will be change in systolic BP over twelve months. Secondary outcomes include quality of life, adverse events and cardiovascular events.

In-depth interviews with 30 patients and 20 health care practitioners will be undertaken to investigate patient and healthcare professionals understanding and views of BP management.

Discussion

The results of this trial will inform whether intensive blood pressure targets can be achieved in people who have had a stroke or TIA in primary care, and help determine whether or not further research is required before recommending such targets for this population.

Trial Registration

ISRCTN29062286

Platelet function following acute cerebral ischemia

BACKGROUND

Studies have previously identified increased levels of platelet activation following acute ischemic stroke. In order to evaluate new antiplatelet agents and their combinations, there is a need for accurate measures of platelet activation.

METHODS

Blood was taken from 17 patients within 24 hours of an acute ischemic stroke, and then at 3, 7, 14 and 42 days. For comparison, a group of 18 stable arteriopaths had identical tests performed. Platelet aggregation was measured using a free platelet counting technique, and platelet surface P-selectin and monocyte platelet aggregates (MPAs) were measured using flow cytometry. Soluble P-selectin and D-dimers were measured by an enzyme linked immune assay.

RESULTS

The initial level of MPAs was significantly raised in the stroke patients compared with the stable patients (p = 0.04, 14.2% vs. 9.3%); however, this difference was not significantly higher than later study points (14.2%, 10.1%, 9.3%, 11.9%, 11.3%; days 1, 3, 7, 14 and 42 respectively. Day 1 vs. day 7 p = 0.07 ANOVA). No changes in P-selectin or platelet aggregation were identified. D-dimer levels were significantly higher on day 7 than day 42 (p < 0.01), and fibrinogen levels were elevated on both days 3 and 14 compared with day 42. Fibrinogen levels were not elevated compared with stable patients.

CONCLUSIONS

MPA levels are elevated following an acute ischemic stroke compared to stable patients, but no significant change was seen with other platelet markers. This study suggests MPAs are a more sensitive marker of platelet activation than either P-selectin or aggregation.

The future of restorative neurosciences in stroke: driving the translational research pipeline from basic science to rehabilitation of people after stroke

BACKGROUND

Major advances during the past 50 years highlight the immense potential for restoration of function after neural injury, even in the damaged adult human brain. Yet, the translation of these advances into clinically useful treatments is painstakingly slow.

OBJECTIVE

Here, we consider why the traditional model of a "translational research pipeline" that transforms basic science into novel clinical practice has failed to improve rehabilitation practice for people after stroke.

RESULTS

We find that (1) most treatments trialed in vitro and in animal models have not yet resulted in obviously useful functional gains in patients; (2) most clinical trials of restorative treatments after stroke have been limited to small-scale studies; (3) patient recruitment for larger clinical trials is difficult; (4) the determinants of patient outcomes and what patients want remain complex and ill-defined, so that basic scientists have no clear view of the clinical importance of the problems that they are addressing; (5) research in academic neuroscience centers is poorly integrated with practice in front-line hospitals and the community, where the majority of patients are treated; and (6) partnership with both industry stakeholders and patient pressure groups is poorly developed, at least in the United Kingdom where research in the translational restorative neurosciences in stroke depends on public sector research funds and private charities.

CONCLUSIONS

We argue that interaction between patients, front-line clinicians, and clinical and basic scientists is essential so that they can explore their different priorities, skills, and concerns. These interactions can be facilitated by funding research consortia that include basic and clinical scientists, clinicians and patient/carer representatives with funds targeted at those impairments that are major determinants of patient and carer outcomes. Consortia would be instrumental in developing a lexicon of common methods, standardized outcome measures, data sharing and long-term goals. Interactions of this sort would create a research-friendly, rather than only target-led, culture in front-line stroke rehabilitation services.

Impact of model perfumes on surfactant and mixed surfactant self-assembly

The impact of some model perfumes on surfactant self-assembly has been investigated, using small-angle neutron scattering. A range of different model perfumes, with differing degrees of hydrophilicity/hydrophobicity, have been explored, and in order of increasing hydrophobicity include phenyl ethanol (PE), rose oxide (RO), limonene (LM), linalool (LL), and dihydrogen mercenol (DHM). The effect of their solubilization on the nonionic surfactant micelles of dodecaethylene monododecyl ether (C12EO12) and on the mixed surfactant aggregates of C12EO12 and the cationic dialkyl chain surfactant dihexadecyl dimethyl ammonium bromide (DHDAB) has been quantified. For PE and LL the effect of their solubilization on the micelle, mixed micelle/lamellar and lamellar regimes of the C12EO12/DHDAB mixtures, has also been determined. For the C12EO12 and mixed DHDAB/C12EO12 micelles PE is solubilized predominantly at the hydrophilic/hydrophobic interface, whereas the more hydrophobic perfumes, from RO to DHM, are solubilized predominantly in the hydrophobic core of the micelles. For the C12EO12 micelles, with increasing perfume concentration, the more hydrophobic perfumes (RO to DHM) promote micellar growth. Relatively modest growth is observed for RO and LM, whereas substantial growth is observed for LL and DHM. In contrast, for the addition of PE the C12EO12 micelles remain as relatively small globular micelles, with no significant growth. For the C12EO12/DHDAB mixed micelles, the pattern of behavior with the addition of perfume is broadly similar, except that the micellar growth with increasing perfume concentration for the more hydrophobic perfumes is less pronounced. In the Lbeta (Lv) region of the DHDAB-rich C12EO12/DHDAB phase diagram, the addition of PE results in a less structured (less rigid) lamellar phase, and ultimately a shift toward a structure more consistent with a sponge or bicontinuous phase. In the mixed L1/Lbeta region of the phase diagram PE induces a slight shift in the coexistence from Lbeta toward L1. The addition of LL to the Lbeta (Lv) region of the DHDAB-rich C12EO12/DHDAB phase diagram also results in a reduction in the lamellar structure (less rigid lamellae), and a shift toward a structure more consistent with a sponge or bicontinuous phase, or a coexisting phase of small vesicles. For the mixed L1/Lbeta region of the phase diagram LL induces a shift toward a greater L beta component.

Study design and methods of the BoTULS trial: a randomised controlled trial to evaluate the clinical effect and cost effectiveness of treating upper limb spasticity due to stroke with botulinum toxin type A

BACKGROUND

Following a stroke, 55-75% of patients experience upper limb problems in the longer term. Upper limb spasticity may cause pain, deformity and reduced function, affecting mood and independence. Botulinum toxin is used increasingly to treat focal spasticity, but its impact on upper limb function after stroke is unclear.The aim of this study is to evaluate the clinical and cost effectiveness of botulinum toxin type A plus an upper limb therapy programme in the treatment of post stroke upper limb spasticity.

METHODS

TRIAL DESIGN

A multi-centre open label parallel group randomised controlled trial and economic evaluation.

PARTICIPANTS

Adults with upper limb spasticity at the shoulder, elbow, wrist or hand and reduced upper limb function due to stroke more than 1 month previously.

INTERVENTIONS

Botulinum toxin type A plus upper limb therapy (intervention group) or upper limb therapy alone (control group).

OUTCOMES

Outcome assessments are undertaken at 1, 3 and 12 months. The primary outcome is upper limb function one month after study entry measured by the Action Research Arm Test (ARAT). Secondary outcomes include: spasticity (Modified Ashworth Scale); grip strength; dexterity (Nine Hole Peg Test); disability (Barthel Activities of Daily Living Index); quality of life (Stroke Impact Scale, Euroqol EQ-5D) and attainment of patient-selected goals (Canadian Occupational Performance Measure). Health and social services resource use, adverse events, use of other antispasticity treatments and patient views on the treatment will be compared. PARTICIPANTS are clinically reassessed at 3, 6 and 9 months to determine the need for repeat botulinum toxin type A and/or therapy.Randomisation : A web based central independent randomisation service. Blinding: Outcome assessments are undertaken by an assessor who is blinded to the randomisation group.

SAMPLE SIZE

332 participants provide 80% power to detect a 15% difference in treatment successes between intervention and control groups. Treatment success is defined as improvement of 3 points for those with a baseline ARAT of 0-3 and 6 points for those with ARAT of 4-56.

TRIAL REGISTRATION

ISRCTN78533119 Eudra CT 2004-002427-40 CTA 17136/0230/001 FUNDING: National Institute for Health Research, Health Technology Assessment Programme. Ipsen Ltd provide botulinum toxin type A (Dysport(R)).

Impact on patients' health status following early identification of a COPD exacerbation

The current study aimed to assess the impact on patient health status during an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). A total of 421 COPD patients were enrolled in a multicentre, single-arm study with a 6-month observational follow-up period. Patients received two inhalations of Symbicort 200 Turbuhaler(R) twice a day. Patients were assessed before the run-in period, at baseline and at 1, 3 and 6 months. Patients were instructed to report a change in respiratory symptoms lasting >24 h. This defined an AECOPD. In addition to the initial call, the St George's Respiratory Questionnaire (SGRQ), COPD Control Questionnaire (CCQ), Medical Research Council (MRC) dyspnoea scale and activities of daily living (ADL) were completed at 5-7 and 12-14 days. A group of 176 patients reported at least one AECOPD. Exacerbations were associated with statistically significant mean changes (worsening) in the SGRQ activity and impact domains at onset (mean +/- sd 12.1 +/- 18.1 and 14.0 +/- 15.2), during the first (9.8 +/- 19.0 and 9.4 +/- 16.6) and second weeks (3.1 +/- 15.5 and 3.3 +/- 14.7). Clinically significant deterioration in SGRQ impact scores was shown in 71% of patients following early identification, with 55 and 37% during the first and second weeks of an AECOPD, respectively. Acute exacerbation severely impacts on health status. The current study provides valuable information on the change in health status during an acute exacerbation of chronic obstructive pulmonary disease that can be utilised for future trials that evaluate therapeutic intervention.

Clinical practice with anti-dementia drugs: a consensus statement from British Association for Psychopharmacology

The British Association for Psychopharmacology (BAP) coordinated a meeting of experts to review the evidence on the drug treatment for dementia. The level of evidence (types) was rated using a standard system: Types 1a and 1b (evidence from meta-analysis of randomised controlled trials or at least one controlled trial respectively); types 2a and 2b (one well-designed study or one other type of quasi experimental study respectively); type 3 (non-experimental descriptive studies); and type 4 (expert opinion). There is type 1a evidence for cholinesterase inhibitors (donepezil, rivastigmine and galantamine) for mild to moderate Alzheimer's disease; memantine for moderate to severe Alzheimer's disease; and for the use of bright light therapy and aromatherapy. There is type 1a evidence of no effect of anti inflammatory drugs or statins. There is conflicting evidence regarding oestrogens, with type 2a evidence of a protective effect of oestrogens but 1b evidence of a harmful effect. Type 1a evidence for any effect of B12 and folate will be forthcoming when current trials report. There is type 1b evidence for gingko biloba in producing a modest benefit of cognitive function; cholinesterase inhibitors for the treatment of people with Lewy body disease (particularly neuropsychiatric symptoms); cholinesterase inhibitors and memantine in treatment cognitive impairment associated with vascular dementia; and the effect of metal collating agents (although these should not be prescribed until more data on safety and efficacy are available). There is type 1b evidence to show that neither cholinesterase inhibitors nor vitamin E reduce the risk of developing Alzheimer's disease in people with mild cognitive impairment; and there is no evidence that there is any intervention that can prevent the onset of dementia. There is type 1b evidence for the beneficial effects of adding memantine to cholinesterase inhibitors, and type 2b evidence of positive switching outcomes from one cholinesterase inhibitor to another. There is type 2a evidence for a positive effect of reminiscence therapy, and type 2a evidence that cognitive training does not work. There is type 3 evidence to support the use of psychological interventions in dementia. There is type 2 evidence that a clinical diagnosis of dementia can be made accurately and that brain imaging increases that accuracy. Although the consensus statement dealt largely with medication, the role of dementia care in secondary services (geriatric medicine and old age psychiatry) and primary care, along with health economics, was discussed. There is ample evidence that there are effective treatments for people with dementia, and Alzheimer's disease in particular. Patients, their carers, and clinicians deserve to be optimistic in a field which often attracts therapeutic nihilism.

The Microstructure of Di-alkyl Chain Cationic/Nonionic Surfactant Mixtures: Observation of Coexisting Lamellar and Micellar Phases and Depletion Induced Phase Separation

The evolution of the microstructure and composition occurring in the aqueous solutions of di-alkyl chain cationic/nonionic surfactant mixtures has been studied in detail using small angle neutron scattering, SANS. For all the systems studied we observe an evolution from a predominantly lamellar phase, for solutions rich in di-alkyl chain cationic surfactant, to mixed cationic/nonionic micelles, for solutions rich in the nonionic surfactant. At intermediate solution compositions there is a region of coexistence of lamellar and micellar phases, where the relative amounts change with solution composition. A number of different di-alkyl chain cationic surfactants, DHDAB, 2HT, DHTAC, DHTA methyl sulfate, and DISDA methyl sulfate, and nonionic surfactants, C12E12 and C12E23, are investigated. For these systems the differences in phase behavior is discussed, and for the mixture DHDAB/C12E12 a direct comparison with theoretical predictions of phase behavior is made. It is shown that the phase separation that can occur in these mixed systems is induced by a depletion force arising from the micellar component, and that the size and volume fraction of the micelles are critical factors.

CHHIPS (Controlling Hypertension and Hypotension Immediately Post-Stroke) Pilot Trial: rationale and design

RATIONALE

High and low blood pressure (BP) levels are common following acute stroke, with up to 60% of patients being hypertensive (SBP > 160 mmHg) and nearly 20% having relative hypotension (SBP < or = 140 mmHg), within the first few hours of ictus, both conditions being associated with an adverse prognosis. At present, the optimum management of blood pressure in the immediate post-stroke period is unclear.

OBJECTIVE

The primary aim of the Controlling Hypertension and Hypotension Immediately Post-Stroke (CHHIPS) Pilot Trial is to assess whether hypertension and relative hypotension, manipulated therapeutically in the first 24 h following acute stroke, affects short-term outcome measures.

DESIGN

The CHHIPS Pilot Trial is a UK based multi-centre, randomized, double-blind, placebo-controlled, titrated dose trial.

SETTING

Acute stroke and medical units in teaching and district general hospitals, in the UK.

PATIENTS

The CHHIPS Pilot Study aims to recruit 2050 patients, with clinically suspected stroke, confirmed by brain imaging, who have no compelling indication or contraindication for BP manipulation.

STUDY OUTCOMES

The primary outcome measure will be the effects of acute pressor therapy (initiated < or = 12 h from stroke onset) or depressor therapy (started < or = 24 h post-ictus) on death and dependency at 14 days post-stroke. Secondary outcome measures will include the influence of therapy on early neurological deterioration, the effectiveness of treatment in manipulating BP levels, the influence of time to treatment and stroke type on response and a cost-effectiveness analysis.

Partitioning of small amphiphiles at surfactant bilayer/water interfaces: an avoided level crossing muon spin resonance study

The temperature-dependent variation of local environment and reorientation dynamics of the small amphiphile 2-phenylethanol in lamellar phase dispersions of the dichain cationic surfactants, 2,3-diheptadecyl ester ethoxypropyl-1,1,1-trimethylammonium chloride (DHTAC) and dioctadecyldimethylammonium chloride (DODMAC), and the nonionic surfactant, tetra(ethylene glycol) n-dodecyl ether (C12E4), have been determined using avoided level crossing muon spin resonance spectroscopy (ALC-muSR). For cosurfactant radicals the hydrophobic or hydrophilic character of the surrounding media can be determined from their magnetic resonance signatures. Comparison of the three different bilayer-forming surfactant systems shows that the ALC-muSR technique is able to distinguish both major and subtle differences in the partitioning of the cosurfactant radicals between the different systems.

Morbidity and Irish Catholic descent in Britain. Relating health disadvantage to socio-economic position

In common with some other ethnic and religious minorities whose forebears migrated from their country of origin, Irish Catholics in Britain are less well off than the host population in terms of socio-economic position and health. Results are presented from a Scottish study, where Catholic religion of origin mainly indicates Irish ancestry, and it is estimated that about one-third of the population is of significant Irish descent. In this study, excess of physical and mental health problems and disability have previously been reported for those of Catholic background, particularly in the eldest cohort (aged 56 in 1988), and have not been fully explained by health-related behaviour. In this paper, we examine a number of key health measures, namely self-assessed health, number of symptoms in the month prior to interview, sadness or depression, disability and lung function, and various indicators of socio-economic position (head of household social class, main source of income, car ownership, housing tenure and school-leaving age), which all show Catholic disadvantage. Using longitudinal results from the 723 respondents who completed interviews both at sweeps one (1988) and three (1995), it is estimated that about half of the morbidity excess amongst middle-aged Catholics in Glasgow can be explained by socio-economic disadvantage. The health and socio-economic position of white minorities and disadvantaged religious minorities like Catholics in Scotland should be monitored by a co-ordinated information strategy.

Children followed with difficulty: how do they differ?

OBJECTIVE

To determine if very low birthweight children followed with ease differ in any perinatal or sociodemographic characteristics, or outcomes, compared with children followed with more difficulty.

METHODOLOGY

Consecutive children of birthweight < 1000 g or with gestational ages < 28 weeks born in 1991 (n = 51) or of birthweight < 1500 g born in 1992 (n = 166) at the Royal Women's Hospital, Melbourne, surviving to 5 years of age, were assessed at 5 years of age, corrected for prematurity. Those who attended on the first mutually agreed appointment without substantial reluctance were considered to have been followed with ease. The remainder were considered to have been followed with difficulty. Outcomes included impairments such as cerebral palsy, blindness, deafness, and low IQ. Children had a disability if they had any of cerebral palsy, blindness, deafness requiring amplification, or an IQ more than 1 SD below the mean.

RESULTS

Of the 217 survivors, 204 (94%) were assessed fully at 5 years of age. Of the 204 children assessed, 153 (75%) were followed with ease, and 51 (25%) with difficulty. Of data available in the perinatal period, significantly fewer children followed with more difficulty came from intact families, and more of their mothers had fewer than 12 years of schooling. More children followed with difficulty had a disability (41% compared with 19%), as they predominantly had lower IQ scores (mean difference in IQ - 12.7, 95% confidence interval - 18.0, - 7.4). The association between difficulty of assessment and both higher rates of disability and lower IQ scores remained after adjustment for significant perinatal and sociodemographic variables.

CONCLUSIONS

Children followed with difficulty can partly be recognized on several sociodemographic characteristics in the perinatal period, and have substantially worse sensorineural outcomes than those followed with ease. In any longitudinal study, the more incomplete the follow up, the lower will be the rate of adverse sensorineural outcome.