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Holland SA, Wellwood I, Kuys S. Effect of abnormal body weight on mortality and functional recovery in adults after stroke: An umbrella review. Int J Stroke 2024; 19:397-405. [PMID: 37897100 DOI: 10.1177/17474930231212972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
BACKGROUND Several published systematic reviews have drawn conflicting conclusions on the effect of abnormal body weight (i.e. being underweight, overweight or obese) on outcomes following stroke. The 'obesity paradox' seen in several diseases (wherein obesity, often associated with mortality and morbidity, appears to be protective and improve outcomes) may be evident after stroke, but inconsistent results of existing reviews, and the issue of being underweight, are worth investigating further. AIMS To better understand the impact of body weight on prognosis after stroke, we aimed to answer the following research question: What is the effect of abnormal body weight (underweight, overweight, or obesity) on mortality and functional recovery in adults after stroke? SUMMARY OF REVIEW We conducted an umbrella review to synthesize existing evidence on the effects of abnormal body weight on stroke outcomes. We searched Cumulated Index to Nursing and Allied Health Literature (CINAHL) Complete, COCHRANE Database of Systematic Reviews, PubMed, Medline, PEDro, and EMBASE Classic + EMBASE, from inception until 28 February 2023. Seven systematic reviews (1,136,929 participants) from 184 primary studies (counting duplicates) were included. While the risk of mortality increases with being underweight (body mass index (BMI) < 18.5 kg/m2), excess body weight (being overweight (BMI = 25-29.9 kg/m2) or obese (BMI > 30 kg/m2)) is associated with reduced mortality. The impact of abnormal body weight on functional recovery is less clear; data from studies of being underweight are associated with poor functional outcomes while those from studies of excess body weight are inconclusive. CONCLUSION Abnormal body weight effects post-stroke outcomes and should be considered in clinical decision-making, prognostic research, and clinical trials of rehabilitation interventions. The "obesity paradox" is evident after stroke, and excess body weight is associated with reduced mortality compared to normal body weight. It is recommended that body weight is routinely recorded for stroke patients, and further research, including well-designed cohort studies with reliable weight data, is needed to further investigate the impact of body weight and distribution on post-stroke outcomes.
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Affiliation(s)
- Stephanie A Holland
- Department of Physiotherapy, Sunshine Hospital, Western Health, Saint Albans, VIC, Australia
| | - Ian Wellwood
- Australian Catholic University, Ballarat, VIC, Australia
| | - Suzanne Kuys
- Australian Catholic University, Banyo, QLD, Australia
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Browning S, Holland S, Wellwood I, Bilney B. Spatiotemporal Gait Parameters in Adults With Premanifest and Manifest Huntington's Disease: A Systematic Review. J Mov Disord 2023; 16:307-320. [PMID: 37558234 PMCID: PMC10548085 DOI: 10.14802/jmd.23111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/15/2023] [Accepted: 08/09/2023] [Indexed: 08/11/2023] Open
Abstract
OBJECTIVE To systematically review and critically evaluate literature on spatiotemporal gait deviations in individuals with premanifest and manifest Huntington's Disease (HD) in comparison with healthy cohorts. METHODS We conducted a systematic review, guided by the Joanna Briggs Institute's Manual for Evidence Synthesis and pre-registered with the International Prospective Register of Systematic Reviews. Eight electronic databases were searched. Studies comparing spatiotemporal footstep parameters in adults with premanifest and manifest HD to healthy controls were screened, included and critically appraised by independent reviewers. Data on spatiotemporal gait changes and variability were extracted and synthesised. Meta-analysis was performed on gait speed, cadence, stride length and stride length variability measures. RESULTS We screened 2,721 studies, identified 1,245 studies and included 25 studies (total 1,088 participants). Sample sizes ranged from 14 to 96. Overall, the quality of the studies was assessed as good, but reporting of confounding factors was often unclear. Meta-analysis found spatiotemporal gait deviations in participants with HD compared to healthy controls, commencing in the premanifest stage. Individuals with premanifest HD walk significantly slower (-0.17 m/s; 95% confidence interval [CI] [-0.22, -0.13]), with reduced cadence (-6.63 steps/min; 95% CI [-10.62, -2.65]) and stride length (-0.09 m; 95% CI [-0.13, -0.05]). Stride length variability was also increased in premanifest cohorts by 2.18% (95% CI [0.69, 3.68]), with these changes exacerbated in participants with manifest disease. CONCLUSION Findings suggest individuals with premanifest and manifest HD display significant spatiotemporal footstep deviations. Clinicians could monitor individuals in the premanifest stage of disease for gait changes to identify the onset of Huntington's symptoms.
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Affiliation(s)
- Sasha Browning
- Faculty of Health Sciences, Australian Catholic University, Ballarat, Australia
| | - Stephanie Holland
- Faculty of Health Sciences, Australian Catholic University, Ballarat, Australia
| | - Ian Wellwood
- Faculty of Health Sciences, Australian Catholic University, Ballarat, Australia
| | - Belinda Bilney
- Faculty of Health Sciences, Australian Catholic University, Ballarat, Australia
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Hossain MZ, Chew-Graham CA, Sowden E, Blakeman T, Wellwood I, Tierney S, Deaton C. Challenges in the management of people with heart failure with preserved ejection fraction (HFpEF) in primary care: A qualitative study of general practitioner perspectives. Chronic Illn 2022; 18:410-425. [PMID: 33401942 PMCID: PMC9163769 DOI: 10.1177/1742395320983871] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To explore the perspectives of general practitioners (GPs) on the identification and management of people, including those from ethnic minority groups, with Heart Failure with Preserved Ejection Fraction (HFpEF). METHODS Qualitative study. Semi-structured, face-to-face or telephone interviews and focus groups were conducted with 35 GPs in England, which were audio-recorded and transcribed verbatim. Framework analysis was used to manage and interpret data. RESULTS Themes presented reflect four inter-related challenges: GPs' 1) lack of understanding HFpEF, impacting on 2) difficulties in communicating the diagnosis, leading to 3) uncertainty in managing people with HFpEF, further hindered by (4) discontinuity across the primary/secondary interface. All were considered more challenging by GPs when managing people from different cultures and languages. DISCUSSION HFpEF is not well understood by GPs, leading to diagnostic difficulty, management uncertainty and potential inequity in care offered. People with HFpEF are seen as complex, with multiple long-term conditions and requiring personalised care. Challenges in their management occur across the healthcare system. This study has identified learning needs for GPs around identification and on-going support for people with HFpEF in primary care. It will contribute to the development of more flexible and patient-centred pathways across the primary/secondary care interface.
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Affiliation(s)
- Muhammad Z Hossain
- Faculty of Medicine and Health Sciences, School of Medicine, Keele University, Keele, UK
| | - Carolyn A Chew-Graham
- Faculty of Medicine and Health Sciences, School of Medicine, Keele University, Keele, UK
| | - Emma Sowden
- NIHR School for Primary Care Research, Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Tom Blakeman
- NIHR School for Primary Care Research, Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Ian Wellwood
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, School of Clinical Medicine, Cambridge, UK
| | - Stephanie Tierney
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Christi Deaton
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, School of Clinical Medicine, Cambridge, UK
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Petrova M, Wong G, Kuhn I, Wellwood I, Barclay S. Timely community palliative and end-of-life care: a realist synthesis. BMJ Support Palliat Care 2021:bmjspcare-2021-003066. [PMID: 34887313 DOI: 10.1136/bmjspcare-2021-003066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 09/19/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Community-based and home-based palliative and end-of-life care (PEoLC) services, often underpinned by primary care provision, are becoming increasingly popular. One of the key challenges associated with them is their timely initiation. The latter requires an accurate enough prediction of how close to death a patient is. METHODS Using 'realist synthesis' tools, this review sought to develop explanations of how primary care and community PEoLC programmes generate their outcomes, with the explanations presented as context-mechanism-outcome configurations. Medline, Embase, CINAHL, PsycINFO, Web of Science, ASSIA, Sociological Abstracts and SCIE Social Care Online were originally searched. A multistage process of focusing the review was employed, with timely identification of the EoL stage and timely initiation of associated services representing the final review focus. Synthesised sources included 21 full-text documents and 324 coded abstracts, with 253 'core contents' abstracts generating >800 codes. RESULTS Numerous PEoLC policies and programmes are embedded in a framework of Preparation and Planning for Death and Dying, with identification of the dying stage setting in motion key systems and services. This is challenged by: (1) accumulated evidence demonstrating low accuracy of prognostic judgements; (2) many individuals' orientation towards Living and Hope; (3) expanding grey zones between palliative and curative care; (4) the complexity of referral decisions; (5) the loss of pertinent information in hierarchical relationships and (6) the ambiguous value of having 'more time'. CONCLUSION Prioritising temporal criteria in initiating PEoLC services is not sufficiently supported by current evidence and can have significant unintended consequences. PROSPERO REGISTRATION NUMBER CRD42018097218.
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Affiliation(s)
- Mila Petrova
- Palliative & End of Life Care in Cambridge (PELiCAM) Research Group, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Geoff Wong
- Nuffied Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Isla Kuhn
- Medical Library, University of Cambridge, Cambridge, UK
| | - Ian Wellwood
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephen Barclay
- Palliative & End of Life Care in Cambridge (PELiCAM) Research Group, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Forsyth F, Brimicombe J, Cheriyan J, Edwards D, Hobbs FR, Jalaludeen N, Mant J, Pilling M, Schiff R, Taylor CJ, Zaman MJ, Deaton C, Chakravorty M, Maclachlan S, Kane E, Odone J, Thorley N, Borja‐Boluda S, Wellwood I, Sowden E, Blakeman T, Chew‐Graham C, Hossain M, Sharpley J, Gordon B, Taffe J, Long A, Aziz A, Swayze H, Rutter H, Schramm C, MacDonald S, Papworth H, Smith J, Needs C, Cronk D, Newark C, Blake D, Brown A, Basuita A, Gayton E, Glover V, Fox R, Crawshaw J, Ashdown H, A'Court C, Ayerst R, Hernandez‐Diaz B, Knox K, Wooding N, Wanninayake S, Keast C, Jones A, Brown K, Gaw M, Thomas N, Dixon S, Angeleri‐Rand E. Diagnosis of patients with heart failure with preserved ejection fraction in primary care: cohort study. ESC Heart Fail 2021. [PMCID: PMC8712851 DOI: 10.1002/ehf2.13612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Aims Heart failure with preserved ejection fraction (HFpEF) accounts for half of all heart failure (HF), but low awareness and diagnostic challenges hinder identification in primary care. Our aims were to evaluate the recruitment and diagnostic strategy in the Optimise HFpEF cohort and compare with recent recommendations for diagnosing HFpEF. Methods and results Patients were recruited from 30 primary care practices in two regions in England using an electronic screening algorithm and two secondary care sites. Baseline assessment collected clinical and patient‐reported data and diagnosis by history, assessment, and trans‐thoracic echocardiogram (TTE). A retrospective evaluation compared study diagnosis with H2FPEF score and HFA‐PEFF diagnostic algorithm. A total of 152 patients (86% primary care, mean age 78.5, 40% female) were enrolled; 93 (61%) had HFpEF confirmed. Most participants had clinical features of HFpEF, but those with confirmed HFpEF were more likely female, obese, functionally impaired, and symptomatic. Some echocardiographic findings were diagnostic for HFpEF, but no difference in natriuretic peptide levels were observed. The H2FPEF and HFA‐PEFF scores were not significantly different by group, although confirmed HFpEF cases were more likely to have scores indicating high probability of HFpEF. Conclusions Patients with HFpEF in primary care are difficult to identify, and greater awareness of the condition, with clear diagnostic pathways and specialist support, are needed. Use of diagnostic algorithms and scores can provide systematic approaches to diagnosis but may be challenging to apply in older multi‐morbid patients. Where diagnostic uncertainty remains, pragmatic decisions are needed regarding the value of additional testing versus management of presumptive HFpEF.
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Affiliation(s)
- Faye Forsyth
- Primary Care Unit, Department of Public Health and Primary Care University of Cambridge School of Clinical Medicine East Forvie, Cambridge Biomedical Campus Cambridge CB2 0SR UK
| | - James Brimicombe
- Primary Care Unit, Department of Public Health and Primary Care University of Cambridge School of Clinical Medicine East Forvie, Cambridge Biomedical Campus Cambridge CB2 0SR UK
| | - Joseph Cheriyan
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine University of Cambridge School of Clinical Medicine Cambridge UK
| | - Duncan Edwards
- Primary Care Unit, Department of Public Health and Primary Care University of Cambridge School of Clinical Medicine East Forvie, Cambridge Biomedical Campus Cambridge CB2 0SR UK
| | - F.D. Richard Hobbs
- Nuffield Department of Primary Care Health Sciences University of Oxford Oxford UK
| | - Navazh Jalaludeen
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine University of Cambridge School of Clinical Medicine Cambridge UK
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care University of Cambridge School of Clinical Medicine East Forvie, Cambridge Biomedical Campus Cambridge CB2 0SR UK
| | - Mark Pilling
- Primary Care Unit, Department of Public Health and Primary Care University of Cambridge School of Clinical Medicine East Forvie, Cambridge Biomedical Campus Cambridge CB2 0SR UK
| | - Rebekah Schiff
- Department of Ageing and Health Guy's and St. Thomas' NHS Foundation Trust London UK
| | - Clare J. Taylor
- Nuffield Department of Primary Care Health Sciences University of Oxford Oxford UK
| | - M. Justin Zaman
- Department of Cardiology West Suffolk Hospital Bury St Edmonds UK
| | - Christi Deaton
- Primary Care Unit, Department of Public Health and Primary Care University of Cambridge School of Clinical Medicine East Forvie, Cambridge Biomedical Campus Cambridge CB2 0SR UK
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Hartley P, Romero-Ortuno R, Wellwood I, Deaton C. Changes in muscle strength and physical function in older patients during and after hospitalisation: a prospective repeated-measures cohort study. Age Ageing 2021; 50:153-160. [PMID: 32902637 DOI: 10.1093/ageing/afaa103] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Indexed: 01/11/2023] Open
Abstract
AIM to investigate changes in knee-extension strength and physical function in older adults during and after acute hospital admission, and the contributions of illness severity, frailty and sedentary activity to changes in knee-extension strength. METHODS prospective repeated-measures cohort study on a sample of participants aged ≥75 recruited within 24 hours of acute hospital admission. Knee-extension, grip strength and functional mobility (de Morton Mobility Index, DEMMI) were measured at recruitment, day 7 (or discharge if earlier), and at follow-up 4-6 weeks later. During the first 7 days, continuous measurement of physical activity and daily measurements of muscle strength were taken. Participants recalled the functional ability they had 2-weeks before admission and self-reported it at follow-up (Barthel Index, BI). RESULTS sixty-five of 70 participants (median age 84 years) had at least one repeated measure of muscle strength in hospital. Knee-extension strength declined during hospitalisation by 11% (P < 0.001), but did not change post-hospitalisation (P = 0.458). Grip strength did not change during hospitalisation (P = 0.665) or from discharge to follow-up (P = 0.508). General functional ability (BI) deteriorated between 2 weeks before admission and follow-up (P < 0.001). Functional mobility (DEMMI) improved during hospitalisation (P < 0.001), but did not change post-hospitalisation (P = 0.508). A repeated-measures mixed model showed that greater loss in knee-extension strength during hospitalisation was associated with increased sedentary time, frailty and baseline strength and lower baseline inflammatory levels. CONCLUSIONS our observations add to a growing body of evidence on potential risk factors for hospital-associated deconditioning.
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Affiliation(s)
- Peter Hartley
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Department of Physiotherapy, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Roman Romero-Ortuno
- Discipline of Medical Gerontology, Trinity College Dublin, Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin, Ireland
| | - Ian Wellwood
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Christi Deaton
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Beks H, King O, Clapham R, Alston L, Glenister K, McKinstry C, Quilliam C, Wellwood I, Williams C, Wong Shee A. Community health programs delivered through information and communications technology in high-income countries: a scoping review (Preprint). J Med Internet Res 2020; 24:e26515. [PMID: 35262498 PMCID: PMC8943572 DOI: 10.2196/26515] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/15/2021] [Accepted: 11/18/2021] [Indexed: 11/13/2022] Open
Abstract
Background The COVID-19 pandemic has required widespread and rapid adoption of information and communications technology (ICT) platforms by health professionals. Transitioning health programs from face-to-face to remote delivery using ICT platforms has introduced new challenges. Objective The objective of this review is to scope for ICT-delivered health programs implemented within the community health setting in high-income countries and rapidly disseminate findings to health professionals. Methods The Joanna Briggs Institute’s scoping review methodology guided the review of the literature. Results The search retrieved 7110 unique citations. Each title and abstract was screened by at least two reviewers, resulting in 399 citations for full-text review. Of these 399 citations, 72 (18%) were included. An additional 27 citations were identified through reviewing the reference lists of the included studies, resulting in 99 citations. Citations examined 83 ICT-delivered programs from 19 high-income countries. Variations in program design, ICT platforms, research design, and outcomes were evident. Conclusions Included programs and research were heterogeneous, addressing prevalent chronic diseases. Evidence was retrieved for the effectiveness of nurse and allied health ICT-delivered programs. Findings indicated that outcomes for participants receiving ICT-delivered programs, when compared with participants receiving in-person programs, were either equivalent or better. Gaps included a paucity of co-designed programs, qualitative research around group programs, programs for patients and carers, and evaluation of cost-effectiveness. During COVID-19 and beyond, health professionals in the community health setting are encouraged to build on existing knowledge and address evidence gaps by developing and evaluating innovative ICT-delivered programs in collaboration with consumers and carers.
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Affiliation(s)
- Hannah Beks
- School of Medicine, Deakin University, Geelong, Australia
| | | | - Renee Clapham
- St Vincents Health Australia, Melbourne, Australia
- Ballarat Health Services, Ballarat, Australia
| | - Laura Alston
- School of Medicine, Deakin University, Geelong, Australia
- Colac Area Health, Colac, Australia
- Global Obesity Centre, Institute for Health Transformation, Deakin University, Geelong, Australia
| | - Kristen Glenister
- Department of Rural Health, University of Melbourne, Wangaratta, Australia
- Department of Rural Health, University of Melbourne, Shepparton, Australia
| | - Carol McKinstry
- La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - Claire Quilliam
- Department of Rural Health, University of Melbourne, Wangaratta, Australia
| | - Ian Wellwood
- Faculty of Health Sciences, Australian Catholic University, Ballarat, Australia
| | | | - Anna Wong Shee
- School of Medicine, Deakin University, Geelong, Australia
- Ballarat Health Services, Ballarat, Australia
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Padberg I, Hotter B, Liebenau A, Knispel P, Lehnerer S, Heel S, Wellwood I, Meisel A. Unmet Need for Social and Emotional Support and Lack of Recalled Screening Is Associated with Depression in the Long-Term Course After Stroke. Risk Manag Healthc Policy 2020; 13:285-293. [PMID: 32280291 PMCID: PMC7131991 DOI: 10.2147/rmhp.s228265] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 12/22/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose Details on adequate care and prevalence of depression in long-term stroke aftercare are limited. We aimed to determine long-term depression rates after stroke and to test for an association between depression and inadequate screening, socio-economic complications and lack of sub-optimal care. Patients and Methods In this cross-sectional study, 57 patients were re-invited into the clinic 2-3 years after stroke. Patients were interviewed about recalled screening concerning depression and unmet needs. Depression, the patient's social situation, and confounders were assessed by standardized scores. Results In our study, 20% (n = 11) of patients were classified as depressed by the HDRS-17 score result. However, only 36% of all patients recalled to have been previously screened for depression and only 43% of those patients also recalled out-patient screening. Patients classified as depressed reported significantly lower recalled screening rates (9% vs 43%; p = 0.036) and higher rates of self-reported unmet need with emotional problems (72% vs 18%; p < 0.001). Depression in our study was further associated with a worse socio-economic situation, fewer social contacts, unmet needs with regard to emotional problems and higher rates of recommendations to apply for additional social support. Conclusion Our data suggest that systematic out-patient screening for depression is lacking in stroke aftercare. Furthermore, the high rate of unmet emotional needs, the poor socio-economic situation and the higher rates of recommendations for social counselling and application for benefits suggest an undersupply of care in the out-patient setting that is more prominent in patients with depression and warrants further studies to investigate the underlying causes.
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Affiliation(s)
- Inken Padberg
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Benjamin Hotter
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Neurocure Clinical Research Center, Department of Neurology, Charité Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Andrea Liebenau
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Petra Knispel
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Berliner Schlaganfall-Allianz e.V., Berlin, Germany
| | - Sophie Lehnerer
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Neurocure Clinical Research Center, Department of Neurology, Charité Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Sabine Heel
- Zentrum für Ambulante Neuropsychologie und Verhaltenstherapie (ZANV), Berlin, Germany
| | - Ian Wellwood
- Department of Public-Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Andreas Meisel
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Neurocure Clinical Research Center, Department of Neurology, Charité Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany.,Berliner Schlaganfall-Allianz e.V., Berlin, Germany
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9
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Early F, Wilson PM, Deaton C, Wellwood I, Haque HW, Fox SE, Yousaf A, Meysner OD, Ward JR, Singh SJ, Fuld JP. Pulmonary rehabilitation referral and uptake from primary care for people living with COPD: a mixed-methods study. ERJ Open Res 2020; 6:00219-2019. [PMID: 32083112 PMCID: PMC7024763 DOI: 10.1183/23120541.00219-2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/11/2019] [Indexed: 11/05/2022] Open
Abstract
Healthcare service and patient barriers contribute to low referral to and uptake of pulmonary rehabilitation (PR). Solutions should support skilled clinician-patient conversations and span primary care-PR boundaries to prevent disjointed working. http://bit.ly/2PVKHZf.
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Affiliation(s)
- Frances Early
- Dept of Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | | | - Christi Deaton
- Clinical Nursing Research Group, Primary Care Unit, Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Ian Wellwood
- Clinical Nursing Research Group, Primary Care Unit, Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Hena Wali Haque
- Dept of Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Sarah Emma Fox
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Azka Yousaf
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Oliver D Meysner
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - James R Ward
- Engineering Design Centre, University of Cambridge, UK
| | - Sally J Singh
- Dept of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Jonathan Paul Fuld
- Dept of Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
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10
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Hartley P, Romero-Ortuno R, Wellwood I, Deaton C. 71 Changes in Muscle Strength in Older Patients During Hospitalisation: A Prospective Repeated Measures Cohort Study. Age Ageing 2020. [DOI: 10.1093/ageing/afz188.02] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Hospital associated deconditioning is a well-established phenomenon. Whilst mechanisms are not well understood, one is thought to be skeletal muscle wasting and/or loss of muscle strength. The primary aim of this study was to investigate changes in knee-extension muscle strength in older patients during and after an acute-hospital admission. We also aimed to explore the potential contributions of frailty, acute-illness severity and sedentary activity, with changes in knee-extension strength.
Methods
This was a prospective repeated-measures cohort study. Measurements of muscle strength and functional mobility were taken at recruitment, on day 7 of admission (or at discharge if earlier) and again 4-6 weeks post-hospitalisation. During the first 7 days of admission, daily measurements of muscle strength were taken.
Results
We recruited 70 participants, of which 65 had at least one repeated measure in hospital. Median age was 84 years, and participants participated in the study for a median of 6 days whilst in hospital, on average participants were ‘active’ for less than 4% of the day. Knee-extension strength significantly reduced by approximately 11% during hospitalisation, but no significant changes occurred post-hospitalisation. A repeated-measures mixed model included 292 observations from 62 participants and showed a significant decrease in the reduction in muscle strength as patients' sedentary time decreased on days 2 to 7 of the study. Additionally, the model showed that a higher frailty score, higher baseline knee-extension strength, lower baseline c-reactive protein levels were associated with greater loss in knee-extension strength during hospitalisation. Association between change in functional mobility after hospitalisation and change in knee-extension strength during hospitalisation was non-significant.
Conclusion
Our findings provide an important link in understanding the mechanisms and relative contributions of risk factors to hospital associated deconditioning. Further research is needed to confirm these findings and examine the impact of reducing sedentary time on muscle strength during and post-hospitalisation.
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Affiliation(s)
- P Hartley
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Department of Physiotherapy, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - R Romero-Ortuno
- Discipline of Medical Gerontology, Trinity College Dublin, Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin, Ireland
| | - I Wellwood
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - C Deaton
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Lehnerer S, Hotter B, Padberg I, Knispel P, Remstedt D, Liebenau A, Grittner U, Wellwood I, Meisel A. Social work support and unmet social needs in life after stroke: a cross-sectional exploratory study. BMC Neurol 2019; 19:220. [PMID: 31492151 PMCID: PMC6729017 DOI: 10.1186/s12883-019-1451-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 08/27/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Stroke patients are often affected by long-term disabilities with needs concerning social issues. There is relatively little consideration of social recovery of patients and the support required to return to work, receive social benefits, participate in daily life activities, maintain contact with family and friends and to organize financial affairs. In our study we aimed to investigate if existing tools record social needs adequately. We analyzed the current provision of social support provided in long-term care after stroke and whether unmet social needs were associated with quality of life, caregiver burden, overall function and degree of disability. METHODS Our analysis is part of the Managing Aftercare of Stroke study (MAS-I), a cross-sectional exploratory study of patient needs 2-3 years after initial stroke. Assessment tools included the Nikolaus-score (social situation), the EuroQoL (quality of life), the German Burden Scale for Family Caregivers (caregiver burden), the modified Rankin Scale (disability / dependence), Stroke Impact Scale (function and degree of disability) and the Stroke Survivor Needs Questionnaire (unmet needs). RESULTS Overall 57 patients were included in MAS-I, with ten patients classified in urgent need of socio-economic support according to the Nikolaus-score. Patients with lower than normal Nikolaus-score had a higher degree of disability. Thirty percent of all patients had never received professional social support. Social worker contact happened mostly during the stay in acute hospital or rehabilitation institution. Only four patients (11%) reported long-term support after discharge. Apart from social worker contact during acute care, 43% of patients had unmet needs in the long-term aftercare. Forty percent of all patients included in MAS-I were recommended for social work intervention after an in-depth analysis of their situation. Finally, we saw that unmet social needs were associated with lower quality of life and higher caregiver burden. CONCLUSIONS Our data suggest significant unmet needs in social care in long-term stroke patients. Screening tools for unmet social needs such as the Nikolaus-score do not holistically report patients' needs. TRIAL REGISTRATION Clinicaltrials.Gov NCT02320994 . Registered 19 December 2014 (retrospectively registered).
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Affiliation(s)
- Sophie Lehnerer
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Department of Neurology, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Benjamin Hotter
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Department of Neurology, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Inken Padberg
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Clinical Epidemiology and Health Services in Stroke, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Petra Knispel
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Stroke Alliance (BSA), Charitéplatz 1, 10117 Berlin, Germany
| | - Dike Remstedt
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Andrea Liebenau
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch 2, 10178 Berlin, Germany
| | - Ian Wellwood
- Department of Public Health and Primary Care, Cambridge Institute of Public Health, University of Cambridge, Cambridge, CB2 0SR UK
| | - Andreas Meisel
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Department of Neurology, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Stroke Alliance (BSA), Charitéplatz 1, 10117 Berlin, Germany
| | - on behalf of the BSA Long Term Care Study Group
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Department of Neurology, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- NeuroCure Clinical Research Center, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Clinical Epidemiology and Health Services in Stroke, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Stroke Alliance (BSA), Charitéplatz 1, 10117 Berlin, Germany
- Institute of Biometry and Clinical Epidemiology, Charité University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch 2, 10178 Berlin, Germany
- Department of Public Health and Primary Care, Cambridge Institute of Public Health, University of Cambridge, Cambridge, CB2 0SR UK
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Rankin G, Summers R, Cowan K, Barker K, Button K, Carroll SP, Fashanu B, Moran F, O'Neill B, Ten Hove R, Waterfield J, Westwater-Wood S, Wellwood I. Identifying Priorities for Physiotherapy Research in the UK: the James Lind Alliance Physiotherapy Priority Setting Partnership. Physiotherapy 2019; 107:161-168. [PMID: 32026816 DOI: 10.1016/j.physio.2019.07.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To identify unanswered questions for physiotherapy research and help set and prioritise the top 10 generic research priorities for the UK physiotherapy profession; updating previous clinical condition- specific priorities to include patient and carer perspectives, and reflect changes in physiotherapy practice, service provision and new technologies. DESIGN The James Lind Alliance (JLA) Priority Setting Partnership (PSP) methodology was adopted, utilising evidence review, survey and consensus methods. PARTICIPANTS Anyone with experience and/or an interest in UK physiotherapy: patients, carers, members of the public, physiotherapists, student physiotherapists, other healthcare professionals, researchers, educators, service providers, commissioners and policy makers. RESULTS Five hundred and ten respondents (50% patients, carers or members of the public) identified 2152 questions (termed "uncertainties"). Sixty-five indicative questions were developed from the uncertainties using peer reviewed thematic analysis. These were ranked in a second national survey (1,020 responses (62% were complete)). The top 25 questions were reviewed in a final prioritisation workshop using an adapted nominal group technique. The top 10 research priorities focused on optimisation (top priority); access; effectiveness; patient and carer knowledge, experiences, needs and expectations; supporting patient engagement and self-management; diagnosis and prediction. CONCLUSIONS This study is currently the UK's most inclusive consultation exercise to identify patients'and healthcare professionals'priorities for physiotherapy research. The exercise deliberately sought to capture generic issues relevant to all specialisms within physiotherapy. The research priorities identified a range of gaps in existing evidence to inform physiotherapy policy and practice. The results will assist research commissioning bodies and inform funding decisions and strategy.
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Affiliation(s)
- Gabrielle Rankin
- Chartered Society of Physiotherapy, 14 Bedford Row, London WC1R 4ED, UK.
| | - Rachael Summers
- Health Sciences, University of Southampton, Highfield, Southampton SO17 1BJ, UK
| | - Katherine Cowan
- Senior Adviser, James Lind Alliance, University of Southampton, Alpha House, Enterprise Road, Southampton SO16 7NS, UK.
| | - Karen Barker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford OX3 7LD, UK.
| | - Kate Button
- School of Healthcare Sciences, Cardiff University, Newport Road, CF24 0AB, UK.
| | - Sean Paul Carroll
- School of Health and Life Sciences, Govan Mbeki Building, Glasgow Caledonian University, Glasgow G4 0BA, UK.
| | - Billy Fashanu
- Southend University Hospital NHS Foundation Trust, Prittlewell Chase, Westcliff-on-Sea, Southend SS0 0RY, UK.
| | - Fidelma Moran
- School of Health Sciences, Ulster University, Newtownabbey, Northern Ireland BT37 OQB, UK.
| | - Brenda O'Neill
- School of Health Sciences, Ulster University, Newtownabbey, Northern Ireland BT37 OQB, UK.
| | - Ruth Ten Hove
- Chartered Society of Physiotherapy, 14 Bedford Row, London WC1R 4ED, UK.
| | - Jackie Waterfield
- School of Health Sciences, Queen Margaret University, Edinburgh EH21 6UU, UK.
| | - Sarah Westwater-Wood
- School of Health Sciences, Clinical Sciences Building, City Hospital Campus, Nottingham NG5 1PB, UK.
| | - Ian Wellwood
- Cambridge Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Forvie Site, Cambridge CB2 0SR, UK.
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Walter FM, Thompson MJ, Wellwood I, Abel GA, Hamilton W, Johnson M, Lyratzopoulos G, Messenger MP, Neal RD, Rubin G, Singh H, Spencer A, Sutton S, Vedsted P, Emery JD. Evaluating diagnostic strategies for early detection of cancer: the CanTest framework. BMC Cancer 2019; 19:586. [PMID: 31200676 PMCID: PMC6570853 DOI: 10.1186/s12885-019-5746-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 05/23/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Novel diagnostic triage and testing strategies to support early detection of cancer could improve clinical outcomes. Most apparently promising diagnostic tests ultimately fail because of inadequate performance in real-world, low prevalence populations such as primary care or general community populations. They should therefore be systematically evaluated before implementation to determine whether they lead to earlier detection, are cost-effective, and improve patient safety and quality of care, while minimising over-investigation and over-diagnosis. METHODS We performed a systematic scoping review of frameworks for the evaluation of tests and diagnostic approaches. RESULTS We identified 16 frameworks: none addressed the entire continuum from test development to impact on diagnosis and patient outcomes in the intended population, nor the way in which tests may be used for triage purposes as part of a wider diagnostic strategy. Informed by these findings, we developed a new framework, the 'CanTest Framework', which proposes five iterative research phases forming a clear translational pathway from new test development to health system implementation and evaluation. CONCLUSION This framework is suitable for testing in low prevalence populations, where tests are often applied for triage testing and incorporated into a wider diagnostic strategy. It has relevance for a wide range of stakeholders including patients, policymakers, purchasers, healthcare providers and industry.
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Affiliation(s)
- Fiona M. Walter
- The Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, CB1 8RN UK
| | | | - Ian Wellwood
- The Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, CB1 8RN UK
| | - Gary A. Abel
- University of Exeter, St Luke’s Campus, Exeter, EX1 2LU UK
| | | | - Margaret Johnson
- The Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, CB1 8RN UK
| | - Georgios Lyratzopoulos
- Department of Behavioural Science and Health, Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, University College London, London, UK
| | - Michael P. Messenger
- National Institute of Health Research (NIHR) Leeds In Vitro Diagnostic Cooperative (IVDC), Leeds Centre for Personalised Medicine and Health, University of Leeds, Leeds, UK
| | - Richard D. Neal
- Academic Unit of Primary Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Greg Rubin
- Institute of Health and Society, University of Newcastle, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle, NE1 4LP UK
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX USA
| | - Anne Spencer
- Health Economics Group, University of Exeter, St Luke’s Campus, Exeter, EX1 2LU Devon UK
| | - Stephen Sutton
- The Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, CB1 8RN UK
| | - Peter Vedsted
- Research Centre for Cancer Diagnosis – CaP, The Research Unit for General Practice and Research Clinic for Innovative Health Care Delivery, Department of Clinical Medicine, Aarhus University, Bartholins Alle 2, 8000 Aarhus, Denmark
| | - Jon D. Emery
- Centre for Cancer Research and Department of General Practice, University of Melbourne, 10th floor, Victorian Comprehensive Cancer Centre, 305 Grattan St, Melbourne, VIC 3010 Australia
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Early F, Wilson P, Deaton C, Wellwood I, Dickerson T, Ward J, Jongepier L, Barlow R, Singh SJ, Benson J, Brimicombe J, Kim L, Haque H, Fuld J. Developing an intervention to increase REferral and uptake TO pulmonary REhabilitation in primary care in patients with chronic obstructive pulmonary disease (the REsTORE study): mixed methods study protocol. BMJ Open 2019; 9:e024806. [PMID: 30670521 PMCID: PMC6347857 DOI: 10.1136/bmjopen-2018-024806] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) is a progressive lung disease associated with breathlessness, inability to exercise, frequent infections, hospitalisation and reduced quality of life. Pulmonary rehabilitation (PR), providing supervised exercise and education, is an effective and cost-effective treatment for COPD but is significantly underused. Interventions to improve referral and uptake have been tested and some positive results reported. However, interventions are diverse and no clear recommendations for practice can be made. This study aims to understand the challenges to referral and uptake in primary care, where most referrals originate, and to develop a flexible toolkit of resources to support referral and uptake to PR in primary care in the UK. METHODS AND ANALYSIS This is a mixed methods study informed by normalisation process theory and burden of treatment theory. In the first phase, general practitioners, practice nurses and PR providers will be invited to complete an online survey to inform a broad exploration of the topic areas. In phase 2 interviews and focus groups will be conducted with patients, healthcare professionals (HCP) in primary care, PR providers and commissioners to gain an in-depth understanding of the issues and needs. Toolkit development in phase 3 will draw together the learning from phases 1 and 2 and employ an iterative development process to build the toolkit jointly with patients and HCPs. It will be tested in primary care for usability and acceptability. ETHICS AND DISSEMINATION The study has ethical and Health Research Authority approval (Research Ethics Committee reference number 17/EE/0136). It is registered with the International Standard Registered Clinical/Social Study Number (ISRCTN) registry (trial ID: ISRCTN20669629, assignment date 20 March 2018, trial start date 1 April 2016). Dissemination will be aimed at patients, carers/families, service providers, commissioners and national interest groups. Methods will include conferences, presentations, academic publications and plain English reports and will be supported by the British Lung Foundation. TRIAL REGISTRATION NUMBER ISRCTN20669629 ; Pre-results.
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Affiliation(s)
- Frances Early
- Centre for Self Management Support, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Patricia Wilson
- Centre for Health Services Studies, University of Kent, Canterbury, UK
| | - Christi Deaton
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Ian Wellwood
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Terry Dickerson
- Department of Engineering, University of Cambridge, Cambridge, UK
| | - James Ward
- Department of Engineering, University of Cambridge, Cambridge, UK
| | - Lianne Jongepier
- COPD Team, NHS North East Essex Clinical Commissioning Group, Colchester, UK
| | - Ruth Barlow
- Provide Community Interest Company, Colchester, UK
| | - Sally J Singh
- Cardiac/Pulmonary Rehabilitation Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - John Benson
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - James Brimicombe
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Lois Kim
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Hena Haque
- Centre for Self Management Support, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jonathan Fuld
- Centre for Self Management Support, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Early F, Wellwood I, Kuhn I, Deaton C, Fuld J. Interventions to increase referral and uptake to pulmonary rehabilitation in people with COPD: a systematic review. Int J Chron Obstruct Pulmon Dis 2018; 13:3571-3586. [PMID: 30464439 PMCID: PMC6214582 DOI: 10.2147/copd.s172239] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Pulmonary rehabilitation (PR) reduces the number and duration of hospital admissions and readmissions, and improves health-related quality of life in patients with COPD. Despite clinical guideline recommendations, under-referral and limited uptake to PR contribute to poor treatment access. We reviewed published literature on the effectiveness of interventions to improve referral to and uptake of PR in patients with COPD when compared to standard care, alternative interventions, or no intervention. The review followed recognized methods. Search terms included "pulmonary rehabilitation" AND "referral" OR "uptake" applied to MEDLINE, EMBASE, CINAHL, PsycINFO, ASSIA, BNI, Web of Science, and Cochrane Library up to January 2018. Titles, abstracts, and full papers were reviewed independently and quality appraised. The protocol was registered (PROSPERO # 2016:CRD42016043762). We screened 5,328 references. Fourteen papers met the inclusion criteria. Ten assessed referral and five assessed uptake (46,146 patients, 409 clinicians, 82 hospital departments, 122 general practices). One was a systematic review which assessed uptake. Designs, interventions, and scope of studies were diverse, often part of multifaceted evidence-based management of COPD. Examples included computer-based prompts at practice nurse review, patient information, clinician education, and financial incentives. Four studies reported statistically significant improvements in referral (range 3.5%-36%). Two studies reported statistically significant increases in uptake (range 18%-21.5%). Most studies had methodological and reporting limitations. Meta-analysis was not conducted due to heterogeneity of study designs. This review demonstrates the range of approaches aimed at increasing referral and uptake to PR but identifies limited evidence of effectiveness due to the heterogeneity and limitations of study designs. Research using robust methods with clear descriptions of intervention, setting, and target population is required to optimize access to PR across a range of settings.
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Affiliation(s)
- Frances Early
- Centre for Self-Management Support, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK,
| | - Ian Wellwood
- Clinical Nursing Research Group, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Isla Kuhn
- Medical Library, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Christi Deaton
- Clinical Nursing Research Group, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Jonathan Fuld
- Centre for Self-Management Support, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK,
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Hotter B, Padberg I, Liebenau A, Knispel P, Heel S, Steube D, Wissel J, Wellwood I, Meisel A. Identifying unmet needs in long-term stroke care using in-depth assessment and the Post-Stroke Checklist - The Managing Aftercare for Stroke (MAS-I) study. Eur Stroke J 2018; 3:237-245. [PMID: 31008354 DOI: 10.1177/2396987318771174] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 03/23/2018] [Indexed: 11/16/2022] Open
Abstract
Introduction Detailed data on the long-term consequences and treatment of stroke are scarce. We aimed to assess the needs and disease burden of community-dwelling stroke patients and their carers and to compare their treatment to evidence-based guidelines by a stroke neurologist. Methods We invited long-term stroke patients from two previous acute clinical studies (n = 516) in Berlin, Germany to participate in an observational, cross-sectional study. Participants underwent a comprehensive interview and examination using the Post-Stroke Checklist and validated standard measures of: self-reported needs, quality of life, overall outcome, spasticity, pain, aphasia, cognition, depression, secondary prevention, social needs and caregiver burden. Results Fifty-seven participants (median initial National Institutes of Health Stroke Scale score 10 interquartile range 4-12.75) consented to assessment (median 41 months (interquartile range 36-50) after stroke. Modified Rankin Scale was 2 (median; interquartile range 1-3), EuroQoL index value was 0.81 (median; interquartile range 0.70-1.00). The frequencies for disabilities in the major domains were: spasticity 35%; cognition 61%; depression 20%; medication non-compliance 14%. Spasticity (p = 0.008) and social needs (p < 0.001) had the strongest impact on quality of life. The corresponding items in the Post-Stroke Checklist were predictive for low mood (p < 0.001), impaired cognition (p = 0.015), social needs (p = 0.005) and caregiver burden (p = 0.031). In the comprehensive interview, we identified the following needs: medical review (30%), optimization of pharmacotherapy (18%), outpatient therapy (47%) and social work input (33%). Conclusion These results suggest significant unmet needs and gaps in health and social care in long-term stroke patients. Further research to develop a comprehensive model for managing stroke aftercare is warranted.Clinical Trial Registration: clinicaltrials.gov NCT02320994.
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Affiliation(s)
- Benjamin Hotter
- Center for Stroke Research Berlin and Department of Neurology, Charité University Hospital Berlin, Berlin, Germany
| | - Inken Padberg
- Center for Stroke Research Berlin and Department of Neurology, Charité University Hospital Berlin, Berlin, Germany
| | - Andrea Liebenau
- Center for Stroke Research Berlin and Department of Neurology, Charité University Hospital Berlin, Berlin, Germany
| | - Petra Knispel
- Center for Stroke Research Berlin and Department of Neurology, Charité University Hospital Berlin, Berlin, Germany
| | - Sabine Heel
- Zentrum für ambulante Neuropsychologie und Verhaltenstherapie, Berlin, Germany
| | | | - Jörg Wissel
- Department Neurorehabilitation and Physical Therapy, Department of Neurology, Vivantes Hospital Spandau, Berlin, Germany
| | - Ian Wellwood
- Department of Public Health and Primary Care, Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Andreas Meisel
- Center for Stroke Research Berlin and Department of Neurology, Charité University Hospital Berlin, Berlin, Germany
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Pindus DM, Mullis R, Lim L, Wellwood I, Rundell AV, Abd Aziz NA, Mant J. Correction: Stroke survivors' and informal caregivers' experiences of primary care and community healthcare services - A systematic review and meta-ethnography. PLoS One 2018; 13:e0196185. [PMID: 29668761 PMCID: PMC5905972 DOI: 10.1371/journal.pone.0196185] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Pindus DM, Mullis R, Lim L, Wellwood I, Rundell AV, Abd Aziz NA, Mant J. Stroke survivors' and informal caregivers' experiences of primary care and community healthcare services - A systematic review and meta-ethnography. PLoS One 2018; 13:e0192533. [PMID: 29466383 PMCID: PMC5821463 DOI: 10.1371/journal.pone.0192533] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 01/25/2018] [Indexed: 11/28/2022] Open
Abstract
Objective To describe and explain stroke survivors and informal caregivers’ experiences of primary care and community healthcare services. To offer potential solutions for how negative experiences could be addressed by healthcare services. Design Systematic review and meta-ethnography. Data sources Medline, CINAHL, Embase and PsycINFO databases (literature searched until May 2015, published studies ranged from 1996 to 2015). Eligibility criteria Primary qualitative studies focused on adult community-dwelling stroke survivors’ and/or informal caregivers’ experiences of primary care and/or community healthcare services. Data synthesis A set of common second order constructs (original authors’ interpretations of participants’ experiences) were identified across the studies and used to develop a novel integrative account of the data (third order constructs). Study quality was assessed using the Critical Appraisal Skills Programme checklist. Relevance was assessed using Dixon-Woods’ criteria. Results 51 studies (including 168 stroke survivors and 328 caregivers) were synthesised. We developed three inter-dependent third order constructs: (1) marginalisation of stroke survivors and caregivers by healthcare services, (2) passivity versus proactivity in the relationship between health services and the patient/caregiver dyad, and (3) fluidity of stroke related needs for both patient and caregiver. Issues of continuity of care, limitations in access to services and inadequate information provision drove perceptions of marginalisation and passivity of services for both patients and caregivers. Fluidity was apparent through changing information needs and psychological adaptation to living with long-term consequences of stroke. Limitations Potential limitations of qualitative research such as limited generalisability and inability to provide firm answers are offset by the consistency of the findings across a range of countries and healthcare systems. Conclusions Stroke survivors and caregivers feel abandoned because they have become marginalised by services and they do not have the knowledge or skills to re-engage. This can be addressed by: (1) increasing stroke specific health literacy by targeted and timely information provision, and (2) improving continuity of care between specialist and generalist services. Systematic review registration number PROSPERO 2015:CRD42015026602
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Affiliation(s)
- Dominika M. Pindus
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Worts’ Causeway, Cambridge CB1 8RN, United Kingdom
| | - Ricky Mullis
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Worts’ Causeway, Cambridge CB1 8RN, United Kingdom
| | - Lisa Lim
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Worts’ Causeway, Cambridge CB1 8RN, United Kingdom
| | - Ian Wellwood
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Worts’ Causeway, Cambridge CB1 8RN, United Kingdom
| | - A. Viona Rundell
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Worts’ Causeway, Cambridge CB1 8RN, United Kingdom
| | - Noor Azah Abd Aziz
- Department of Family Medicine, National University of Malaysia, Bandar Tun Razak Cheras, Kuala Lumpur, Malaysia
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Worts’ Causeway, Cambridge CB1 8RN, United Kingdom
- * E-mail:
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Rankin G, Barker K, Cowan K, Fashanu B, Jones K, Lane A, Moran F, Summers R, Wellwood I. Identifying priorities for physiotherapy research in the UK: the James Lind Alliance Physiotherapy Priority Setting Partnership. Physiotherapy 2017. [DOI: 10.1016/j.physio.2017.11.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mullis R, Wellwood I, Kuhn I, Coughlin P, Mant J. Primary care interventions to improve uptake and adherence to exercise programmes in people with peripheral arterial disease: a systematic review. Physiotherapy 2017. [DOI: 10.1016/j.physio.2017.11.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Neumann K, Grittner U, Piper SK, Rex A, Florez-Vargas O, Karystianis G, Schneider A, Wellwood I, Siegerink B, Ioannidis JPA, Kimmelman J, Dirnagl U. Increasing efficiency of preclinical research by group sequential designs. PLoS Biol 2017; 15:e2001307. [PMID: 28282371 PMCID: PMC5345756 DOI: 10.1371/journal.pbio.2001307] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Despite the potential benefits of sequential designs, studies evaluating treatments or experimental manipulations in preclinical experimental biomedicine almost exclusively use classical block designs. Our aim with this article is to bring the existing methodology of group sequential designs to the attention of researchers in the preclinical field and to clearly illustrate its potential utility. Group sequential designs can offer higher efficiency than traditional methods and are increasingly used in clinical trials. Using simulation of data, we demonstrate that group sequential designs have the potential to improve the efficiency of experimental studies, even when sample sizes are very small, as is currently prevalent in preclinical experimental biomedicine. When simulating data with a large effect size of d = 1 and a sample size of n = 18 per group, sequential frequentist analysis consumes in the long run only around 80% of the planned number of experimental units. In larger trials (n = 36 per group), additional stopping rules for futility lead to the saving of resources of up to 30% compared to block designs. We argue that these savings should be invested to increase sample sizes and hence power, since the currently underpowered experiments in preclinical biomedicine are a major threat to the value and predictiveness in this research domain.
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Affiliation(s)
- Konrad Neumann
- Department of Biostatistics and Clinical Epidemiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrike Grittner
- Department of Biostatistics and Clinical Epidemiology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research, Charité Universitätsmedizin Berlin, Berlin, Germany
- * E-mail:
| | - Sophie K. Piper
- Department of Biostatistics and Clinical Epidemiology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research, Charité Universitätsmedizin Berlin, Berlin, Germany
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Andre Rex
- Center for Stroke Research, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Oscar Florez-Vargas
- Bio-health Informatics Group, School of Computer Science, The University of Manchester, Manchester, United Kingdom
| | | | - Alice Schneider
- Department of Biostatistics and Clinical Epidemiology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ian Wellwood
- Center for Stroke Research, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Public Health and Primary Care, Cambridge Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
| | - Bob Siegerink
- Center for Stroke Research, Charité Universitätsmedizin Berlin, Berlin, Germany
- Center for Transforming Biomedical Research, Berlin Institute of Health, Berlin, Germany
| | - John P. A. Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), and Departments of Medicine, of Health Research and Policy, and of Statistics, Stanford University, Stanford, California, United States of America
| | - Jonathan Kimmelman
- STREAM Research Group, Biomedical Ethics Unit, McGill University, Montreal, Canada
| | - Ulrich Dirnagl
- Center for Stroke Research, Charité Universitätsmedizin Berlin, Berlin, Germany
- NeuroCure Clinical Research Center, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Center for Transforming Biomedical Research, Berlin Institute of Health, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Berlin Site, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Berlin site, Berlin, Germany
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Early F, Wellwood I, Kuhn I, Dickerson T, Ward J, Brimicombe J, Deaton C, Fuld J. P212 Interventions to increase referral to and uptake of pulmonary rehabilitation programmes for people with chronic obstructive pulmonary disease (COPD): a systematic review. Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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23
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Nolte CH, Erdur H, Grittner U, Schneider A, Piper SK, Scheitz JF, Wellwood I, Bath PMW, Diener HC, Lees KR, Endres M. Impact of heart rate on admission on mortality and morbidity in acute ischaemic stroke patients - results from VISTA. Eur J Neurol 2016; 23:1750-1756. [DOI: 10.1111/ene.13115] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 06/27/2016] [Indexed: 01/24/2023]
Affiliation(s)
- C. H. Nolte
- Department of Neurology; Center for Stroke Research; Berlin Institute of Health; Charite-Universitätsmedzin; Berlin Germany
- Centre for Stroke Research; Berlin Germany
| | - H. Erdur
- Department of Neurology; Center for Stroke Research; Berlin Institute of Health; Charite-Universitätsmedzin; Berlin Germany
| | | | | | | | - J. F. Scheitz
- Department of Neurology; Center for Stroke Research; Berlin Institute of Health; Charite-Universitätsmedzin; Berlin Germany
- Centre for Stroke Research; Berlin Germany
| | - I. Wellwood
- Department of Public Health and Primary Care; University of Cambridge; Cambridge UK
| | - P. M. W. Bath
- School of Medicine; University of Nottingham; Nottingham UK
| | - H.-C. Diener
- Klinik für Neurologie und Schlaganfall-Zentrum Universitätsklinikum; Essen Germany
| | - K. R. Lees
- Institute of Cardiovascular and Medical Sciences; University of Glasgow; Glasgow UK
| | - M. Endres
- Department of Neurology; Center for Stroke Research; Berlin Institute of Health; Charite-Universitätsmedzin; Berlin Germany
- Centre for Stroke Research; Berlin Germany
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24
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Padberg I, Knispel P, Zöllner S, Sieveking M, Schneider A, Steinbrink J, Heuschmann PU, Wellwood I, Meisel A. Social work after stroke: identifying demand for support by recording stroke patients' and carers' needs in different phases after stroke. BMC Neurol 2016; 16:111. [PMID: 27439602 PMCID: PMC4955160 DOI: 10.1186/s12883-016-0626-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 06/11/2016] [Indexed: 11/10/2022] Open
Abstract
Background Previous studies examining social work interventions in stroke often lack information on content, methods and timing over different phases of care including acute hospital, rehabilitation and out-patient care. This limits our ability to evaluate the impact of social work in multidisciplinary stroke care. We aimed to quantify social-work-related support in stroke patients and their carers in terms of timing and content, depending on the different phases of stroke care. Methods We prospectively collected and evaluated data derived from a specialized “Stroke-Service-Point” (SSP); a “drop in” center and non-medical stroke assistance service, staffed by social workers and available to all stroke patients, their carers and members of the public in the metropolitan region of Berlin, Germany. Results Enquiries from 257 consenting participants consulting the SSP between March 2010 and April 2012 related to out-patient and in-patient services, therapeutic services, medical questions, medical rehabilitation, self-help groups and questions around obtaining benefits. Frequency of enquiries for different topics depended on whether patients were located in an in-patient or out-patient setting. The majority of contacts involved information provision. While the proportion of male and female patients with stroke was similar, about two thirds of the carers contacting the SSP were female. Conclusion The social-work-related services provided by a specialized center in a German metropolitan area were diverse in terms of topic and timing depending on the phase of stroke care. Targeting the timing of interventions might be important to increase the impact of social work on patient’s outcome. Electronic supplementary material The online version of this article (doi:10.1186/s12883-016-0626-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Inken Padberg
- Research Group "Clinical Epidemiology and Health Services in Stroke"(CEHRiS), Center for Stroke Research Berlin (CSB), Charité University Medicine, Charitéplatz 1, 10117, Berlin, Germany.
| | - Petra Knispel
- Center for Stroke Research Berlin (CSB), Charité University Medicine, Berlin, Germany.,Berliner Schlaganfall-Allianz e.V., Berlin, Germany
| | - Susanne Zöllner
- Center for Stroke Research Berlin (CSB), Charité University Medicine, Berlin, Germany.,Berliner Schlaganfall-Allianz e.V., Berlin, Germany
| | - Meike Sieveking
- Center for Stroke Research Berlin (CSB), Charité University Medicine, Berlin, Germany.,Berliner Schlaganfall-Allianz e.V., Berlin, Germany
| | - Alice Schneider
- Research Group "Clinical Epidemiology and Health Services in Stroke"(CEHRiS), Center for Stroke Research Berlin (CSB), Charité University Medicine, Charitéplatz 1, 10117, Berlin, Germany
| | - Jens Steinbrink
- Center for Stroke Research Berlin (CSB), Charité University Medicine, Berlin, Germany
| | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany.,Clinical Trial Center Würzburg, University Hospital Würzburg, Würzburg, Germany.,Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
| | - Ian Wellwood
- Institute of Public Health, University of Cambridge, Cambridge, UK.,Research Group "Clinical Epidemiology and Health Services in Stroke"(CEHRiS), Center for Stroke Research Berlin (CSB), Charité University Medicine, Charitéplatz 1, 10117, Berlin, Germany
| | - Andreas Meisel
- Center for Stroke Research Berlin (CSB), Charité University Medicine, Berlin, Germany.,Berliner Schlaganfall-Allianz e.V., Berlin, Germany.,Neurocure Clinical Research Center, Department of Neurology, Charité University Medicine, Berlin, Germany
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Ayis S, Wellwood I, Rudd AG, McKevitt C, Parkin D, Wolfe CDA. Variations in Health-Related Quality of Life (HRQoL) and survival 1 year after stroke: five European population-based registers. BMJ Open 2015; 5:e007101. [PMID: 26038354 PMCID: PMC4458636 DOI: 10.1136/bmjopen-2014-007101] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE There were two main objectives: to describe and compare clinical outcomes and Patient-Reported Outcome Measures (PROMs) collected using standardised procedures across the European Registers of Stroke (EROS) at 3 and 12 months after stroke; and to examine the relationship between patients' Health-Related Quality of Life (HRQoL) at 3 months after stroke and survival up to 1 year across the 5 populations. DESIGN Analysis of data from population-based stroke registers. SETTING European populations in Dijon (France); Kaunas (Lithuania); London (UK); Warsaw (Poland) and Sesto Fiorentino (Italy). PARTICIPANTS Patients with ischaemic or intracerebral haemorrhage (ICH) stroke, registered between 2004 and 2006. OUTCOME MEASURES (1) HRQoL, assessed by the physical component summary (PCS) and mental component summary (MCS) of the Short-Form Health Survey (SF-12), mapped into the EQ-5D to estimate responses on 5 dimensions (mobility, activity, pain, anxiety and depression, and self-care) and utility scores. (2) Mortality within 3 months and within 1 year of stroke. RESULTS Of 1848 patients, 325 were lost to follow-up and 500 died within a year of stroke. Significant differences in mortality, HRQoL and utility scores were found, and remained after adjustments. Kaunas had an increased risk of death; OR 2.34, 95% CI (1.32 to 4.14) at 3 months after stroke in Kaunas, compared with London. Sesto Fiorentino had the highest adjusted PCS: 43.54 (SD=0.96), and Dijon had the lowest adjusted MCS 38.67 (SD=0.67). There are strong associations between levels of the EQ-5D at 3 months and survival within the year. The trend across levels suggests a dose-response relationship. CONCLUSIONS The study demonstrated significant variations in survival, HRQoL and utilities across populations that could not be explained by stroke severity and sociodemographic factors. Strong associations between HRQoL at 3 months and survival to 1 year after stroke were identified.
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Affiliation(s)
- Salma Ayis
- Division of Health and Social Care Research, King's College London, London, UK
- NIHR Biomedical Research Centre at Guy's & St Thomas’ NHS Foundation Trust and King's College London, London, UK
| | - Ian Wellwood
- Division of Health and Social Care Research, King's College London, London, UK
- Department of Public Health and Primary Care, Cambridge Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Anthony G Rudd
- Division of Health and Social Care Research, King's College London, London, UK
- NIHR Biomedical Research Centre at Guy's & St Thomas’ NHS Foundation Trust and King's College London, London, UK
| | - Christopher McKevitt
- Division of Health and Social Care Research, King's College London, London, UK
- NIHR Biomedical Research Centre at Guy's & St Thomas’ NHS Foundation Trust and King's College London, London, UK
| | - David Parkin
- Division of Health and Social Care Research, King's College London, London, UK
- NIHR Biomedical Research Centre at Guy's & St Thomas’ NHS Foundation Trust and King's College London, London, UK
| | - Charles D A Wolfe
- Division of Health and Social Care Research, King's College London, London, UK
- NIHR Biomedical Research Centre at Guy's & St Thomas’ NHS Foundation Trust and King's College London, London, UK
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26
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Sorinola I, Fleming M, Robert-Lewis S, Wolfe C, Wellwood I, Newham D. Effect of combined somatosensory stimulation and task specific training on upper limb function in chronic stroke: a randomised controlled trial. Physiotherapy 2015. [DOI: 10.1016/j.physio.2015.03.1379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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27
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Punnoose A, Norrish A, Wellwood I, Pak K. The effectiveness of shockwave therapy on achilles and patellar tendinopathy: a systematic review and meta-analysis. Physiotherapy 2015. [DOI: 10.1016/j.physio.2015.03.1139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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28
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Otal B, Olma MC, Flöel A, Wellwood I. Inhibitory non-invasive brain stimulation to homologous language regions as an adjunct to speech and language therapy in post-stroke aphasia: a meta-analysis. Front Hum Neurosci 2015; 9:236. [PMID: 25972805 PMCID: PMC4412051 DOI: 10.3389/fnhum.2015.00236] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 04/13/2015] [Indexed: 11/22/2022] Open
Abstract
Chronic communication impairment is common after stroke, and conventional speech and language therapy (SLT) strategies have limited effectiveness in post-stroke aphasia. Neurorehabilitation with non-invasive brain stimulation techniques (NIBS)—particularly repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS)—may enhance the effects of SLT in selected patients. Applying inhibitory NIBS to specific homologous language regions may induce neural reorganization and reduce interhemispheric competition. This mini review highlights randomized controlled trials (RCTs) and randomized cross-over trials using low-frequency rTMS or cathodal tDCS over the non-lesioned non-language dominant hemisphere and performs an exploratory meta-analysis of those trials considered combinable. Using a random-effects model, a meta-analysis of nine eligible trials involving 215 participants showed a significant mean effect size of 0.51 (95% CI = 0.24–0.79) for the main outcome “accuracy of naming” in language assessment. No heterogeneity was observed (I2 = 0%). More multicenter RCTs with larger populations and homogenous intervention protocols are required to confirm these and the longer-term effects.
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Affiliation(s)
- Begonya Otal
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Germany
| | - Manuel C Olma
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Germany
| | - Agnes Flöel
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Germany ; Department of Neurology, NeuroCure Clinical Research Center, Charité University Medicine Berlin, Germany
| | - Ian Wellwood
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Germany
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29
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Fleming MK, Sorinola IO, Roberts-Lewis SF, Wolfe CD, Wellwood I, Newham DJ. The Effect of Combined Somatosensory Stimulation and Task-Specific Training on Upper Limb Function in Chronic Stroke. Neurorehabil Neural Repair 2014; 29:143-52. [DOI: 10.1177/1545968314533613] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. Somatosensory stimulation (SS) is a potential adjuvant to stroke rehabilitation, but the effect on function needs further investigation. Objective. To explore the effect of combining SS with task-specific training (TST) on upper limb function and arm use in chronic stroke survivors and determine underlying mechanisms. Methods. In this double-blinded randomized controlled trial (ISRCTN 05542931), 33 patients (mean 37.7 months poststroke) were block randomized to 2 groups: active or sham SS. They received 12 sessions of 2 hours of SS (active or sham) to all 3 upper limb nerves immediately before 30 minutes of TST. The primary outcome was the Action Research Arm Test (ARAT) score. Secondary outcomes were time to perform the ARAT, Fugl-Meyer Assessment score (FM), Motor Activity Log (MAL), and Goal Attainment Scale (GAS). Underlying mechanisms were explored using transcranial magnetic stimulation stimulus–response curves and intracortical inhibition. Outcomes were assessed at baseline, immediately following the intervention (mean 2 days), and 3 and 6 months (mean 96 and 190 days) after the intervention. Results. The active group (n = 16) demonstrated greater improvement in ARAT score and time immediately postintervention (between-group difference; P < .05), but not at 3- or 6-month follow-ups ( P > .2). Within-group improvements were seen for both groups for ARAT and GAS, but for the active group only for FM and MAL ( P < .05). Corticospinal excitability did not change. Conclusions. Long-lasting improvements in upper limb function were observed following TST. Additional benefit of SS was seen immediately post treatment, but did not persist and the underlying mechanisms remain unclear.
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Affiliation(s)
| | | | - Sarah F. Roberts-Lewis
- School of Biomedical Sciences, King’s College London, London, UK
- School of Medicine, King’s College London, London, UK
| | - Charles D. Wolfe
- School of Medicine, King’s College London, London, UK
- National Institute for Health Research Comprehensive Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, UK
| | - Ian Wellwood
- School of Medicine, King’s College London, London, UK
- National Institute for Health Research Comprehensive Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, UK
| | - Di J. Newham
- School of Biomedical Sciences, King’s College London, London, UK
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30
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Del Giudice A, D'Amico D, Sobesky J, Wellwood I. Accuracy of the spot sign on computed tomography angiography as a predictor of haematoma enlargement after acute spontaneous intracerebral haemorrhage: a systematic review. Cerebrovasc Dis 2014; 37:268-76. [PMID: 24777174 DOI: 10.1159/000360754] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 02/18/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND A common early complication of intracerebral haemorrhage (ICH) is haematoma enlargement (HE), a strong independent predictor of a poor outcome. Therapeutic options to limit haematoma progression are currently scarce. Haemostatic therapy may be effective in patients with ICH, but it carries the risk of thromboembolic events in unselected patients. Accurate patient selection would, therefore, be of key importance for delivering potentially successful therapeutic strategies. Currently, there is no gold standard to accurately predict HE. The presence of contrast extravasation within the haematoma on computed tomography angiography (CTA), the 'spot sign', has been reported in several studies and seems a particularly promising marker but lacks a standardised evaluation so far. SUMMARY We conducted a systematic review of published data to address the research question: In adults with acute spontaneous ICH, how accurately does the spot sign predict HE on follow-up imaging and thus poor functional outcome or mortality? We searched PubMed and Embase databases (from 1980 to May 2012), using a highly sensitive search strategy and including all studies involving adult patients with spontaneous ICH evaluated with CTA and follow-up CT scans, reporting any measure of clinical outcome, and reporting or allowing calculation of accuracy measures of the spot sign in predicting HE and clinical outcome. Baseline characteristics, accuracy measures and effect measures, as well as bias assessment, were reported according to PRISMA recommendations. The quality of the studies was appraised using an adapted version of the REMARK reporting recommendations. From 259 potentially relevant studies, we finally selected 6 studies (1 of them was a multicentre cohort study) covering a total of 709 patients. Studies varied substantially in terms of size, methodological quality, definitions of terms, outcomes selected and results. In particular, definition of the spot sign was not consistent in all studies. Furthermore, the only outcome measure consistently available was HE, while definitions and analyses of clinical outcomes seemed not adequate. Lastly, the choice of candidate variables for univariate and multivariate analyses did not include all determinants of HE and poor functional outcome. High heterogeneity was demonstrated (I(2): 94% for HE) with substantial potential of bias. KEY MESSAGES Studies of the spot sign are diverse and therefore complex to interpret. Our research question could not be answered due to heterogeneity and potential of bias in the selected studies. Further appropriately powered studies using standardised definitions and taking all predictors of HE and poor clinical outcome into account are required for a proper clinical implementation.
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Affiliation(s)
- Angela Del Giudice
- Centre for Stroke Research Berlin, Charité-Universitaetsmedizin, Berlin, Germany
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31
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Flöel A, Werner C, Grittner U, Hesse S, Jöbges M, Knauss J, Seifert M, Steinhagen-Thiessen E, Gövercin M, Dohle C, Fischer W, Schlieder R, Nave AH, Meisel A, Ebinger M, Wellwood I. Physical fitness training in Subacute Stroke (PHYS-STROKE)--study protocol for a randomised controlled trial. Trials 2014; 15:45. [PMID: 24491065 PMCID: PMC3922602 DOI: 10.1186/1745-6215-15-45] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 01/21/2014] [Indexed: 12/02/2022] Open
Abstract
Background Given the rising number of strokes worldwide, and the large number of individuals left with disabilities after stroke, novel strategies to reduce disability, increase functions in the motor and the cognitive domains, and improve quality of life are of major importance. Physical activity is a promising intervention to address these challenges but, as yet, there is no study demonstrating definite outcomes. Our objective is to assess whether additional treatment in the form of physical fitness-based training for patients early after stroke will provide benefits in terms of functional outcomes, in particular gait speed and the Barthel Index (co-primary outcome measures) reflecting activities of daily living (ADL). We will gather secondary functional outcomes as well as mechanistic parameters in an exploratory approach. Methods/Design Our phase III randomised controlled trial will recruit 215 adults with moderate to severe limitations of walking and ADL 5 to 45 days after stroke onset. Participants will be stratified for the prognostic variables of “centre”, “age”, and “stroke severity”, and randomly assigned to one of two groups. The interventional group receives physical fitness training delivered as supported or unsupported treadmill training (cardiovascular active aerobic training; five times per week, over 4 weeks; each session 50 minutes; total of 20 additional physical fitness training sessions) in addition to standard rehabilitation treatment. The control intervention consists of relaxation sessions (non-cardiovascular active; five times per week week, over 4 weeks; each session 50 minutes) in addition to standard rehabilitation treatment. Co-primary efficacy endpoints will be gait speed (in m/s, 10 m walk) and the Barthel Index (100 points total) at 3 months post-stroke, compared to baseline measurements. Secondary outcomes include standard measures of quality of life, sleep and mood, cognition, arm function, maximal oxygen uptake, and cardiovascular risk factors including blood pressure, pulse, waist-to-hip ratio, markers of inflammation, immunity and the insulin-glucose pathway, lipid profile, and others. Discussion The goal of this endpoint-blinded, phase III randomised controlled trial is to provide evidence to guide post-stroke physical fitness-based rehabilitation programmes, and to elucidate the mechanisms underlying this intervention. Trial registration Registered in ClinicalTrials.gov with the Identifier NCT01953549.
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Affiliation(s)
- Agnes Flöel
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.
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32
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Bokhari FAS, Wellwood I, Rudd AG, Langhorne P, Dennis MS, Wolfe CDA. Selective admission into stroke unit and patient outcomes: a tale of four cities. Health Econ Rev 2014; 4:1. [PMID: 24405520 PMCID: PMC3892120 DOI: 10.1186/2191-1991-4-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 12/17/2013] [Indexed: 06/03/2023]
Abstract
: Care of stroke patients costs considerably more in specialized stroke units (SU) compared to care in general medical wards (GMW) but the technology may be cost effective if it leads to significantly improved outcomes. While randomized control trials show better outcomes for stroke patients admitted to SU, observational studies report mixed findings. In this paper we use individual level data from first-ever stroke patients in four European cities and find evidence of selection by the initial severity of stroke into SU in some cities. In these cases, the impact of admission to SU on outcomes is overestimated by multivariate logit models even after controlling for case-mix. However, when the imbalance in patient characteristics and severity of stroke by admission to SU and GMW is adjusted using propensity score methods, the differences in outcomes are no longer statistically significant in most cases. Our analysis explains why earlier studies using observational data have found mixed results on the benefits of admission to SU.
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Affiliation(s)
- Farasat AS Bokhari
- School of Economics and ESRC Centre for Competition Policy, University of East Anglia, Norwich, UK
| | - Ian Wellwood
- Department of Primary Care and Public Health Sciences, Division of Health and Social Care Research, King’s College London, London, UK and NIHR Biomedical Research Centre, Guy’s & St Thomas’ NHS Foundation Trust, King’s College London, London, UK
| | - Anthony G Rudd
- Department of Primary Care and Public Health Sciences, Division of Health and Social Care Research, King’s College London, London, UK and NIHR Biomedical Research Centre, Guy’s & St Thomas’ NHS Foundation Trust, King’s College London, London, UK
| | - Peter Langhorne
- Academic Section of Geriatric Medicine, University of Glasgow, Glasgow, UK
| | - Martin S Dennis
- Division of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - Charles DA Wolfe
- Department of Primary Care and Public Health Sciences, Division of Health and Social Care Research, King’s College London, London, UK and NIHR Biomedical Research Centre, Guy’s & St Thomas’ NHS Foundation Trust, King’s College London, London, UK
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33
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Grube MM, Koennecke HC, Walter G, Meisel A, Sobesky J, Nolte CH, Wellwood I, Heuschmann PU. Influence of acute complications on outcome 3 months after ischemic stroke. PLoS One 2013; 8:e75719. [PMID: 24086621 PMCID: PMC3782455 DOI: 10.1371/journal.pone.0075719] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 08/16/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Early medical complications are potentially modifiable factors influencing in-hospital outcome. We investigated the influence of acute complications on mortality and poor outcome 3 months after ischemic stroke. METHODS Data were obtained from patients admitted to one of 13 stroke units of the Berlin Stroke Registry (BSR) who participated in a 3-months-follow up between June 2010 and September 2012. We examined the influence of the cumulative number of early in-hospital complications on mortality and poor outcome (death, disability or institutionalization) 3 months after stroke using multivariable logistic regression analyses and calculated attributable fractions to determine the impact of early complications on mortality and poor outcome. RESULTS A total of 2349 ischemic stroke patients alive at discharge from acute care were included in the analysis. Older age, stroke severity, pre-stroke dependency and early complications were independent predictors of mortality 3 months after stroke. Poor outcome was independently associated with older age, stroke severity, pre-stroke dependency, previous stroke and early complications. More than 60% of deaths and poor outcomes were attributed to age, pre-stroke dependency and stroke severity and in-hospital complications contributed to 12.3% of deaths and 9.1% of poor outcomes 3 months after stroke. CONCLUSION The majority of deaths and poor outcomes after stroke were attributed to non-modifiable factors. However, early in-hospital complications significantly affect outcome in patients who survived the acute phase after stroke, underlining the need to improve prevention and treatment of complications in hospital.
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Affiliation(s)
- Maike Miriam Grube
- Center for Stroke Research Berlin (CSB), Klinik für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Division of Health and Social Care Research, King’s College London, London, United Kingdom
- * E-mail:
| | | | | | - Andreas Meisel
- Center for Stroke Research Berlin (CSB), Klinik für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Sobesky
- Center for Stroke Research Berlin (CSB), Klinik für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Hans Nolte
- Center for Stroke Research Berlin (CSB), Klinik für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ian Wellwood
- Center for Stroke Research Berlin (CSB), Klinik für Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Ulrich Heuschmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Center for Clinical Studies, University Hospital Würzburg, Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
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Ayis SA, Coker B, Bhalla A, Wellwood I, Rudd AG, Di Carlo A, Bejot Y, Ryglewicz D, Rastenyte D, Langhorne P, Dennis MS, McKevitt C, Wolfe CDA. Variations in acute stroke care and the impact of organised care on survival from a European perspective: the European Registers of Stroke (EROS) investigators. J Neurol Neurosurg Psychiatry 2013; 84:604-12. [PMID: 23385847 DOI: 10.1136/jnnp-2012-303525] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND The need for stroke care is escalating with an ageing population, yet methods to estimate the delivery of effective care across countries are not standardised or robust. Associations between quality and intensity of care and stroke outcomes are often assumed but have not been clearly demonstrated. OBJECTIVE To examine variations in acute care processes across six European populations and investigate associations between the delivery of care and survival. METHODS Data were obtained from population-based stroke registers of six centres in France, Lithuania, UK, Spain, Poland and Italy between 2004 and 2006 with follow-up for 1 year. Variations in the delivery of care (stroke unit, multidisciplinary team and acute drug treatments) were analysed adjusting for case mix and sociodemographic factors using logistic regression methods. Unadjusted and adjusted survival probabilities were estimated and stratified by levels of Organised Care Index. RESULTS Of 1918 patients with a first-ever stroke registered, 30.7% spent more than 50% of their hospital stay in a stroke unit (13.9-65.4%) among centres with a stroke unit available. The percentage of patients assessed by a stroke physician varied between 7.1% and 96.6%. There were significant variations after adjustment for confounders, in the organisation of care across populations. Significantly higher probabilities of survival (p<0.01) were associated with increased organisational care. CONCLUSIONS This European study demonstrated associations between delivery of care and stroke outcomes. The implementation of evidence-based interventions is suboptimal and understanding better ways to implement these interventions in different healthcare settings should be a priority for health systems.
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Affiliation(s)
- Salma Ahmed Ayis
- Division of Health and Social Care Research, Department of Primary Care and Public Health Sciences, King's College London, 5th floor, Capital House, 42 Weston Street, London SE1 3QD, UK.
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Abstract
BACKGROUND Dysphagia is common after stroke, leading to adverse outcome. There is a paucity of high-quality evidence for dysphagia therapy, thus making it difficult to determine the best approaches to treatment. Clinical decisions are often based on usual practice, however no formal method of monitoring practice patterns exists. AIMS To determine speech and language therapists' (SLTs) approaches to direct dysphagia therapy with stroke patients in the UK and Ireland. METHODS & PROCEDURES A 24-item questionnaire was developed, piloted and delivered in a web-based cross-sectional survey targeting all SLTs working with stroke patients in the UK and Ireland. OUTCOMES & RESULTS A total of 138 SLTs responded from a range of clinical settings and levels of experience. There was variation in the responses to all questions. Respondents reported treating patients a median of once a day, 3 days a week for 15 min. The most commonly recommended direct exercises were supervised swallow trials (recommended 'frequently or always' by 73%). Despite most respondents having access to an instrumental swallowing assessment, over half reported rarely or never conducting one before recommending exercises. Most (93%) did not use a protocol for systematically progressing patients' exercises and only 37% reported using standardized outcome measures. CONCLUSIONS & IMPLICATIONS This survey gives valuable insight into the direct dysphagia therapy practices of SLTs based in the UK and Ireland working in stroke. It highlights discrepancies between reported approaches and recommendations from existing evidence and clinical guidelines. The variation in responses indicates a need to develop a consensus statement and further research to guide practice.
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Affiliation(s)
- S K Archer
- Centre of Human and Aerospace Physiological Sciences, King's College London, London, UK.
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Grube MM, Koennecke HC, Walter G, Thümmler J, Meisel A, Wellwood I, Heuschmann PU. Association Between Socioeconomic Status and Functional Impairment 3 Months After Ischemic Stroke. Stroke 2012; 43:3325-30. [DOI: 10.1161/strokeaha.112.669580] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Maike Miriam Grube
- From the Center for Stroke Research Berlin (CSB), Charité–Universitätsmedizin Berlin, Berlin, Germany (M.M.G., J.T., A.M., I.W., P.U.H.); Vivantes Klinikum im Friedrichshain, Berlin, Germany (H. C.K.); Vivantes Klinikum Spandau, Berlin, Germany (G.W.); Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany (P.U.H.); Center for Clinical Studies, University Hospital Würzburg, Würzburg, Germany (P.U.H.); and Comprehensive Heart Failure Center, University of Würzburg,
| | - Hans-Christian Koennecke
- From the Center for Stroke Research Berlin (CSB), Charité–Universitätsmedizin Berlin, Berlin, Germany (M.M.G., J.T., A.M., I.W., P.U.H.); Vivantes Klinikum im Friedrichshain, Berlin, Germany (H. C.K.); Vivantes Klinikum Spandau, Berlin, Germany (G.W.); Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany (P.U.H.); Center for Clinical Studies, University Hospital Würzburg, Würzburg, Germany (P.U.H.); and Comprehensive Heart Failure Center, University of Würzburg,
| | - Georg Walter
- From the Center for Stroke Research Berlin (CSB), Charité–Universitätsmedizin Berlin, Berlin, Germany (M.M.G., J.T., A.M., I.W., P.U.H.); Vivantes Klinikum im Friedrichshain, Berlin, Germany (H. C.K.); Vivantes Klinikum Spandau, Berlin, Germany (G.W.); Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany (P.U.H.); Center for Clinical Studies, University Hospital Würzburg, Würzburg, Germany (P.U.H.); and Comprehensive Heart Failure Center, University of Würzburg,
| | - Jane Thümmler
- From the Center for Stroke Research Berlin (CSB), Charité–Universitätsmedizin Berlin, Berlin, Germany (M.M.G., J.T., A.M., I.W., P.U.H.); Vivantes Klinikum im Friedrichshain, Berlin, Germany (H. C.K.); Vivantes Klinikum Spandau, Berlin, Germany (G.W.); Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany (P.U.H.); Center for Clinical Studies, University Hospital Würzburg, Würzburg, Germany (P.U.H.); and Comprehensive Heart Failure Center, University of Würzburg,
| | - Andreas Meisel
- From the Center for Stroke Research Berlin (CSB), Charité–Universitätsmedizin Berlin, Berlin, Germany (M.M.G., J.T., A.M., I.W., P.U.H.); Vivantes Klinikum im Friedrichshain, Berlin, Germany (H. C.K.); Vivantes Klinikum Spandau, Berlin, Germany (G.W.); Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany (P.U.H.); Center for Clinical Studies, University Hospital Würzburg, Würzburg, Germany (P.U.H.); and Comprehensive Heart Failure Center, University of Würzburg,
| | - Ian Wellwood
- From the Center for Stroke Research Berlin (CSB), Charité–Universitätsmedizin Berlin, Berlin, Germany (M.M.G., J.T., A.M., I.W., P.U.H.); Vivantes Klinikum im Friedrichshain, Berlin, Germany (H. C.K.); Vivantes Klinikum Spandau, Berlin, Germany (G.W.); Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany (P.U.H.); Center for Clinical Studies, University Hospital Würzburg, Würzburg, Germany (P.U.H.); and Comprehensive Heart Failure Center, University of Würzburg,
| | - Peter Ulrich Heuschmann
- From the Center for Stroke Research Berlin (CSB), Charité–Universitätsmedizin Berlin, Berlin, Germany (M.M.G., J.T., A.M., I.W., P.U.H.); Vivantes Klinikum im Friedrichshain, Berlin, Germany (H. C.K.); Vivantes Klinikum Spandau, Berlin, Germany (G.W.); Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany (P.U.H.); Center for Clinical Studies, University Hospital Würzburg, Würzburg, Germany (P.U.H.); and Comprehensive Heart Failure Center, University of Würzburg,
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Liman TG, Zietemann V, Wiedmann S, Jungehuelsing GJ, Endres M, Wollenweber FA, Wellwood I, Dichgans M, Heuschmann PU. Prediction of vascular risk after stroke - protocol and pilot data of the Prospective Cohort with Incident Stroke (PROSCIS). Int J Stroke 2012; 8:484-90. [PMID: 22928669 DOI: 10.1111/j.1747-4949.2012.00871.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
RATIONALE Long-term risk of vascular disease is substantially increased after stroke with several models proposed to predict subsequent stroke and other vascular events after an index event. However, recent validation studies demonstrate limited predictive properties of available prognostic models. AIMS We aim to determine prediction models of different complexity for the combined vascular end-point of stroke, myocardial infarction, and vascular death at three-years after first-ever stroke. An independent external validation of the developed models will be performed. DESIGN Prospective observational hospital-based cohort study of patients after first-ever stroke. METHODS The new predictive models will be developed using the following steps: (1) Development of a basic score based on clinical history data (e.g. hypertension, myocardial infarction, and atrial fibrillation); (2) Development of an advanced score including additional factors such as blood-based biomarkers and results of vascular imaging; (3) Comparing the models fit using different methods (discrimination, calibration); (4) Assessment of clinical utility of an advanced score using methods based on reclassification tables (e.g. net reclassification improvement, integrated discrimination improvement, decision curve analysis); and (5) Investigation of external validity. OUTCOMES Primary outcome is a combined vascular end-point composed of stroke, myocardial infarction, and vascular death at three-years after stroke. Furthermore, each component of the composite end-point will be investigated individually and the patterns and time points of risk transitions between vascular end-points and stroke sub-types will be determined.
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Affiliation(s)
- Thomas G Liman
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.
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Liman TG, Neeb L, Rosinski J, Wellwood I, Reuter U, Doehner W, Heuschmann PU, Endres M. Peripheral endothelial function and arterial stiffness in women with migraine with aura: a case-control study. Cephalalgia 2012; 32:459-66. [PMID: 22523187 DOI: 10.1177/0333102412444014] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Vascular dysfunction may be involved in migraine pathophysiology and contribute to the increased risk of ischemic stroke in migraine, particularly in women with migraine with aura (MA). However, data on endothelial function in MA are controversial. Here, we investigated whether systemic endothelial function and arterial stiffness are altered in women with MA, using a novel peripheral arterial tonometry device for the first time. METHODS Twenty-nine female MA patients without comorbidities and 30 healthy women were included, and carotid intima-media thickness was assessed by a standardized procedure. Endothelial function was assessed using peripheral arterial tonometry. Reactive hyperaemic response of digital pulse amplitude was measured following 5 minutes of forearm occlusion of the brachial artery. Arterial stiffness was assessed by fingertip tonometry derived and heart-rate-adjusted augmentation index. RESULTS No differences were found in peripheral arterial tonometry ratio (2.3 ± 0.6 vs 2.2 ± 0.8; p = 0.58) and left carotid intima-media thickness (in µm: 484 ± 119 vs 508 ± 60; p = 0.37). Women with MA had higher heart-rate-averaged augmentation index [median (interquartile range, IQR) of 5 (IQR 0.5 to 18) vs -5 (IQR -16.8 to 8.3), p = 0.005] and heart-rate-adjusted augmentation index [1 (IQR -6 to 12.5) vs -8 (IQR -20.3 to 2.5), p = 0.008] than healthy controls. CONCLUSION Peripheral endothelial function is not impaired in women with MA, but they have greater arterial stiffness. This may contribute to the increased stroke risk in women with MA.
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Affiliation(s)
- T G Liman
- Charité-Universitätsmedizin Berlin, Germany.
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Krebes S, Ebinger M, Baumann AM, Kellner PA, Rozanski M, Doepp F, Sobesky J, Gensecke T, Leidel BA, Malzahn U, Wellwood I, Heuschmann PU, Audebert HJ. Development and validation of a dispatcher identification algorithm for stroke emergencies. Stroke 2012; 43:776-81. [PMID: 22223240 DOI: 10.1161/strokeaha.111.634980] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Recent innovations such as CT installation in ambulances may lead to earlier start of stroke-specific treatments. However, such technically complex mobile facilities require effective methods of correctly identifying patients before deployment. We aimed to develop and validate a new dispatcher identification algorithm for stroke emergencies. METHODS Dispatcher identification algorithm for stroke emergencies was informed by systematic qualitative analysis of the content of emergency calls to ambulance dispatchers for patients with stroke or transient ischemic attack (N=117) and other neurological (N=39) and nonneurological (N=51) diseases (Part A). After training of dispatchers, sensitivity and predictive values were determined prospectively in patients admitted to Charité hospitals by using the discharge diagnosis as reference standard (Part B). RESULTS Part A: Dysphasic/dysarthric symptoms (33%), unilateral symptoms (22%) and explicitly stated suspicion of stroke (47%) were typically identified in patients with stroke but infrequently in nonstroke cases (all <10%). Convulsive symptoms (41%) were frequent in other neurological diseases but not strokes (3%). Pain (26%) and breathlessness (31%) were often expressed in nonneurological emergencies (6% and 7% in strokes). Part B: Between October 15 and December 16, 2010, 5774 patients were admitted by ambulance with 246 coded with final stroke diagnoses. Sensitivity of dispatcher identification algorithm for stroke emergencies for detecting stroke was 53.3% and positive predictive value was 47.8% for stroke and 59.1% for stroke and transient ischemic attack. Of all 275 patients with stroke dispatcher codes, 215 (78.5%) were confirmed with neurological diagnosis. CONCLUSIONS Using dispatcher identification algorithm for stroke emergencies, more than half of all patients with stroke admitted by ambulance were correctly identified by dispatchers. Most false-positive stroke codes had other neurological diagnoses.
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Affiliation(s)
- Sebastian Krebes
- Center for Stroke Research, Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12200 Berlin, Germany
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Wellwood I, Wu O, Langhorne P, McKevitt C, Di Carlo A, Rudd AG, Wolfe CDA. Developing a tool to assess quality of stroke care across European populations: the EROS Quality Assessment Tool. Stroke 2011; 42:1207-11. [PMID: 21474805 DOI: 10.1161/strokeaha.110.598938] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE There are significant differences in the provision of care and outcome after stroke across countries. The European Registers of Stroke study aimed to develop, test, and refine a tool to assess quality of care. METHODS We used a systematic review and grading of evidence for stroke care across the clinical pathway and developed and field-tested a quality tool that was delivered by post and later by site visit at 7 centers. Items were refined by using an algorithm that took into account the level of evidence, measurement properties, and consensus of opinion obtained using, the Delphi techniques. RESULTS The tool included 251 items across 11 domains, of which 214 items could be categorized by any level of evidence. Overall agreement between postal and site visit modes of delivery was acceptable (κ=0.77), with most items having a κ>0.5. The refinement process resulted in 2 practical versions of the tool (93 items and 22 items). Positive responses to items in the tool indicated implementation of evidence-based stroke care. In field testing, the proportion of positive responses to evidence-based items ranged from 43% to 79% across populations. Proportions of different types of evidence being implemented were similar: high quality 62%, limited quality 72%, and expert opinion 54% across the populations. More than half (4 of 7) of the centers provided stroke unit care and thrombolysis, but availability and access to inpatient rehabilitation varied significantly, with poor access to community follow-up for rehabilitation and medical management. CONCLUSIONS The European Registers of Stroke Quality Assessment Tool has potential to be used as a framework to compare services and promote increased implementation of evidence-based care.
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Affiliation(s)
- Ian Wellwood
- Division of Health and Social Care Research, King's College London, King's College Hospital NHS Foundation Trust, Guy's Campus, 7th Floor, Capital House, 42 Weston St, London SE1 3QD, UK.
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Heuschmann PU, Wiedmann S, Wellwood I, Rudd A, Di Carlo A, Bejot Y, Ryglewicz D, Rastenyte D, Wolfe CDA. Three-month stroke outcome: the European Registers of Stroke (EROS) investigators. Neurology 2010; 76:159-65. [PMID: 21148118 DOI: 10.1212/wnl.0b013e318206ca1e] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Contemporaneous data on variations in outcome after first-ever-lifetime stroke between European populations are lacking. We compared differences in case fatality rates, functional outcome, and living conditions 3 months after stroke within the European Registers of Stroke Collaboration. METHODS Population-based stroke registers were established in France (Dijon), Italy (Sesto Fiorentino), Lithuania (Kaunas), the United Kingdom (London), Spain (Menorca), and Poland (Warsaw). All patients with first-ever-lifetime stroke of all age groups from the source population (1,087,048 inhabitants) were included. Data collection took part between 2004 and 2006. The study investigated population variations in outcome at 3 months (death, institutionalization due to stroke, or Barthel Index below 12 points) using multivariable logistic regression analyses adjusted for age, sex, stroke severity, stroke subtype, and comorbidities. RESULTS A total of 2,034 patients with first-ever-lifetime stroke were included. Median age was 73 years, 52% were female. The mean weighted cumulative risk of death was 21.8% (95% confidence interval 20.0 to 23.6) with a 3-fold variation across populations. The weighted proportion of poor outcome was 41.3% (95% confidence interval 39.0 to 43.7) with a 2-fold variation across populations. CONCLUSION More than 40% of patients had a poor outcome, defined as being dead, dependent, or institutionalized 3 months after stroke. Substantial outcome variations were found between populations that were explained by case mix variables in this analysis, yet a trend toward a higher risk of poor outcome was present in Kaunas.
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Affiliation(s)
- P U Heuschmann
- Center for Stroke Research Berlin (CSB), Charité–Universitätsmedizin Berlin, Berlin, Germany
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Di Carlo A, Lamassa M, Wellwood I, Bovis F, Baldereschi M, Nencini P, Poggesi A, Cramaro A, Pescini F, Lucente G, Wolfe CDA, Inzitari D. Stroke unit care in clinical practice: an observational study in the Florence center of the European Registers of Stroke (EROS) Project. Eur J Neurol 2010; 18:686-94. [PMID: 20840380 DOI: 10.1111/j.1468-1331.2010.03207.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Randomized trials and meta-analyses indicate positive effects of stroke unit (SU) care on survival and dependency of patients with stroke. However, data on the advantages of SU in 'real-world' settings are limited. We prospectively assessed, in a large University Hospital, the effect of SU versus other conventional wards (OCW) care on all-cause mortality, death or dependency, death or institutionalization. METHODS In a prospective observational study in the European Registers of Stroke Project, patients hospitalized for first-in-a-lifetime stroke were evaluated for demographics, risk factors, clinical presentation, resource use, 3-month and 1-year survival, and functional outcome. RESULTS Overall, 355 patients (54.1% men, mean age 73.4 ± 14.5 years) were registered, 140 (39.4%) admitted to the SU, and 215 (60.6%) to OCW. OCW patients were older, whilst SU patients had more severe strokes according to NIHSS (P for trend = 0.025). SU patients were significantly more often treated by specialists in stroke medicine, stroke nurses, physiotherapists and speech therapists (all P < 0.001), psychologists (P = 0.025), dietitians (P < 0.001), and social workers (P = 0.003). MRI, carotid, and transcranial Doppler were significantly more often performed in SU patients (all P < 0.001). Intravenous fluids (P = 0.003) and intravenous anticoagulation (P < 0.001) were more often prescribed in SU. Controlling for case-mix, SU significantly reduced 1-year mortality (P = 0.020), death or dependency at 3 months (P = 0.006) and 1 year (P = 0.043), and death or institutionalization at 3 months (P = 0.001) and 1 year (P = 0.009). CONCLUSIONS We confirmed the benefits of SU care in a clinical setting. Further analyses should define the contribution of individual components of care to stroke outcome.
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Affiliation(s)
- A Di Carlo
- Institute of Neurosciences, Italian National Research Council Department of Neurological and Psychiatric Sciences, University of Florence, Florence, Italy.
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Wellwood I, Langhorne P, McKevitt C, Bernhardt J, Rudd A, Wolfe C. An Observational Study of Acute Stroke Care in Four Countries: The European Registers of Stroke Study. Cerebrovasc Dis 2009; 28:171-6. [DOI: 10.1159/000226116] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2008] [Accepted: 04/16/2009] [Indexed: 11/19/2022] Open
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Dixon SM, Wellwood I. Walking aids for reducing walking impairment and disability after stroke. Hippokratia 2005. [DOI: 10.1002/14651858.cd004297.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Kwakkel G, van Peppen R, Wagenaar RC, Wood Dauphinee S, Richards C, Ashburn A, Miller K, Lincoln N, Partridge C, Wellwood I, Langhorne P. Effects of augmented exercise therapy time after stroke: a meta-analysis. Stroke 2004; 35:2529-39. [PMID: 15472114 DOI: 10.1161/01.str.0000143153.76460.7d] [Citation(s) in RCA: 648] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE To present a systematic review of studies that addresses the effects of intensity of augmented exercise therapy time (AETT) on activities of daily living (ADL), walking, and dexterity in patients with stroke. SUMMARY OF REVIEW A database of articles published from 1966 to November 2003 was compiled from MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, PEDro, DARE, and PiCarta using combinations of the following key words: stroke, cerebrovascular disorders, physical therapy, physiotherapy, occupational therapy, exercise therapy, rehabilitation, intensity, dose-response relationship, effectiveness, and randomized controlled trial. References presented in relevant publications were examined as well as abstracts in proceedings. Studies that satisfied the following selection criteria were included: (1) patients had a diagnosis of stroke; (2) effects of intensity of exercise training were investigated; and (3) design of the study was a randomized controlled trial (RCT). For each outcome measure, the estimated effect size (ES) and the summary effect size (SES) expressed in standard deviation units (SDU) were calculated for ADL, walking speed, and dexterity using fixed and random effect models. Correlation coefficients were calculated between observed individual effect sizes on ADL of each study, additional time spent on exercise training, and methodological quality. Cumulative meta-analyses (random effects model) adjusted for the difference in treatment intensity in each study was used for the trials evaluating the effects of AETT provided. Twenty of the 31 candidate studies, involving 2686 stroke patients, were included in the synthesis. The methodological quality ranged from 2 to 10 out of the maximum score of 14 points. The meta-analysis resulted in a small but statistically significant SES with regard to ADL measured at the end of the intervention phase. Further analysis showed a significant homogeneous SES for 17 studies that investigated effects of increased exercise intensity within the first 6 months after stroke. No significant SES was observed for the 3 studies conducted in the chronic phase. Cumulative meta-analysis strongly suggests that at least a 16-hour difference in treatment time between experimental and control groups provided in the first 6 months after stroke is needed to obtain significant differences in ADL. A significant SES supporting a higher intensity was also observed for instrumental ADL and walking speed, whereas no significant SES was found for dexterity. CONCLUSIONS The results of the present research synthesis support the hypothesis that augmented exercise therapy has a small but favorable effect on ADL, particularly if therapy input is augmented at least 16 hours within the first 6 months after stroke. This meta-analysis also suggests that clinically relevant treatment effects may be achieved on instrumental ADL and gait speed.
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Affiliation(s)
- Gert Kwakkel
- Department of Physical Therapy and Research Institute for Fundamental and Clinical Human Movement Sciences, VU University Medical Center, Amsterdam, The Netherlands.
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47
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Dixon SM, Wellwood I. Walking aids for reducing walking impairment and disability after stroke. Hippokratia 2002. [DOI: 10.1002/14651858.cd004297.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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48
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Egerton T, Maxwell D, Granat M, Wellwood I, Langhorne P, McAlpine C, McDonald J. Measurement of Upright Activity of Patients in Stroke Units. Physiotherapy 2002. [DOI: 10.1016/s0031-9406(05)60564-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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49
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Bishop-Miller J, Wellwood I, Mearns N, Lewis S, Colledge N. Assessing the Value of Falls Risk Factor Checklists in a Geriatric Assessment Unit. Age Ageing 1997. [DOI: 10.1093/ageing/26.suppl_3.p4-b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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50
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Dennis M, Wellwood I, O'Rourke S, MacHale S, Warlow C. How Reliable Are Simple Questions in Assessing Outcome after Stroke? Cerebrovasc Dis 1997. [DOI: 10.1159/000108158] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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