Development of a measure of functioning for stroke recovery: The functional recovery measure

PURPOSE

To develop a parsimonious measure of functioning for persons after stroke.

METHOD

A sub-set of 206 community-dwelling subjects with a first stroke from a larger cohort was interviewed within 9 months using 39 items from five indices assessing functioning. Information was collected on influencing variables: age, stroke type and severity, and previous health. Two statistical methods, factor analysis and Rasch analysis, confirmed the item structure, hierarchy and dimensionality of the measure. Statistics confirmed fit to the model; internal consistency was also assessed. Items were deleted iteratively based on fit and relationship to the construct.

RESULTS

The subjects were predominately male (63%) aged on average 68-years-old. A 12-item unidimensional functioning measure was developed. All items and persons fit the Rasch model with stable item-person reliability indices of 0.98 and 0.91, respectively. Item precision (standard errors) ranged from 0.14-0.37 logits. Gaps in measurement occurred at the extremes of the measure and there was a small ceiling effect.

CONCLUSIONS

A 12-item measure captured the concept of functioning that could be used as a prototype to quantify recovery post-stroke. These items could form the basis for a measure of functioning.

Fecundity of Cryptosporidium parvum is correlated with intracellular levels of the viral symbiont CPV

Differences in the virulence and fecundity of Cryptosporidium parvum isolates have been observed by several researchers studying cryptosporidiosis. The purpose of the present study was to determine if there was a correlation between intracellular levels of the viral symbiont CPV in C. parvum and fecundity of two isolates of the parasite, namely C. parvum Beltsville (B) and C. parvum Iowa (I). Dairy calves infected with 10(6)C. parvum-B excreted 5-fold more oocysts compared with calves infected with the same number of C. parvum-I oocysts. The increased fecundity of the former strain was corroborated by semi-quantitative PCR assay of DNA isolated from cell cultures infected with either C. parvum-B or C. parvum-I. Quantitative reverse transcriptase-PCR analysis of viral RNA revealed a 3-fold greater number of CPV in C. parvum-B compared with C. parvum-I oocysts. These findings may indicate a role for CPV in fecundity and possibly virulence of C. parvum.

Audit of antenatal clinic for high-risk obstetric patients; activity and outcomes

A specialised clinic for the antenatal care of high-risk patients was established in Cork in January 2004. It is led by 2 specialists in materno-fetal medicine and provides care for patients from a large catchment area. Small clinic numbers, specialised midwives, ready access to medical experts and fetal assessment facilities, facilitate an efficient use of resources. We report on the experience and utcomes of this clinic after the first year in operation. A database was set up to store relevant information on patients who attended the clinic in 2004. 143 patients attended. Risk categories included maternal medical disease (62%); multiple pregnancy (11%); previous poor obstetric history (10%); fetal anomaly (8%). Average gestation; 35.9 weeks, average birth weight; 2598g. Caesarean section rate; 41%/o. Perinatal mortality rate 67 per 1000 (uncorrected); and 20% neonates required NICU care. This approach to high-risk obstetric care resulted in favourable outcomes. The management strategy applied in Cork may be a suitable prototype for comparable areas throughout Ireland.

Image-guided lung radiotherapy: Bringing technology into routine clinical practice

18093

Background: Cone-beam CT (CBCT), an imaging system integrated into the RT treatment unit, produces 3D images far superior to the conventional 2D portal images used for verification of patient (pt) set-up. This allows direct matching to the RT treatment planning CT images, potentially increasing the precision of RT delivery. We report on the broad implementation of this new RT image-guided paradigm in lung cancer patients at our center. Methods: All lung cancer pts undergoing radical RT were planned using 4DCT and imaged daily for repositioning with CBCT since 04/06. Initially, CBCT datasets were compared with the planning CT to assess the setup error (bone surrogate), using two immobilisation methods: evacuated bags (EB) and chest-board (ChB). Discrepancies >3 mm between the two datasets, in any direction, were corrected before the start of each RT fraction. Data were retrospectively analyzed to assess the initial and residual discrepancies (43 pts; 1,128 CBCTs).Alternative matching strategies were also tested (carina & tumor) using both manual and automatic methods (30 pts). Protocols had REB approval. Results: In total, 657 (58%) RT treatments required adjustment after initial positioning on the treatment couch. The two immobilization methods were equivalent (p=0.18); the mean pt shift required for ChB pts was 55±18mm and for EB pts was 69±32mm. Given that residual uncertainties were <3 mm, margin calculations reveal that large reductions (54–79%) may be possible for tumors not influenced by respiratory motion. The performance of automatic matching was reasonable for carina (correlation [r] 0.8–0.84) and bone (r 0.58–0.81) but discrepancies were seen for tumor (r 0.63–0.69). Conclusions: Daily CBCT provides greatly increased accuracy of set-up, to within 3 mm of the planned bony anatomy, which may improve tumor control by confirming geographic accuracy. The role of image-guided RT in reducing the volume of irradiated normal tissue may play an important role in addressing toxicity concerns associated with combined modality treatment and facilitate safe RT dose escalation. In addition to increasing RT precision, daily CBCT allows routine visualisation of the tumor as well as to bony anatomy, presenting an exciting opportunity to adapt the treatment plan based on an individual response.

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Appraisal, assessment and career development for doctors in training: the Mersey Deanery personal development portfolio

OBJECTIVES

To develop a robust valid and exportable appraisal and assessment process for doctors in training which is portfolio based and works at all hospitals within the deanery. It is called the personal development portfolio.

DESIGN

For every senior house officer, there was a recorded meeting with his or her supervisor, at the beginning, midterm and at the end of the post. An outside assessor witnessed the exit assessment meeting.

SETTING

The Wirral Hospital, a District General Hospital with 72 senior house officers in 10 different specialties was used as a pilot site to develop the process. Then the process was exported and implemented at the other 12 trusts of the deanery.

MAIN OUTCOME MEASURES

Records were kept of the induction, midterm and exit assessment meetings. A record was kept of the number of senior house officers succeeding and failing at their exit assessments. Also, the number promoted to the specialist registrar grade was recorded.

RESULTS

The process was performed every 6 months on 11 occasions between 2000 and 2005. It involved 72 senior house officers in 10 different specialties. On each occasion, participation usually exceeded 70%: 623 were appraised and assessed and 609 of them (97.8%) had satisfactory exit assessments. For 14 doctors (2.2%), the process identified a cause for concern, which was usually accepted by the doctor and sometimes allowed remedial action to be taken. Twenty-six (4.2%) were promoted to the specialist registrar grade in this period. The process also identified the strengths and weaknesses of the senior house officer posts in the 10 different specialties that had such posts, and was used to encourage good medical teaching practice in them. Over 4 years, we exported the process to all the other 12 Trusts in the Mersey Deanery. Once established, the process was easy to use for both trainees and trainers, although it was time consuming.

CONCLUSIONS

It was possible to develop and implement a portfolio based appraisal and assessment process, which was accepted by senior house officers and their trainers in all specialties at all hospitals within the deanery. Now that the senior house officer grade has been superseded by the Foundation and the training grade years, the principles of the personal development portfolio are being used to appraise and assess doctors in these grades too.

Appraisal, Assessment and Career Development for Doctors in Training: The Mersey Deanery Personal Development Portfolio

Objectives

To develop a robust valid and exportable appraisal and assessment process for doctors in training which is portfolio based and works at all hospitals within the deanery. It is called the personal development portfolio.

Design

For every senior house officer, there was a recorded meeting with his or her supervisor, at the beginning, midterm and at the end of the post. An outside assessor witnessed the exit assessment meeting.

Setting

The Wirral Hospital, a District General Hospital with 72 senior house officers in 10 different specialties was used as a pilot site to develop the process. Then the process was exported and implemented at the other 12 trusts of the deanery.

Main outcome measures

Records were kept of the induction, midterm and exit assessment meetings. A record was kept of the number of senior house officers succeeding and failing at their exit assessments. Also, the number promoted to the specialist registrar grade was recorded.

Results

The process was performed every 6 months on 11 occasions between 2000 and 2005. It involved 72 senior house officers in 10 different specialties. On each occasion, participation usually exceeded 70%: 623 were appraised and assessed and 609 of them (97.8%) had satisfactory exit assessments. For 14 doctors (2.2%), the process identified a cause for concern, which was usually accepted by the doctor and sometimes allowed remedial action to be taken. Twenty-six (4.2%) were promoted to the specialist registrar grade in this period. The process also identified the strengths and weaknesses of the senior house officer posts in the 10 different specialties that had such posts, and was used to encourage good medical teaching practice in them. Over 4 years, we exported the process to all the other 12 Trusts in the Mersey Deanery. Once established, the process was easy to use for both trainees and trainers, although it was time consuming.

Conclusions

It was possible to develop and implement a portfolio based appraisal and assessment process, which was accepted by senior house officers and their trainers in all specialties at all hospitals within the deanery. Now that the senior house officer grade has been superceded by the Foundation and the training grade years, the principles of the personal development portfolio are being used to appraise and assess doctors in these grades too.

Upper-limb function and recovery in the acute phase poststroke

This study evaluates stroke patients with upper-limb (UL) motor deficits using measures of impairment and "activity limitation" to quantify recovery of UL function poststroke and to identify predictors of UL function and predictors of UL recovery following stroke. The study also compares the recovery of UL function with that of the lower limb (LL). Measures of impairment and "activity limitation" of the UL and LL improved over the first 5 weeks. The Box and Block Test performance improved the most over 5 weeks (standardized response mean [SRM] = 1.34), followed closely by the 5-meter walk test (SRM = 0.97). Performances on measures of UL "activity limitation" measured at 1 week poststroke were the most important predictors of UL function 5 weeks poststroke. The results of this study do not support the belief that recovery of LL function is faster than that of UL.

Safety of telephone consultation for "non-serious" emergency ambulance service patients

OBJECTIVE

To assess the safety of nurses and paramedics offering telephone assessment, triage, and advice as an alternative to immediate ambulance dispatch for emergency ambulance service callers classified by lay call takers as presenting with "non-serious" problems (category C calls).

DESIGN

Data for this study were collected as part of a pragmatic randomised controlled trial reported elsewhere. The intervention arm of the trial comprised nurse or paramedic telephone consultation using a computerised decision support system to assess, triage, and advise patients whose calls to the emergency ambulance service had been classified as "non-serious" by call takers applying standard priority dispatch criteria. A multidisciplinary expert clinical panel reviewed data from ambulance service, accident and emergency department, hospital inpatient and general practice records, and call transcripts for patients triaged by nurses and paramedics into categories that indicated that dispatch of an emergency ambulance was unnecessary. All cases for which one or more members of the panel rated that an emergency ambulance should have been dispatched were re-reviewed by the entire panel for an assessment of the "life risk" that might have resulted.

SETTING

Ambulance services in London and the West Midlands, UK.

STUDY POPULATION

Of 635 category C patients assessed by nurses and paramedics, 330 (52%) cases that had been triaged as not requiring an emergency ambulance were identified.

MAIN OUTCOME MEASURES

Assessment of safety of triage decisions.

RESULTS

Sufficient data were available from the routine clinical records of 239 (72%) subjects to allow review by the specialist panel. For 231 (96.7%) sets of case notes reviewed, the majority of the panel concurred with the nurses' or paramedics' triage decision. Following secondary review of the records of the remaining eight patients, only two were rated by the majority as having required an emergency ambulance within 14 minutes. For neither of these did a majority of the panel consider that the patient would have been at "life risk" without an emergency ambulance being immediately dispatched. However, the transcripts of these two calls indicated that the correct triage decision had been communicated to the patient, which suggests that the triage decision had been incorrectly entered into the decision support system.

CONCLUSIONS

Telephone advice may be a safe method of managing many category C callers to 999 ambulance services. A clinical trial of the full implementation of this intervention is needed, large enough to exclude the possibility of rare adverse events.

Safety of telephone consultation for "non-serious" emergency ambulance service patients

OBJECTIVE

To assess the safety of nurses and paramedics offering telephone assessment, triage, and advice as an alternative to immediate ambulance dispatch for emergency ambulance service callers classified by lay call takers as presenting with "non-serious" problems (category C calls).

DESIGN

Data for this study were collected as part of a pragmatic randomised controlled trial reported elsewhere. The intervention arm of the trial comprised nurse or paramedic telephone consultation using a computerised decision support system to assess, triage, and advise patients whose calls to the emergency ambulance service had been classified as "non-serious" by call takers applying standard priority dispatch criteria. A multidisciplinary expert clinical panel reviewed data from ambulance service, accident and emergency department, hospital inpatient and general practice records, and call transcripts for patients triaged by nurses and paramedics into categories that indicated that dispatch of an emergency ambulance was unnecessary. All cases for which one or more members of the panel rated that an emergency ambulance should have been dispatched were re-reviewed by the entire panel for an assessment of the "life risk" that might have resulted.

SETTING

Ambulance services in London and the West Midlands, UK.

STUDY POPULATION

Of 635 category C patients assessed by nurses and paramedics, 330 (52%) cases that had been triaged as not requiring an emergency ambulance were identified.

MAIN OUTCOME MEASURES

Assessment of safety of triage decisions.

RESULTS

Sufficient data were available from the routine clinical records of 239 (72%) subjects to allow review by the specialist panel. For 231 (96.7%) sets of case notes reviewed, the majority of the panel concurred with the nurses' or paramedics' triage decision. Following secondary review of the records of the remaining eight patients, only two were rated by the majority as having required an emergency ambulance within 14 minutes. For neither of these did a majority of the panel consider that the patient would have been at "life risk" without an emergency ambulance being immediately dispatched. However, the transcripts of these two calls indicated that the correct triage decision had been communicated to the patient, which suggests that the triage decision had been incorrectly entered into the decision support system.

CONCLUSIONS

Telephone advice may be a safe method of managing many category C callers to 999 ambulance services. A clinical trial of the full implementation of this intervention is needed, large enough to exclude the possibility of rare adverse events.

Incorporating the International Classification of Functioning, Disability, and Health (ICF) into an electronic health record to create indicators of function: proof of concept using the SF-12

OBJECTIVE

The purpose of this proof-of-concept study was to assess the feasibility of using a generic health measure to create coded functional status indicators and compare the characterization of a stroke population using coded functional indicators and using health-related quality-of-life summary measures alone.

DESIGN

Multiple raters assigned International Classification of Functioning, Disability, and Health (ICF) codes to the items of the 12-Item Short Form Health Survey (SF-12). Data for comparing the information from the SF-12 and from ICF codes were derived from the Montreal Stroke Cohort Study that was set up to examine the long-term impact of stroke. Available for analysis were data from 604 persons with stroke, average age 69 years, and 488 controls, average age 62 years.

MEASUREMENT

The SF-12 provides two summary scores, one for physical health and one for mental health. Domains of the ICF are coded to three digits, before the decimal; specific categorizations of impairments, activity limitations, and participation restrictions are coded to four digits before the decimal.

RESULTS

Persons with stroke scored, on average, approximately 10 points lower than controls on physical and mental health. The ICF coding indicated that this was attributed, not surprisingly, to greater difficulty in doing moderate activities including housework, climbing stairs, and working and was not attributed to differences in pain. Differences in mental health were attributed most strongly to greater fatigue (impairment in energy), but all areas of mental health were affected to some degree.

CONCLUSION

The ICF coding provided enhanced functional status information in a format compatible with the structure of administrative health databases.

High temperature ferromagnetism with a giant magnetic moment in transparent co-doped SnO(2-delta)

The occurrence of room temperature ferromagnetism is demonstrated in pulsed laser deposited thin films of Sn(1-x)Co(x)O(2-delta) (x<0.3). Interestingly, films of Sn(0.95)Co(0.05)O(2-delta) grown on R-plane sapphire not only exhibit ferromagnetism with a Curie temperature close to 650 K, but also a giant magnetic moment of 7.5+/-0.5 micro(B)/Co, not yet reported in any diluted magnetic semiconductor system. The films are semiconducting and optically highly transparent.

The Stroke Rehabilitation Assessment of Movement (STREAM): A Comparison With Other Measures Used to Evaluate Effects of Stroke and Rehabilitation

Background and Purpose. The Stroke Rehabilitation Assessment of Movement (STREAM) is a relatively new measure of voluntary movement and basic mobility. The main objectives of this study were: (1) to examine the relationship of the STREAM to other measures of impairment and disability and (2) to compare its usefulness for evaluating effects of stroke and rehabilitation and for assessing change over time with that of other measures of impairment and disability. Subjects and Methods. The performance of 63 patients with acute stroke on the STREAM and other measures of impairment and disability was evaluated during the first week after stroke and 4 weeks and 3 months later. Results. Scores on the STREAM were associated with scores on the Box and Block test, Balance Scale, Barthel Index, gait speed, and the Timed “Up & Go” Test (with Pearson correlation coefficients ranging from .57 to .80) and were associated with categories of the Barthel Index and Balance Scale. The STREAM's ability to predict discharge destination from the acute care hospital, as well as to predict gait speed and Barthel Index scores at 3 months poststroke, was comparable to that of other commonly used measures. Standardized response mean estimates provided supporting evidence for the ability of the STREAM to reflect change over time. Discussion and Conclusion. The results obtained with the STREAM, as compared with other measures of impairment and disability in people with stroke, suggest that it may be useful in clinical practice and research.

Computer assisted assessment and advice for "non-serious" 999 ambulance service callers: the potential impact on ambulance despatch

OBJECTIVE

To investigate the potential impact for ambulance services of telephone assessment and triage for callers who present with non-serious problems (Category C calls) as classified by ambulance service call takers.

DESIGN

Pragmatic controlled trial. Calls identified using priority dispatch protocols as non-serious were allocated to intervention and control groups according to time of call. Ambulance dispatch occurred according to existing procedures. During intervention sessions, nurses or paramedics within the control room used a computerised decision support system to provide telephone assessment, triage and, if appropriate, offer advice to permit estimation of the potential impact on ambulance dispatch.

SETTING

Ambulance services in London and the West Midlands.

SUBJECTS

Patients for whom emergency calls were made to the ambulance services between April 1998 and May 1999 during four hour sessions sampled across all days of the week between 0700 and 2300.

MAIN OUTCOME MEASURES

Triage decision, ambulance cancellation, attendance at an emergency department.

RESULTS

In total, there were 635 intervention calls and 611 controls. Of those in the intervention group, 330 (52.0%) were triaged as not requiring an emergency ambulance, and 119 (36.6%) of these did not attend an emergency department. This compares with 55 (18.1%) of those triaged by a nurse or paramedic as requiring an ambulance (odds ratio 2.62; 95% CI 1.78 to 3.85). Patients triaged as not requiring an emergency ambulance were less likely to be admitted to an inpatient bed (odds ratio 0.55; 95% CI 0.33 to 0.93), but even so 30 (9.2%) were admitted. Nurses were more likely than paramedics to triage calls into the groups classified as not requiring an ambulance. After controlling for age, case mix, time of day, day of week, season, and ambulance service, the results of a logistic regression analysis revealed that this difference was significant with an odds ratio for nurses:paramedics of 1.28 (95% CI 1.12 to 1.47).

CONCLUSIONS

The findings indicate that telephone assessment of Category C calls identifies patients who are less likely to require emergency department care and that this could have a significant impact on emergency ambulance dispatch rates. Nurses were more likely than paramedics to assess calls as requiring an alternative response to emergency ambulance despatch, but the extent to which this relates to aspects of training and professional perspective is unclear. However, consideration should be given to the acceptability, reliability, and cost consequences of this intervention before it can be recommended for full evaluation.

Use of emergency observation and assessment wards: a systematic literature review

INTRODUCTION

Observation and assessment wards allow patients to be observed on a short-term basis and permit patient monitoring and/or treatment for an initial 24-48 hour period. They should permit concentration of emergency activity and resources in one area, and so improve efficiency and minimise disruption to other hospital services. These types of ward go under a variety of names, including observation, assessment, and admission wards. This review aims to evaluate the current literature and discuss assessment/admission ward functionality in terms of organisation, admission criteria, special patient care, and cost effectiveness.

METHODS

Search of the literature using the Medline and BIDS databases, combined with searches of web based resources. Critical assessment of the literature and the data therein is presented.

RESULTS

The advantages and disadvantages of the use of assessment/admission wards were assessed from the current literature. Most articles suggest that these wards improve patient satisfaction, are safe, decrease the length of stay, provide earlier senior involvement, reduce unnecessary admissions, and may be particularly useful in certain diagnostic groups. A number of studies summarise their organisational structure and have shown that strong management, staffing, organisation, size, and location are important factors for efficient running. There is wide variation in the recommended size of these wards. Observation wards may produce cost savings largely relating to the length of stay in such a unit.

CONCLUSION

All types of assessment/admission wards seem to have advantages over traditional admission to a general hospital ward. A successful ward needs proactive management and organisation, senior staff involvement, and access to diagnostics and is dependent on a clear set of policies in terms of admission and care. Many diagnostic groups benefit from this type of unit, excluding those who will inevitably need longer admission. Vigorous financial studies have yet to be undertaken in the UK. Definitions of observation, assessment, and admission ward are suggested.

Comparison of tests for viable and infectious Cryptosporidium parvum oocysts

The purpose of this study was to compare different assays for viable Cryptosporidium parvum incubated in water at a temperature commonly found in the environment. C. parvum oocysts were stored in sterile water for 9 months at 15 degrees C. A sample was removed monthly and analyzed by five different assays to determine oocyst viability. Mouse infection and cell culture showed that C. parvum oocysts remained viable and infectious when stored for 7 months at this temperature. Fluorescence in situ hybridization (FISH) using probes directed to ribosomal RNA was also applied to these oocysts. The proportion of FISH-positive oocysts was 70-80% for the first 2 months of storage, decreased and remained nearly constant at 40-50% for 3-7 months, then decreased to 20% by 8 months, and to 0% by 9 months. Amylopectin content and mRNA for amyloglucosidase (CPAG), as measured by RT-PCR, decreased much more rapidly. By 3 months and for the remainder of the incubation period, amylopectin content was 20% of the original amount present in the oocysts. The CPAG RT-PCR signal at 3 months was 50% of that observed after 1 month storage, 20% at 4 months, and was not detected thereafter. Thus, results from cell culture and mouse infection assay exhibited the best agreement, the FISH assay showed modest agreement with these assays, and CPAG RT-PCR and the amylopectin assay displayed marginal agreement with the other three assays.

Survey of users and providers of recycled water: quality concerns and directions for applied research

Users and providers of recycled water in Queensland, Australia, were canvassed to ascertain concerns about recycled water quality and directions for applied research. Some 79% of respondents had concerns about recycled water quality including microbiological components, such as viruses, parasites and bacteria, salinity related components, aggregate components, such as pH and solids, nutrients, organic components, including pesticides and endocrine disruptors, as well as quality variability. Relative differences in the proportion of concern for some quality characteristics were observed between the areas of different population density with those from the low population areas being more concerned than those from medium or high areas. Some users and providers observed changes in recycled water quality during distribution including nutrients, chlorine, solids, colour and odour. Some 52% of providers and 19% of current users propose to expand their usage and 30% of non-users propose to commence doing so in the next 5 years. Recycled water quality characteristics identified for applied research included microbiological components, organic components, nutrients and salinity.

Microbicides--evaluating multiple formulations of C31G

Despite a significant worldwide need for effective microbicides to reduce sexually transmitted diseases (STD) and HIV transmission, none is currently available. C31G, a surface active anti-infective agent that is active in vitro against bacterial and viral STD pathogens, was evaluated in a 3-day, once-daily dosing clinical trial designed to assess multiple formulations for safety and acceptance. The trial used a scoring algorithm that was based on relevant subject reported symptoms and signs observed at follow-up. Differences in tolerance and acceptability between the formulations were demonstrated, as was consistency with the results from a previous 7-day trial that involved two of the formulations (1.2% HEC gel, 2.0% N-9). The 1.0% C31G co-polymer gel was the best tolerated, most acceptable formulation, and will be advanced to longer, more comprehensive trials. Thus, formulation differences are relevant to microbicide tolerance and acceptability, and the 3-day trial design validated in this study can be used to assess formulations.