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Elameer M, Lumley H, Moore SA, Marshall K, Alton A, Smith FE, Gani A, Blamire A, Rodgers H, Price CIM, Mitra D. A prospective study of MRI biomarkers in the brain and lower limb muscles for prediction of lower limb motor recovery following stroke. Front Neurol 2023; 14:1229681. [PMID: 37941576 PMCID: PMC10628497 DOI: 10.3389/fneur.2023.1229681] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 09/26/2023] [Indexed: 11/10/2023] Open
Abstract
The aim of this prospective observational longitudinal study was to explore and decipher the predictive value of prospective MRI biomarkers in the brain and lower limb muscles for 3-month lower limb motor recovery following stroke. In the brain, we measured the integrity of the corticospinal tract (fractional anisotropy/"FA"). In the muscles, we measured volume, fatty replacement (fat fraction analysis and proton spectroscopy) and oedema. Measurements were taken at two time points: (1) within 4 weeks of stroke (baseline measurement, clinical and imaging) and (2) 3 months following stroke (follow up measurement, clinical only). Clinical measurements consisted of assessments of functional ability and strength (Fugl-Meyer score, motor NIHSS, Functional Ambulation Category/"FAC", and muscle dynamometry). Twenty-three patients completed imaging and clinical assessments at baseline and follow-up; five patients had partial imaging assessment. The results provided some evidence that damage to the corticospinal tract would result in less motor recovery: recovery of the Fugl-Meyer score and dynamometric ankle plantarflexion, ankle dorsiflexion, and knee extension correlated positively and significantly with fractional anisotropy (0.406-0.457; p = 0.034-p = 0.016). However, fractional anisotropy demonstrated a negative correlation with recovery of the Functional Ambulation Category (-0.359, p = 0.046). For the muscle imaging, significant inverse correlation was observed between vastus lateralis fat fraction vs. NIHSS recovery (-0.401, p = 0.04), and a strong positive correlation was observed between ratio of intra- to extra-myocellular lipid concentrations and the recovery of knee flexion (0.709, p = 0.007). This study supports previous literature indicating a positive correlation between the integrity of the corticospinal tract and motor recovery post-stroke, expanding the limited available literature describing this relationship specifically for the lower limb. However, recovery of functional ambulation behaved differently to other clinical recovery markers by demonstrating an inverse relationship with corticospinal tract integrity. The study also introduces some muscle imaging biomarkers as potentially valuable in the prediction of 3-month lower limb motor recovery following stroke.
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Affiliation(s)
- Mat Elameer
- Department of Neuroradiology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
- Stroke Research Group, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Hannah Lumley
- Stroke Research Group, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Sarah A. Moore
- Stroke Research Group, Newcastle University, Newcastle upon Tyne, United Kingdom
- Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle upon Tyne, United Kingdom
| | - Katie Marshall
- Department of Medical Physics, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Abi Alton
- Stroke Research Group, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Fiona E. Smith
- Department of Neuroscience, Manchester Metropolitan University, Manchester, United Kingdom
| | - Akif Gani
- Department of Stroke Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Andrew Blamire
- Newcastle Magnetic Resonance Centre, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Helen Rodgers
- Stroke Research Group, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Dipayan Mitra
- Department of Neuroradiology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
- Stroke Research Group, Newcastle University, Newcastle upon Tyne, United Kingdom
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Shaw L, McCue P, Brown P, Buckley C, Del Din S, Francis R, Hunter H, Lambert A, Lord S, Price CIM, Rodgers H, Rochester L, Moore SA. Auditory rhythmical cueing to improve gait in community-dwelling stroke survivors (ACTIVATE): a pilot randomised controlled trial. Pilot Feasibility Stud 2022; 8:239. [PMID: 36371213 PMCID: PMC9652598 DOI: 10.1186/s40814-022-01193-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 10/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Gait impairment limiting mobility and restricting activities is common after stroke. Auditory rhythmical cueing (ARC) uses a metronome beat delivered during exercise to train stepping and early work reports gait improvements. This study aimed to establish the feasibility of a full scale multicentre randomised controlled trial to evaluate an ARC gait and balance training programme for use by stroke survivors in the home and outdoors. Methods A parallel-group observer-blind pilot randomised controlled trial was conducted. Adults within 2 years of stroke with a gait-related mobility impairment were recruited from four NHS stroke services and randomised to an ARC gait and balance training programme (intervention) or the training programme without ARC (control). Both programmes consisted of 3x30 min sessions per week for 6 weeks undertaken at home/nearby outdoor community. One session per week was supervised and the remainder self-managed. Gait and balance performance assessments were undertaken at baseline, 6 and 10 weeks. Key trial outcomes included recruitment and retention rates, programme adherence, assessment data completeness and safety. Results Between November 2018 and February 2020, 59 participants were randomised (intervention n=30, control n=29), mean recruitment rate 4/month. At baseline, 6 weeks and 10 weeks, research assessments were conducted for 59/59 (100%), 47/59 (80%) and 42/59 (71%) participants, respectively. Missing assessments were largely due to discontinuation of data collection from mid-March 2020 because of the UK COVID-19 pandemic lockdown. The proportion of participants with complete data for each individual performance assessment ranged from 100% at baseline to 68% at 10 weeks. In the intervention group, 433/540 (80%) total programme exercise sessions were undertaken, in the control group, 390/522 (75%). Falls were reported by five participants in the intervention group, six in the control group. Three serious adverse events occurred, all unrelated to the study. Conclusion We believe that a definitive multicentre RCT to evaluate the ARC gait and balance training programme is feasible. Recruitment, programme adherence and safety were all acceptable. Although we consider that the retention rate and assessment data completeness were not sufficient for a future trial, this was largely due to the UK COVID-19 pandemic lockdown. Trial registration ISRCTN, ISRCTN10874601, Registered on 05/03/2018, Supplementary Information The online version contains supplementary material available at 10.1186/s40814-022-01193-y.
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Pisani L, Algera AG, Neto AS, Azevedo L, Pham T, Paulus F, de Abreu MG, Pelosi P, Dondorp AM, Bellani G, Laffey JG, Schultz MJ, Martinez A, Leal L, Jorge Pereira A, de Oliveira Maia M, Neto JA, Piras C, Caser EB, Moreira CL, Braga Gusman P, Dalcomune DM, Ribeiro de Carvalho AG, Gondim LAR, Castelo Branco Reis LM, da Cunha Ribeiro D, de Assis Simões L, Campos RS, Fernandez Versiani dos Anjos JC, Bruzzi Carvalho F, Alves RA, Nunes LB, Réa-Neto Á, de Oliveira MC, Tannous L, Cardoso Gomes B, Rodriguez FB, Abelha P, Lugarinho ME, Japiassu A, de Melo HK, Lopes EA, Varaschin P, de Souza Dantas VC, Freitas Knibel M, Ponte M, de Azambuja Rodrigues PM, Costa Filho RC, Saddy F, Wanderley Castellões TF, Silva SA, Osorio LAG, Mannarino D, Espinoza R, Righy C, Soares M, Salluh J, Tanaka L, Aragão D, Tavares ME, Kehdi MGP, Rezende VMC, Carbonell RCC, Teixeira C, de Oliveira RP, Maccari JG, Castro PS, Berto P, Schwarz P, Torelly AP, Lisboa T, Moraes E, Dal-Pizzol F, Tomasi Damiani C, Ritter C, Ferreira JC, Teixeira Costa R, Caruso P, Amendola CP, de Oliveira AMRR, Silva UVA, Sanches LC, Almeida RDS, Azevedo LC, Park M, Schettino G, Assunção MS, Silva E, Barboza CE, Junior APN, Marzocchi Tierno PFGM, Malbouisson LM, Oliveira L, Cristovao D, Neto ML, Rego Ê, Fernandes FE, Romano MLP, Cavalcanti AB, de Souza Barros D, Rodgers H, Dixon B, Smith R, Kol M, Wong H, Schmid W, Hermans G, Ceunen H, Bourgeois M, Anquez N, Suzumura ÉA, Decruyenaere J, DeCrop L, Neto AS, Souza dos Santos R, Beraldo D, dos Santos MC, Pellegrini JAS, Piras C, Oliveira V, Munhoz C, Meira KL, Peçanha AC, da Silva Ramos FJ, Maia I, Bahl M, Biondi R, Prado D, Pinto SF, Salgado J, Falcão LF, Macruz T, de Oliveira GA, Cavalcanti AB, Romano MLP, Ruas K, Mecatti GC, Caser EB, Gava IA, Carreño N, Morales M, Avendaño R, Aguirre S, Luciano PM, Sribar A, Klaric V, Skilijic S, Dvorscak MB, Krkusek M, Jurjevic M, Karanovic N, Simurina T, Stourac P, Kratochvil M, Pacheco ED, Máca J, Wrigge H, Schlegel C, Treschan TA, Schaefer M, Aytulun A, Kienbaum P, Clarkson K, Jaafar R, Collins D, Mazza BF, Plant R, Melchionda G, Di Lauro E, Cortegiani A, Russotto V, Caione R, Mestria D, Volta CA, Spadaro S, Botteri M, Machado FR, Seghelini E, Brazzi L, Sales G, D'Antini D, Molin A, Severgnini P, Bacuzzi A, Peluso L, Verrastro P, Raimondo P, Ferreira E, Gecaj-Gashi A, Simonis FD, Tuinman PR, Alberts E, van den Hul I, Kuiper M, de Wilde RBP, Koopmans M, Kose I, Zincircioglu Ç, dos Santos RB, Dogan N, Aydin D, Denker AS, Buyukkocak U, Akgun N, Turan G, Senturk E, Demirtürk Z, Özcan PE, Ekinci O, Colombo AS, Saylan S, Eren G, Ulger F, Dilek A, Ulusoy H, Goktas U, Soyoral L, Toman H, Orak Y, Kahveci F, Nogueira AC, Mills GH, Pinder A, Walker R, Harrison J, Snell J, Seasman C, Pearson R, Sharman M, Kaloo C, Bynorth N, Fernandes JB, Matthews K, Hughes C, Rose A, Simeson K, Niska L, Huneke N, Adderly J, Padilla-Harris C, Oliver R, Brohi F, Nóbrega RS, Wilson N, Talbot H, Wilson D, Smith D, Dark P, Evans T, Fisher N, Montgomery J, Fitzell P, Muench C, do CS Martins B, Hugill K, Cirstea E, Bentley A, Lynch K, White I, Cooper J, Brazier M, Devile M, Parris M, Gill P, Soriano F, Patel T, Criswell J, Trodd D, Griffin D, Martin J, Wreybrown C, Bewley J, Sweet K, Grimmer L, Kozlowski M, Morsch RD, James S, Limb J, Cowton A, Rogerson D, Downes C, Melbourne S, Humphries R, Pulletz M, Moreton S, Janes S, Nunes ALB, Corner A, Linnett V, Ritzema J, Watters M, Windebank S, Chenna S, Howard-Griffin R, Turner K, Suresh S, Blaylock H, de Almeida JP, Bell S, Blenk K, Everett L, Hopkins P, Mellis C, Hadfield D, Harris C, Chan A, Birch S, Pegg C, Hajjar L, Plowright C, Cooper L, Hatton T, McCullagh I, Wright S, Scott C, Boyd C, Holliday M, Poultney U, Crowther H, Moulin S, Thornthwaite S, Hollister N, Hunt J, Skinner A, Matsa R, Salt R, Matthews C, Reschreiter H, Camsooksai J, Venner N, Giannini FP, Barcraft-Barnes H, Tbaily L, Pogson D, Mouland J, Rose S, Lamb N, Tarmey N, Knighton J, Giles J, Weller D, Baptiston Nunes AL, Reed I, Hormis A, Pearson S, Harris M, Howe J, Paddle J, Burt K, Welters I, Walker A, Youds L, Rios F, Hendry S, Shaw D, Williams K, Hollands R, Carnahan M, Stickley J, Miller C, Donaldson D, Tonks L, Creagh-Brown B, Van Haren F, Hull D, Boyd O, Ortiz-Ruiz L, Gopal S, Metherell S, Spencer H, Frey C, Brown C, Clifford G, Leaver S, Sottiaux T, Ryan C, Mellinghoff JM, Prudden SP, Green HG, Roy AR, Furneval JF, Bell AB, Lakhani SL, Fasting LF, Murray LM, Lora FS, Preller K, McInerney A, Beavis S, Whileman A, Toms J, Glenn S, Ramali M, Ghosh A, Bullock C, Barrell L, Azevedo LC, Young E, Robertson H, Faulkner M, MacNaughton P, Tyson S, Pulak P, Sewell TA, Smalley C, Jacob R, Santos C, Depuydt P, Alzugaray P, Vidal Melo MF, Joyce K, Needleman J, Ahsan A, Faiz A, Alam AKMS, Khatoon SN, Nath RK, Rahman Chowdhury MA, Fan E, Banik D, Mondol MK, Bhuiyan SR, Nazneed S, Sultana R, Hamid T, Hossain M, Reza ST, Asaduzzaman M, Salim M, Bugedo G, Mostafa Kamal AH, Taher SM, Taohid TM, Karmaker P, Roy S, Das S, Sarkar SA, Dutta ML, Roy P, Iyer S, Qiu H, Krishna B, Sampath S, Pattnaik R, Kasi CK, Shah J, Dongre A, Reza Hashemian SM, Nooraei N, Raessi Estabragh R, Malekmohammad M, Gonzalez M, Khoundabi B, Mobasher M, Mohd Yunos N, Kassim M, Voon CM, Das SS, Azauddin SNS, Dorasamy D, Tai LL, Mat Nor MB, Silesky J, Zarudin N, Hasan MS, Jamaluddin MFH, Othman Jailani MI, Kayashta G, Adhikari A, Pangeni R, Hashmi M, Joseph S, Akhtar A, Cerny V, Qadeer A, Memon I, Ali SM, Idrees F, Kamal S, Hanif S, Rehman AU, Taqi A, Hussain T, Farooq A, Nielsen J, Khaskheli S, Hayat M, Indraratna K, Beane A, Haniffa R, Samaranayake U, Mathanalagan S, Gunaratne A, Mithraratne N, Thilakasiri K, Jibaja M, Pilimatalawwe C, Dilhani YAH, Fernando M, Ranatunge K, Samarasinghe L, Vaas M, Edirisooriya M, Sigera C, Arumoli J, De Silva K, Pham T, Kudavidanage B, Pinto V, Dissanayake L, Chittawatanarat K, Kongpolprom N, Silachamroon U, Pornsuriyasak P, Petnak T, Singhatas P, Tangsujaritvijit V, Wrigge H, Rungruanghiranya S, Piriyapatsom A, Juntaping K, Trongtrakul K, Thungtitigul P, Tajarernmuang P, Chatmongkolchart S, Bhurayanontachai R, Akaraborworn O, Navasakulpong A, Matamis D, Surasit K, Thwaites L, Nadjm B, Vu Quoc D, Nguyen Thi Thanh H, Nguyen Van K, Duong Bich T, Lam Minh Y, Ranero JL, Hashemian SM, Amin P, Clarkson K, Bellani G, Kurahashi K, Villagomez A, Zeggwagh AA, Heunks LM, Laake JH, Palo JE, do Vale Fernandes A, Sandesc D, Arabi Y, Bumbasierevic V, Lorente JA, Larsson A, Piquilloud L, Abroug F, McAuley DF, McNamee L, Hurtado J, Bajwa E, Démpaire G, Francois GM, Sula H, Nunci L, Cani A, Zazu A, Dellera C, Insaurralde CS, Alejandro RV, Daldin J, Vinzio M, Fernandez RO, Cardonnet LP, Bettini LR, Bisso MC, Osman EM, Setten MG, Lovazzano P, Alvarez J, Villar V, Milstein C, Pozo NC, Grubissich N, Plotnikow GA, Vasquez DN, Ilutovich S, Tiribelli N, Chena A, Pellegrini CA, Saenz MG, Estenssoro E, Brizuela M, Gianinetto H, Gomez PE, Cerrato VI, Bezzi MG, Borello SA, Loiacono FA, Fernandez AM, Knowles S, Reynolds C, Inskip DM, Miller JJ, Kong J, Whitehead C, Bihari S, Seven A, Krstevski A, Rodgers HJ, Millar RT, Mckenna TE, Bailey IM, Hanlon GC, Aneman A, Lynch JM, Azad R, Neal J, Woods PW, Roberts BL, Kol MR, Wong HS, Riss KC, Staudinger T, Wittebole X, Berghe C, Bulpa PA, Dive AM, Verstraete R, Lebbinck H, Depuydt P, Vermassen J, Meersseman P, Ceunen H, Rosa JI, Beraldo DO, Piras C, Ampinelli AMR, Nassar Jr AP, Mataloun S, Moock M, Thompson MM, Gonçalves CH, Antônio ACP, Ascoli A, Biondi RS, Fontenele DC, Nobrega D, Sales VM, Shindhe S, Ismail DMABPH, Laffey J, Beloncle F, Davies KG, Cirone R, Manoharan V, Ismail M, Goligher EC, Jassal M, Nishikawa E, Javeed A, Curley G, Rittayamai N, Parotto M, Ferguson ND, Mehta S, Knoll J, Pronovost A, Canestrini S, Bruhn AR, Garcia PH, Aliaga FA, Farías PA, Yumha JS, Ortiz CA, Salas JE, Saez AA, Vega LD, Labarca EF, Martinez FT, Carreño NG, Lora P, Liu H, Qiu H, Liu L, Tang R, Luo X, An Y, Zhao H, Gao Y, Zhai Z, Ye ZL, Wang W, Li W, Li Q, Zheng R, Yu W, Shen J, Li X, Yu T, Lu W, Wu YQ, Huang XB, He Z, Lu Y, Han H, Zhang F, Sun R, Wang HX, Qin SH, Zhu BH, Zhao J, Liu J, Li B, Liu JL, Zhou FC, Li QJ, Zhang XY, Li-Xin Z, Xin-Hua Q, Jiang L, Gao YN, Zhao XY, Li YY, Li XL, Wang C, Yao Q, Yu R, Chen K, Shao H, Qin B, Huang QQ, Zhu WH, Hang AY, Hua MX, Li Y, Xu Y, Di YD, Ling LL, Qin TH, Wang SH, Qin J, Han Y, Zhou S, Vargas MP, Silesky Jimenez JI, González Rojas MA, Solis-Quesada JE, Ramirez-Alfaro CM, Máca J, Sklienka P, Gjedsted J, Christiansen A, Nielsen J, Villamagua BG, Llano M, Burtin P, Buzancais G, Beuret P, Pelletier N, Mortaza S, Mercat A, Chelly J, Jochmans S, Terzi N, Daubin C, Carteaux G, de Prost N, Chiche JD, Daviaud F, Pham T, Fartoukh M, Barberet G, Biehler J, Dellamonica J, Doyen D, Arnal JM, Briquet A, Hraiech S, Papazian L, Follin A, Roux D, Messika J, Kalaitzis E, Dangers L, Combes A, Au SM, Béduneau G, Carpentier D, Zogheib EH, Dupont H, Ricome S, Santoli FL, Besset SL, Michel P, Gelée B, Danin PE, Goubaux B, Crova PJ, Phan NT, Berkelmans F, Badie JC, Tapponnier R, Gally J, Khebbeb S, Herbrecht JE, Schneider F, Declercq PLM, Rigaud JP, Duranteau J, Harrois A, Chabanne R, Marin J, Bigot C, Thibault S, Ghazi M, Boukhazna M, Ould Zein S, Richecoeur JR, Combaux DM, Grelon F, Le Moal C, Sauvadet EP, Robine A, Lemiale V, Reuter D, Dres M, Demoule A, Goldgran-Toledano D, Baboi L, Guérin C, Lohner R, Kraßler J, Schäfer S, Zacharowski KD, Meybohm P, Reske AW, Simon P, Hopf HBF, Schuetz M, Baltus T, Papanikolaou MN, Papavasilopoulou TG, Zacharas GA, Ourailogloy V, Mouloudi EK, Massa EV, Nagy EO, Stamou EE, Kiourtzieva EV, Oikonomou MA, Avila LE, Cortez CA, Citalán JE, Jog SA, Sable SD, Shah B, Gurjar M, Baronia AK, Memon M, Muthuchellappan R, Ramesh VJ, Shenoy A, Unnikrishnan R, Dixit SB, Rhayakar RV, Ramakrishnan N, Bhardwaj VK, Mahto HL, Sagar SV, Palaniswamy V, Ganesan D, Mohammadreza Hashemian S, Jamaati H, Heidari F, Meaney EA, Nichol A, Knapman KM, O'Croinin D, Dunne ES, Breen DM, Clarkson KP, Jaafar RF, Dwyer R, Amir F, Ajetunmobi OO, O'Muircheartaigh AC, Black CS, Treanor N, Collins DV, Altaf W, Zani G, Fusari M, Spadaro S, Volta CA, Graziani R, Brunettini B, Palmese S, Formenti P, Umbrello M, Lombardo A, Pecci E, Botteri M, Savioli M, Protti A, Mattei A, Schiavoni L, Tinnirello A, Todeschini M, Giarratano A, Cortegiani A, Sher S, Rossi A, Antonelli MM, Montini LM, Casalena P, Scafetti S, Panarello G, Occhipinti G, Patroniti N, Pozzi M, Biscione RR, Poli MM, Raimondi F, Albiero D, Crapelli G, Beck E, Pota V, Schiavone V, Molin A, Tarantino F, Monti G, Frati E, Mirabella L, Cinnella G, Fossali T, Colombo R, Terragni P, Pattarino I, Mojoli F, Braschi A, Borotto EE, Cracchiolo AN, Palma DM, Raponi F, Foti G, Vascotto ER, Coppadoro A, Brazzi L, Floris L, Iotti GA, Venti A, Yamaguchi O, Takagi S, Maeyama HN, Watanabe E, Yamaji Y, Shimizu K, Shiozaki K, Futami S, Ryosuke S, Saito K, Kameyama Y, Ueno K, Izawa M, Okuda N, Suzuki H, Harasawa T, Nasu M, Takada T, Ito F, Nunomiya S, Koyama K, Abe T, Andoh K, Kusumoto K, Hirata A, Takaba A, Kimura H, Matsumoto S, Higashijima U, Honda H, Aoki N, Imai H, Ogino Y, Mizuguchi I, Ichikado K, Nitta K, Mochizuki K, Hashida T, Tanaka H, Nakamura T, Niimi D, Ueda T, Kashiwa Y, Uchiyama A, Sabelnikovs O, Oss P, Haddad Y, Liew KY, Ñamendys-Silva SA, Jarquin-Badiola YD, Sanchez-Hurtado LA, Gomez-Flores SS, Marin MC, Villagomez AJ, Lemus JS, Fierro JM, Cervantes MR, Mejia FJF, Gonzalez DR, Dector DM, Estrella CR, Sanchez-Medina JR, Ramirez-Gutierrez A, George FG, Aguirre JS, Buensuseso JA, Poblano M, Dendane T, Zeggwagh AA, Balkhi H, Elkhayari M, Samkaoui N, Ezzouine H, Benslama A, Amor M, Maazouzi W, Cimic N, Beck O, Bruns MM, Schouten JA, Rinia M, Raaijmakers M, Heunks LM, Van Wezel HM, Heines SJ, Buise MP, Simonis FD, Schultz MJ, Goodson JC, rowne TSB, Navarra L, Hunt A, Hutchison RA, Bailey MB, Newby L, Mcarthur C, Kalkoff M, Mcleod A, Casement J, Hacking DJ, Andersen FH, Dolva MS, Laake JH, Barratt-Due A, Noremark KAL, Søreide E, Sjøbø BÅ, Guttormsen AB, Yoshido HHL, Aguilar RZ, Oscanoa FAM, Alisasis AU, Robles JB, Pasanting-Lim RAB, Tan BC, Andruszkiewicz P, Jakubowska K, Cox CM, Alvarez AM, Oliveira BS, Montanha GM, Barros NC, Pereira CS, Messias AM, Monteiro JM, Araujo AM, Catorze NT, Marum SM, Bouw MJ, Gomes RM, Brito VA, Castro S, Estilita JM, Barros FM, Serra IM, Martinho AM, Tomescu DR, Marcu A, Bedreag OH, Papurica M, Corneci DE, Negoita SI, Grigoriev E, Gritsan AI, Gazenkampf AA, Almekhlafi G, Albarrak MM, Mustafa GM, Maghrabi KA, Salahuddin N, Aisa TM, Al Jabbary AS, Tabhan E, Arabi YM, Trinidad OA, Al Dorzi HM, Tabhan EE, Bolon S, Smith O, Mancebo J, Aguirre-Bermeo H, Lopez-Delgado JC, Esteve F, Rialp G, Forteza C, De Haro C, Artigas A, Albaiceta GM, De Cima-Iglesias S, Seoane-Quiroga L, Ceniceros-Barros A, Ruiz-Aguilar AL, Claraco-Vega LM, Soler JA, Lorente MDC, Hermosa C, Gordo F, Prieto-González M, López-Messa JB, Perez MP, Pere CP, Allue RM, Roche-Campo F, Ibañez-Santacruz M, Temprano S, Pintado MC, De Pablo R, Gómez PRA, Ruiz SR, Moles SI, Jurado MT, Arizmendi A, Piacentini EA, Franco N, Honrubia T, Perez Cheng M, Perez Losada E, Blanco J, Yuste LJ, Carbayo-Gorriz C, Cazorla-Barranquero FG, Alonso JG, Alda RS, Algaba Á, Navarro G, Cereijo E, Diaz-Rodriguez E, Marcos DP, Montero LA, Para LH, Sanchez RJ, Blasco Navalpotro MA, Abad RD, Montiel González R, Toribio DP, Castro AG, Artiga MJD, Penuelas O, Roser TP, Olga MF, Curto EG, Sánchez RM, Imma VP, Elisabet GM, Claverias L, Magret M, Pellicer AM, Rodriguez LL, Sánchez-Ballesteros J, González-Salamanca Á, Jimenez AG, Huerta FP, Diaz JCJS, Lopez EB, Moya DDL, Alfonso AAT, Eugenio Luis PS, Cesar PS, Rafael SI, Virgilio CG, Recio NN, Adamsson RO, Rylander CC, Holzgraefe B, Broman LM, Wessbergh J, Persson L, Schiöler F, Kedelv H, Tibblin AO, Appelberg H, Hedlund L, Helleberg J, Eriksson KE, Glietsch R, Larsson N, Nygren I, Nunes SL, Morin AK, Kander T, Adolfsson A, Piquilloud L, Zender HO, Leemann-Refondini C, Elatrous S, Bouchoucha S, Chouchene I, Ouanes I, Ben Souissi A, Kamoun S, Demirkiran O, Aker M, Erbabacan E, Ceylan I, Girgin NK, Ozcelik M, Ünal N, Meco BC, Akyol OO, Derman SS, Kennedy B, Parhar K, Srinivasa L, McNamee L, McAuley D, Steinberg J, Hopkins P, Mellis C, Stansil F, Kakar V, Hadfield D, Brown C, Vercueil A, Bhowmick K, Humphreys SK, Ferguson A, Mckee R, Raj AS, Fawkes DA, Watt P, Twohey L, Thomas RRJM, Morton A, Kadaba V, Smith MJ, Hormis AP, Kannan SG, Namih M, Reschreiter H, Camsooksai J, Kumar A, Rugonfalvi S, Nutt C, Oneill O, Seasman C, Dempsey G, Scott CJ, Ellis HE, Mckechnie S, Hutton PJ, Di Tomasso NN, Vitale MN, Griffin RO, Dean MN, Cranshaw JH, Willett EL, Ioannou N, Gillis S, Csabi P, Macfadyen R, Dawson H, Preez PD, Williams AJ, Boyd O, De Gordoa LOR, Bramall J, Symmonds S, Chau SK, Wenham T, Szakmany T, Toth-Tarsoly P, Mccalman KH, Alexander P, Stephenson L, Collyer T, Chapman R, Cooper R, Allan RM, Sim M, Wrathall DW, Irvine DA, Zantua KS, Adams JC, Burtenshaw AJ, Sellors GP, Welters ID, Williams KE, Hessell RJ, Oldroyd MG, Battle CE, Pillai S, Kajtor I, Sivashanmugave M, Okane SC, Donnelly A, Frigyik AD, Careless JP, May MM, Stewart R, Trinder TJ, Hagan SJ, Wise MP, Cole JM, MacFie CC, Dowling AT, Hurtado J, Nin N, Hurtado J, Nuñez E, Pittini G, Rodriguez R, Imperio MC, Santos C, França AG, Ebeid A, Deicas A, Serra C, Uppalapati A, Kamel G, Banner-Goodspeed VM, Beitler JR, Mukkera SR, Kulkarni S, Lee J, Mesar T, Shinn Iii JO, Gomaa D, Tainter C, Mesar T, Cowley RA, Yeatts DJ, Warren J, Lanspa MJ, Miller RR, Grissom CK, Brown SM, Bauer PR, Gosselin RJ, Kitch BT, Cohen JE, Beegle SH, Gueret RM, Tulaimat A, Choudry S, Stigler W, Batra H, Huff NG, Lamb KD, Oetting TW, Mohr NM, Judy C, Saito S, Kheir FM, Schlichting AB, Delsing A, Elmasri M, Crouch DR, Ismail D, Blakeman TC, Dreyer KR, Gomaa D, Baron RM, Grijalba CQ, Hou PC, Seethala R, Aisiku I, Henderson G, Frendl G, Hou SK, Owens RL, Schomer A, Bumbasirevic V, Jovanovic B, Surbatovic M, Veljovic M, Van Haren F. Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies. The Lancet Global Health 2022; 10:e227-e235. [PMID: 34914899 PMCID: PMC8766316 DOI: 10.1016/s2214-109x(21)00485-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 09/05/2021] [Accepted: 10/01/2021] [Indexed: 12/19/2022] Open
Abstract
Background Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference –1·69 [–9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5–8] vs 6 [5–8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52–23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75–0·86]; p<0·0001). Interpretation Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status. Funding No funding.
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McCue P, Shaw L, Del Din S, Hunter H, Lord S, Price CIM, Rodgers H, Rochester L, Moore SA. Acceptability and deliverability of an auditory rhythmical cueing (ARC) training programme for use at home and outdoors to improve gait and physical activity post-stroke. Arch Physiother 2022; 12:1. [PMID: 34983687 PMCID: PMC8725469 DOI: 10.1186/s40945-021-00126-x] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 11/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although laboratory studies demonstrate that training programmes using auditory rhythmical cueing (ARC) may improve gait post-stroke, few studies have evaluated this intervention in the home and outdoors where deployment may be more appropriate. This manuscript reports stakeholder refinement of an ARC gait and balance training programme for use at home and outdoors, and a study which assessed acceptability and deliverability of this programme. METHODS Programme design and content were refined during stakeholder workshops involving physiotherapists and stroke survivors. A two-group acceptability and deliverability study was then undertaken. Twelve patients post-stroke with a gait related mobility impairment received either the ARC gait and balance training programme or the gait and balance training programme without ARC. Programme provider written notes, participant exercise and fall diaries, adverse event monitoring and feedback questionnaires captured data about deliverability, safety and acceptability of the programmes. RESULTS The training programme consisted of 18 sessions (six supervised, 12 self-managed) of exercises and ARC delivered by a low-cost commercially available metronome. All 12 participants completed the six supervised sessions and 10/12 completed the 12 self-managed sessions. Provider and participant session written records and feedback questionnaires confirmed programme deliverability and acceptability. CONCLUSION An ARC gait and balance training programme refined by key stakeholders was feasible to deliver and acceptable to participants and providers. TRIAL REGISTRATION ISCTRN 12/03/2018.
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Affiliation(s)
- Patricia McCue
- Stroke Research Group, Population Health Sciences Institute, Faculty of Medical Sciences, Henry Wellcome Building, The Medical School, Framlington Place, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, Faculty of Medical Sciences, Henry Wellcome Building, The Medical School, Framlington Place, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Silvia Del Din
- Institute of Translational and Clinical Research, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE1 7RU, UK
| | - Heather Hunter
- Institute of Translational and Clinical Research, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE1 7RU, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Hospital, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| | - Sue Lord
- Auckland University of Technology, 55 Wellesley St E, Auckland, 1010, New Zealand
| | - Christopher I M Price
- Stroke Research Group, Population Health Sciences Institute, Faculty of Medical Sciences, Henry Wellcome Building, The Medical School, Framlington Place, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Helen Rodgers
- Stroke Research Group, Population Health Sciences Institute, Faculty of Medical Sciences, Henry Wellcome Building, The Medical School, Framlington Place, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Hospital, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK.,Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, Rake Lane, North Shields, Tyne and Wear, NE29 8NH, UK
| | - Lynn Rochester
- Institute of Translational and Clinical Research, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE1 7RU, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Hospital, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| | - Sarah A Moore
- Institute of Translational and Clinical Research, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE1 7RU, UK. .,Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, Rake Lane, North Shields, Tyne and Wear, NE29 8NH, UK. .,Department of Sport, Exercise, and Rehabilitation, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, NE7 7XA, UK.
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Wilson N, Howel D, Bosomworth H, Shaw L, Rodgers H. Analysing the Action Research Arm Test (ARAT): a cautionary tale from the RATULS trial. Int J Rehabil Res 2021; 44:166-169. [PMID: 33741815 PMCID: PMC8104013 DOI: 10.1097/mrr.0000000000000466] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 02/21/2021] [Indexed: 11/26/2022]
Abstract
Many studies of stroke rehabilitation use the Action Research Arm Test (ARAT) as an outcome, which measures upper limb function by scoring the ability to complete functional tasks. This report describes an issue encountered when analysing the ARAT subscales in a trial of upper limb therapies after stroke. The subscales of the ARAT at three months followed a 'U-shaped' distribution, and therefore, comparing means or medians was not appropriate. A simple alternative approach was chosen that dichotomised the subscales. When analysing the ARAT, the shape of the distributions must be checked in order to choose the most appropriate descriptive and inferential statistical techniques. In particular, if the data follows a 'U-shaped' distribution, a simple dichotomising or a more sophisticated approach is needed. These should also be considered for heavily skewed distributions, often arising from substantial floor or ceiling effects. Inappropriate analyses can lead to misleading conclusions.
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Affiliation(s)
| | | | - Helen Bosomworth
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Helen Rodgers
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Fernandez-Garcia C, Ternent L, Homer TM, Rodgers H, Bosomworth H, Shaw L, Aird L, Andole S, Cohen D, Dawson J, Finch T, Ford G, Francis R, Hogg S, Hughes N, Krebs HI, Price C, Turner D, Van Wijck F, Wilkes S, Wilson N, Vale L. Economic evaluation of robot-assisted training versus an enhanced upper limb therapy programme or usual care for patients with moderate or severe upper limb functional limitation due to stroke: results from the RATULS randomised controlled trial. BMJ Open 2021; 11:e042081. [PMID: 34035087 PMCID: PMC8154983 DOI: 10.1136/bmjopen-2020-042081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 11/26/2022] Open
Abstract
OBJECTIVE To determine whether robot-assisted training is cost-effective compared with an enhanced upper limb therapy (EULT) programme or usual care. DESIGN Economic evaluation within a randomised controlled trial. SETTING Four National Health Service (NHS) centres in the UK: Queen's Hospital, Barking, Havering and Redbridge University Hospitals NHS Trust; Northwick Park Hospital, London Northwest Healthcare NHS Trust; Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde; and North Tyneside General Hospital, Northumbria Healthcare NHS Foundation Trust. PARTICIPANTS 770 participants aged 18 years or older with moderate or severe upper limb functional limitation from first-ever stroke. INTERVENTIONS Participants randomised to one of three programmes provided over a 12-week period: robot-assisted training plus usual care; the EULT programme plus usual care or usual care. MAIN ECONOMIC OUTCOME MEASURES Mean healthcare resource use; costs to the NHS and personal social services in 2018 pounds; utility scores based on EQ-5D-5L responses and quality-adjusted life years (QALYs). Cost-effectiveness reported as incremental cost per QALY and cost-effectiveness acceptability curves. RESULTS At 6 months, on average usual care was the least costly option (£3785) followed by EULT (£4451) with robot-assisted training being the most costly (£5387). The mean difference in total costs between the usual care and robot-assisted training groups (£1601) was statistically significant (p<0.001). Mean QALYs were highest for the EULT group (0.23) but no evidence of a difference (p=0.995) was observed between the robot-assisted training (0.21) and usual care groups (0.21). The incremental cost per QALY at 6 months for participants randomised to EULT compared with usual care was £74 100. Cost-effectiveness acceptability curves showed that robot-assisted training was unlikely to be cost-effective and that EULT had a 19% chance of being cost-effective at the £20 000 willingness to pay (WTP) threshold. Usual care was most likely to be cost-effective at all the WTP values considered in the analysis. CONCLUSIONS The cost-effectiveness analysis suggested that neither robot-assisted training nor EULT, as delivered in this trial, were likely to be cost-effective at any of the cost per QALY thresholds considered. TRIAL REGISTRATION NUMBER ISRCTN69371850.
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Affiliation(s)
- Cristina Fernandez-Garcia
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Laura Ternent
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Tara Marie Homer
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Helen Rodgers
- Stroke Research Group, Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
- Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Helen Bosomworth
- Stroke Research Group, Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Lydia Aird
- Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Sreeman Andole
- Stroke Medicine, Barking Havering and Redbridge Hospitals NHS Trust, Romford, UK
| | - David Cohen
- Northwick Park, London North West University Healthcare NHS Trust, Harrow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Tracy Finch
- Nursing, Midwifery and Health, Northumbria University, Newcastle upon Tyne, UK
| | - Gary Ford
- Stroke Research Group, Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
- Oxford Academic Health Science Network, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard Francis
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Steven Hogg
- (Lay Investigator) Contact Stroke Research Group, Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Niall Hughes
- Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - H I Krebs
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Christopher Price
- Stroke Research Group, Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
- Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Duncan Turner
- School of Health Sport and Bioscience, University of East London, London, UK
| | - Frederike Van Wijck
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Scott Wilkes
- School of Pharmacy, University of Sunderland, Sunderland, UK
| | - Nina Wilson
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
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Price CI, Shaw L, Islam S, Javanbakht M, Watkins A, McMeekin P, Snooks H, Flynn D, Francis R, Lakey R, Sutcliffe L, McClelland G, Lally J, Exley C, Rodgers H, Russell I, Vale L, Ford GA. Effect of an Enhanced Paramedic Acute Stroke Treatment Assessment on Thrombolysis Delivery During Emergency Stroke Care: A Cluster Randomized Clinical Trial. JAMA Neurol 2021; 77:840-848. [PMID: 32282015 PMCID: PMC7154959 DOI: 10.1001/jamaneurol.2020.0611] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Question Can hospital stroke thrombolysis treatment rates be increased by an enhanced paramedic assessment that includes additional prehospital information collection, a structured hospital handover, practical assistance after handover, a predeparture care checklist, and clinician feedback? Findings In this cluster randomized clinical trial, fewer patients in the intervention group (39.4%) received thrombolysis vs those in the standard care group (44.7%), but there were fewer poor health outcomes (disability or death) after 90 days (intervention group, 64.0% vs standard care group, 66.8%). The results were not statistically significant. Meaning This study found that the enhanced paramedic assessment should not be used to increase thrombolysis volume but may influence the quality of treatment decisions. Importance Rapid thrombolysis treatment for acute ischemic stroke reduces disability among patients who are carefully selected, but service delivery is challenging. Objective To determine whether an enhanced Paramedic Acute Stroke Treatment Assessment (PASTA) intervention increased hospital thrombolysis rates. Design, Setting, and Participants This multicenter, cluster randomized clinical trial took place between December 2015 and July 2018 in 3 ambulance services and 15 hospitals. Clusters were paramedics based within ambulance stations prerandomized to PASTA or standard care. Patients attended by study paramedics were enrolled after admission if a hospital specialist confirmed a stroke and paramedic assessment started within 4 hours of onset. Allocation to PASTA or standard care reflected the attending paramedic’s randomization status. Interventions The PASTA intervention included additional prehospital information collection, a structured hospital handover, practical assistance up to 15 minutes after handover, a predeparture care checklist, and clinician feedback. Standard care reflected national guidelines. Main Outcomes and Measures Primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included time intervals and day 90 health (with poor status defined as a modified Rankin Score >2, to represent dependency or death). Results A total of 11 478 patients were screened following ambulance transportation; 1391 were eligible and approached, but 177 did not consent. Of 1214 patients enrolled (mean [SD] age, 74.7 [13.2] years; 590 women [48.6%]), 500 were assessed by 242 paramedics trained in the PASTA intervention and 714 were assessed by 355 paramedics continuing with standard care. The paramedics trained in the PASTA intervention took a mean of 13.4 (95% CI, 9.4-17.4) minutes longer (P < .001) to complete patient care episodes. There was less thrombolysis among the patients in the PASTA group, but this was not significant (PASTA group, 197 of 500 patients [39.4%] vs the standard care group, 319 of 714 patients [44.7%]; adjusted odds ratio, 0.81 [95% CI, 0.61-1.08]; P = .15). Time from a paramedic on scene to thrombolysis was a mean of 8.5 minutes longer in the PASTA group (98.1 [37.6] minutes) vs the standard care group (89.4 [31.1] minutes; P = .01). Poor health outcomes did not differ significantly but occurred less often among patients in the PASTA group (313 of 489 patients [64.0%]) vs the standard care group (461 of 690 patients [66.8%]; adjusted odds ratio, 0.86 [95% CI, 0.60-1.20]; P = .39). Conclusions and Relevance An enhanced paramedic assessment did not facilitate thrombolysis delivery. The unexpected combination of thrombolysis and health outcomes suggests possible alternative influences on treatment decisions by the intervention, requiring further evaluation. Trial Registration ISRCTN Registry Identifier: ISRCTN12418919
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Affiliation(s)
- Christopher I Price
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Lisa Shaw
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Saiful Islam
- Swansea University Medical School, Swansea, Wales, United Kingdom
| | - Mehdi Javanbakht
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Alan Watkins
- Swansea University Medical School, Swansea, Wales, United Kingdom
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, United Kingdom
| | - Helen Snooks
- Swansea University Medical School, Swansea, Wales, United Kingdom
| | - Darren Flynn
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Richard Francis
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Rachel Lakey
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Lou Sutcliffe
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Joanne Lally
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Catherine Exley
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Helen Rodgers
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom.,Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Ian Russell
- Swansea University Medical School, Swansea, Wales, United Kingdom
| | - Luke Vale
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Gary A Ford
- Medical Sciences Division, University of Oxford, Oxford, United Kingdom.,Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
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Rodgers H, Bosomworth H, Krebs HI, van Wijck F, Howel D, Wilson N, Finch T, Alvarado N, Ternent L, Fernandez-Garcia C, Aird L, Andole S, Cohen DL, Dawson J, Ford GA, Francis R, Hogg S, Hughes N, Price CI, Turner DL, Vale L, Wilkes S, Shaw L. Robot-assisted training compared with an enhanced upper limb therapy programme and with usual care for upper limb functional limitation after stroke: the RATULS three-group RCT. Health Technol Assess 2020; 24:1-232. [PMID: 33140719 PMCID: PMC7682262 DOI: 10.3310/hta24540] [Citation(s) in RCA: 12] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Loss of arm function is common after stroke. Robot-assisted training may improve arm outcomes. OBJECTIVE The objectives were to determine the clinical effectiveness and cost-effectiveness of robot-assisted training, compared with an enhanced upper limb therapy programme and with usual care. DESIGN This was a pragmatic, observer-blind, multicentre randomised controlled trial with embedded health economic and process evaluations. SETTING The trial was set in four NHS trial centres. PARTICIPANTS Patients with moderate or severe upper limb functional limitation, between 1 week and 5 years following first stroke, were recruited. INTERVENTIONS Robot-assisted training using the Massachusetts Institute of Technology-Manus robotic gym system (InMotion commercial version, Interactive Motion Technologies, Inc., Watertown, MA, USA), an enhanced upper limb therapy programme comprising repetitive functional task practice, and usual care. MAIN OUTCOME MEASURES The primary outcome was upper limb functional recovery 'success' (assessed using the Action Research Arm Test) at 3 months. Secondary outcomes at 3 and 6 months were the Action Research Arm Test results, upper limb impairment (measured using the Fugl-Meyer Assessment), activities of daily living (measured using the Barthel Activities of Daily Living Index), quality of life (measured using the Stroke Impact Scale), resource use costs and quality-adjusted life-years. RESULTS A total of 770 participants were randomised (robot-assisted training, n = 257; enhanced upper limb therapy, n = 259; usual care, n = 254). Upper limb functional recovery 'success' was achieved in the robot-assisted training [103/232 (44%)], enhanced upper limb therapy [118/234 (50%)] and usual care groups [85/203 (42%)]. These differences were not statistically significant; the adjusted odds ratios were as follows: robot-assisted training versus usual care, 1.2 (98.33% confidence interval 0.7 to 2.0); enhanced upper limb therapy versus usual care, 1.5 (98.33% confidence interval 0.9 to 2.5); and robot-assisted training versus enhanced upper limb therapy, 0.8 (98.33% confidence interval 0.5 to 1.3). The robot-assisted training group had less upper limb impairment (as measured by the Fugl-Meyer Assessment motor subscale) than the usual care group at 3 and 6 months. The enhanced upper limb therapy group had less upper limb impairment (as measured by the Fugl-Meyer Assessment motor subscale), better mobility (as measured by the Stroke Impact Scale mobility domain) and better performance in activities of daily living (as measured by the Stroke Impact Scale activities of daily living domain) than the usual care group, at 3 months. The robot-assisted training group performed less well in activities of daily living (as measured by the Stroke Impact Scale activities of daily living domain) than the enhanced upper limb therapy group at 3 months. No other differences were clinically important and statistically significant. Participants found the robot-assisted training and the enhanced upper limb therapy group programmes acceptable. Neither intervention, as provided in this trial, was cost-effective at current National Institute for Health and Care Excellence willingness-to-pay thresholds for a quality-adjusted life-year. CONCLUSIONS Robot-assisted training did not improve upper limb function compared with usual care. Although robot-assisted training improved upper limb impairment, this did not translate into improvements in other outcomes. Enhanced upper limb therapy resulted in potentially important improvements on upper limb impairment, in performance of activities of daily living, and in mobility. Neither intervention was cost-effective. FUTURE WORK Further research is needed to find ways to translate the improvements in upper limb impairment seen with robot-assisted training into improvements in upper limb function and activities of daily living. Innovations to make rehabilitation programmes more cost-effective are required. LIMITATIONS Pragmatic inclusion criteria led to the recruitment of some participants with little prospect of recovery. The attrition rate was higher in the usual care group than in the robot-assisted training or enhanced upper limb therapy groups, and differential attrition is a potential source of bias. Obtaining accurate information about the usual care that participants were receiving was a challenge. TRIAL REGISTRATION Current Controlled Trials ISRCTN69371850. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 54. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Helen Rodgers
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Tyneside, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Helen Bosomworth
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Hermano I Krebs
- Mechanical Engineering Department, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Frederike van Wijck
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Denise Howel
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Nina Wilson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tracy Finch
- Nursing, Midwifery and Health, Northumbria University, Newcastle upon Tyne, UK
| | | | - Laura Ternent
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Lydia Aird
- Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Tyneside, UK
| | - Sreeman Andole
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - David L Cohen
- London North West University Healthcare NHS Trust, London, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Gary A Ford
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Medical Sciences Division, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard Francis
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Steven Hogg
- Lay investigator (contact Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK)
| | | | - Christopher I Price
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Tyneside, UK
| | - Duncan L Turner
- School of Health, Sport and Bioscience, University of East London, London, UK
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Scott Wilkes
- School of Medicine, University of Sunderland, Sunderland, UK
| | - Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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9
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Bosomworth H, Rodgers H, Shaw L, Smith L, Aird L, Howel D, Wilson N, Alvarado N, Andole S, Cohen DL, Dawson J, Fernandez-Garcia C, Finch T, Ford GA, Francis R, Hogg S, Hughes N, Price CI, Ternent L, Turner DL, Vale L, Wilkes S, Krebs HI, van Wijck F. Evaluation of the enhanced upper limb therapy programme within the Robot-Assisted Training for the Upper Limb after Stroke trial: descriptive analysis of intervention fidelity, goal selection and goal achievement. Clin Rehabil 2020; 35:119-134. [PMID: 32914639 PMCID: PMC7814096 DOI: 10.1177/0269215520953833] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Objective: To report the fidelity of the enhanced upper limb therapy programme within the Robot-Assisted Training for the Upper Limb after stroke (RATULS) randomized controlled trial, the types of goals selected and the proportion of goals achieved. Design: Descriptive analysis of data on fidelity, goal selection and achievement from an intervention group within a randomized controlled trial. Setting: Out-patient stroke rehabilitation within four UK NHS centres. Subjects: 259 participants with moderate-severe upper limb activity limitation (Action Research Arm Test 0–39) between one week and five years post first stroke. Intervention: The enhanced upper limb therapy programme aimed to provide 36 one-hour sessions, including 45 minutes of face-to-face therapy focusing on personal goals, over 12 weeks. Results: 7877/9324 (84%) sessions were attended; a median of 34 [IQR 29–36] per participant. A median of 127 [IQR 70–190] repetitions were achieved per participant per session attended. Based upon the Canadian Occupational Performance Measure, goal categories were: self-care 1449/2664 (54%); productivity 374/2664 (14%); leisure 180/2664 (7%) and ‘other’ 661/2664 (25%). For the 2051/2664 goals for which data were available, 1287 (51%) were achieved, ranging between 27% by participants more than 12 months post stroke with baseline Action Research Arm Test scores 0–7, and 88% by those less than three months after stroke with scores 8–19. Conclusions: Intervention fidelity was high. Goals relating to self-care were most commonly selected. The proportion of goals achieved varied, depending on time post stroke and baseline arm activity limitation.
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Affiliation(s)
- Helen Bosomworth
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Helen Rodgers
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK.,Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Tyneside, UK.,Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Leanne Smith
- Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Tyneside, UK
| | - Lydia Aird
- Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Tyneside, UK
| | - Denise Howel
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Nina Wilson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Sreeman Andole
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - David L Cohen
- London North West Healthcare NHS Trust, Northwick Park, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - Tracy Finch
- Nursing, Midwifery & Health, Northumbria University, Newcastle upon Tyne, UK
| | - Gary A Ford
- Medical Sciences Division, University of Oxford, and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard Francis
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Steven Hogg
- Lay investigator (contact Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Christopher I Price
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK.,Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Tyneside, UK
| | - Laura Ternent
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Duncan L Turner
- School of Health, Sport and Bioscience, University of East London, London, UK
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Scott Wilkes
- School of Medicine, University of Sunderland, Sunderland, UK
| | | | - Frederike van Wijck
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
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10
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Moore SA, Hrisos N, Errington L, Rochester L, Rodgers H, Witham M, Sayer AA. Exercise as a treatment for sarcopenia: an umbrella review of systematic review evidence. Physiotherapy 2020; 107:189-201. [PMID: 32026819 DOI: 10.1016/j.physio.2019.08.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [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] [Received: 01/22/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Sarcopenia is a progressive and generalised skeletal muscle disorder, and a powerful predictor of adverse health outcomes. Exercise is a widely recommended treatment but consensus about the best approach is lacking. OBJECTIVE To synthesise current systematic review evidence on the effectiveness of exercise in the treatment of sarcopenia to inform clinical practice. DATA SOURCES Five electronic databases were searched (15 November 2018): Cochrane Database of Systematic Reviews; MEDLINE without revisions; EMBASE; Scopus; and Web of Science. STUDY SELECTION OR ELIGIBILITY CRITERIA Systematic reviews and meta-analyses of randomised controlled trials evaluating exercise to treat sarcopenia in adults including sarcopenic outcomes. STUDY APPRAISAL AND SYNTHESIS METHODS Review data were extracted and quality assessed (using the AMSTAR 2) by two independent assessors. Due to a lack of eligible reviews, a narrative synthesis of the evidence was performed. RESULTS Two reviews were identified which included seven studies with 619 participants. Study exercise interventions included: resistance; mixed and whole body vibration training programmes. Review findings demonstrate limited low quality evidence of positive effects of mixed and resistance training in treating sarcopenia. LIMITATIONS Limited eligible reviews restricted synthesis and interpretation of findings. CONCLUSION AND IMPLICATIONS OF KEY FINDINGS There is a lack of high quality research with which to inform the treatment of sarcopenia with exercise. Further research using more precision when selecting sarcopenic populations and outcomes is required in this field. This will enable the identification of effective ways of treating sarcopenia with exercise before evidence-based clinical guidelines can be established.
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Affiliation(s)
- Sarah A Moore
- Institute of Neuroscience | Newcastle University Institute for Ageing, Newcastle University, Newcastle upon Tyne, UK; Northumbria Healthcare NHS Foundation Trust, North Tyneside, UK.
| | - Nina Hrisos
- Institute of Neuroscience | Newcastle University Institute for Ageing, Newcastle University, Newcastle upon Tyne, UK.
| | - Linda Errington
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.
| | - Lynn Rochester
- Institute of Neuroscience | Newcastle University Institute for Ageing, Newcastle University, Newcastle upon Tyne, UK; Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
| | - Helen Rodgers
- Institute of Neuroscience | Newcastle University Institute for Ageing, Newcastle University, Newcastle upon Tyne, UK; Northumbria Healthcare NHS Foundation Trust, North Tyneside, UK; Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
| | - Miles Witham
- Institute of Neuroscience | Newcastle University Institute for Ageing, Newcastle University, Newcastle upon Tyne, UK; NIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust and Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.
| | - Avan A Sayer
- Institute of Neuroscience | Newcastle University Institute for Ageing, Newcastle University, Newcastle upon Tyne, UK; NIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust and Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.
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11
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McCue P, Del Din S, Hunter H, Lord S, Price CIM, Shaw L, Rodgers H, Rochester L, Moore SA. Auditory rhythmical cueing to improve gait and physical activity in community-dwelling stroke survivors (ACTIVATE): study protocol for a pilot randomised controlled trial. Pilot Feasibility Stud 2020; 6:68. [PMID: 32467770 PMCID: PMC7236874 DOI: 10.1186/s40814-020-00605-1] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 04/22/2020] [Indexed: 12/12/2022] Open
Abstract
Background Mobility problems are present in 70–80% of stroke survivors and can result in impaired gait and reduced physical activity limiting independent living. Auditory rhythmic cueing (ARC) has been used to provide auditory feedback and shows promise in improving a variety of walking parameters following stroke. The aim of this pilot study is to assess the feasibility of conducting a multi-centre, observer blind, randomised controlled trial of auditory rhythmical cueing (ARC) intervention in home and community settings in North East England. Methods This pilot observer blind randomised controlled feasibility trial aims to recruit 60 participants over 15 months from community stroke services in the North East of England. Participants will be within 24 months of stroke onset causing new problems with mobility. Each participant will be randomised to the study intervention or control group. Intervention treatment participants will undertake 18 auditory rhythmical cueing (ARC) treatment sessions over 6 weeks (3 × 30 min per week, 6 supervised (physiotherapist/research associate)/12 self-managed) in a home/community setting. A metronome will be used to provide ARC during a series of balance and gait exercises, which will be gradually progressed. The control treatment participants will undertake the same duration balance and gait exercise training programme as the intervention group but without the ARC. Feasibility will be determined in terms of recruitment, retention, adverse events, adherence, collection of descriptive clinical and accelerometer motor performance data at baseline, 6 weeks and 10 weeks and description of participant, provider and clinical therapists’ experiences. As well as using questionnaires to collate participant views, qualitative interviews will be undertaken to further understand how the intervention is delivered in practice in a community setting and to identify aspects perceived important by participants. Discussion The ACTIVATE study will address an important gap in the evidence base by reporting whether it is feasible to deliver auditory rhythmical cueing in the home and community to improve gait and balance parameters following stroke. The feasibility of the study protocol will be established and results will inform the design of a future multi-centre randomised controlled trial. Trial registration Trial register: ISRCTN, Trial identifier: ISRCTN10874601: Date of registration: 12/03/2018.
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Affiliation(s)
- Patricia McCue
- 1Stroke Research Group, Institute of Neuroscience Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, UK
| | - Silvia Del Din
- 2Institute of Neuroscience Henry Wellcome Building, The Medical School, Framlington Place, Newcastle University, Newcastle upon Tyne, NE2 4HH UK
| | - Heather Hunter
- 2Institute of Neuroscience Henry Wellcome Building, The Medical School, Framlington Place, Newcastle University, Newcastle upon Tyne, NE2 4HH UK.,3The Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Hospital, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP UK
| | - Sue Lord
- 5Auckland University of Technology, 55 Wellesley St E, Auckland, 1010 New Zealand
| | - Christopher I M Price
- 1Stroke Research Group, Institute of Neuroscience Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, UK
| | - Lisa Shaw
- 1Stroke Research Group, Institute of Neuroscience Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, UK
| | - Helen Rodgers
- 1Stroke Research Group, Institute of Neuroscience Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, UK.,3The Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Hospital, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP UK.,4Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, Rake Lane, North Shields, Tyne and Wear, NE29 8NH UK
| | - Lynn Rochester
- 2Institute of Neuroscience Henry Wellcome Building, The Medical School, Framlington Place, Newcastle University, Newcastle upon Tyne, NE2 4HH UK.,3The Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Hospital, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP UK
| | - Sarah A Moore
- 1Stroke Research Group, Institute of Neuroscience Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, UK.,4Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, Rake Lane, North Shields, Tyne and Wear, NE29 8NH UK
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12
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Shaw L, Bhattarai N, Cant R, Drummond A, Ford GA, Forster A, Francis R, Hills K, Howel D, Laverty AM, McKevitt C, McMeekin P, Price C, Stamp E, Stevens E, Vale L, Rodgers H. An extended stroke rehabilitation service for people who have had a stroke: the EXTRAS RCT. Health Technol Assess 2020; 24:1-202. [PMID: 32468989 DOI: 10.3310/hta24240] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 12/28/2022] Open
Abstract
BACKGROUND There is limited evidence about the effectiveness of rehabilitation in meeting the longer-term needs of stroke patients and their carers. OBJECTIVE To determine the clinical effectiveness and cost-effectiveness of an extended stroke rehabilitation service (EXTRAS). DESIGN A pragmatic, observer-blind, parallel-group, multicentre randomised controlled trial with embedded health economic and process evaluations. Participants were randomised (1 : 1) to receive EXTRAS or usual care. SETTING Nineteen NHS study centres. PARTICIPANTS Patients with a new stroke who received early supported discharge and their informal carers. INTERVENTIONS Five EXTRAS reviews provided by an early supported discharge team member between 1 and 18 months post early supported discharge, usually over the telephone. Reviewers assessed rehabilitation needs, with goal-setting and action-planning. Control treatment was usual care post early supported discharge. MAIN OUTCOME MEASURES The primary outcome was performance in extended activities of daily living (Nottingham Extended Activities of Daily Living Scale) at 24 months post randomisation. Secondary outcomes at 12 and 24 months included patient mood (Hospital Anxiety and Depression Scale), health status (Oxford Handicap Scale), experience of services and adverse events. For carers, secondary outcomes included carers' strain (Caregiver Strain Index) and experience of services. Cost-effectiveness was estimated using resource utilisation costs (adaptation of the Client Service Receipt Inventory) and quality-adjusted life-years. RESULTS A total of 573 patients (EXTRAS, n = 285; usual care, n = 288) with 194 carers (EXTRAS, n = 103; usual care, n = 91) were randomised. Mean 24-month Nottingham Extended Activities of Daily Living Scale scores were 40.0 (standard deviation 18.1) for EXTRAS (n = 219) and 37.2 (standard deviation 18.5) for usual care (n = 231), giving an adjusted mean difference of 1.8 (95% confidence interval -0.7 to 4.2). The mean intervention group Hospital Anxiety and Depression Scale scores were not significantly different at 12 and 24 months. The intervention did not improve patient health status or carer strain. EXTRAS patients and carers reported greater satisfaction with some aspects of care. The mean cost of resource utilisation was lower in the intervention group: -£311 (95% confidence interval -£3292 to £2787), with a 68% chance of EXTRAS being cost-saving. EXTRAS was associated with 0.07 (95% confidence interval 0.01 to 0.12) additional quality-adjusted life-years. At current conventional thresholds of willingness to pay for a quality-adjusted life-year, there is a 90% chance that EXTRAS is cost-effective. CONCLUSIONS EXTRAS did not improve stroke survivors' performance in extended activities of daily living but did improve their overall satisfaction with services. Given the impact on costs and quality-adjusted life-years, there is a high chance that EXTRAS could be considered cost-effective. FUTURE WORK Further research is required to identify whether or not community-based interventions can improve performance of extended activities of daily living, and to understand the improvements in health-related quality of life and costs seen by provision of intermittent longer-term specialist review. TRIAL REGISTRATION Current Controlled Trials ISRCTN45203373. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 24. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Lisa Shaw
- Stroke Research Group, Institute of Neuroscience, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Nawaraj Bhattarai
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Robin Cant
- Service user, c/o Stroke Research Group, Institute of Neuroscience, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Avril Drummond
- School of Health Sciences, Medical School, Queen's Medical Centre, University of Nottingham, Nottingham, UK
| | - Gary A Ford
- Stroke Research Group, Institute of Neuroscience, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Medical Sciences Division, University of Oxford and John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Anne Forster
- Academic Unit of Elderly Care and Rehabilitation, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Richard Francis
- Stroke Research Group, Institute of Neuroscience, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Katie Hills
- Stroke Research Group, Institute of Neuroscience, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Denise Howel
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Anne Marie Laverty
- Stroke Service, Wansbeck General Hospital, Northumbria Healthcare NHS Foundation Trust, Northumberland, UK
| | - Christopher McKevitt
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Peter McMeekin
- Department of Nursing, Midwifery and Health, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Christopher Price
- Stroke Research Group, Institute of Neuroscience, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Stroke Service, Wansbeck General Hospital, Northumbria Healthcare NHS Foundation Trust, Northumberland, UK
| | - Elaine Stamp
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Eleanor Stevens
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Luke Vale
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Helen Rodgers
- Stroke Research Group, Institute of Neuroscience, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Stroke Service, Wansbeck General Hospital, Northumbria Healthcare NHS Foundation Trust, Northumberland, UK.,Royal Victoria Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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13
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McClelland G, Flynn D, Rodgers H, Price C. Positive predictive value of stroke identification by ambulance clinicians in North East England: a service evaluation. Emerg Med J 2020; 37:474-479. [PMID: 32385043 DOI: 10.1136/emermed-2019-208902] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 07/09/2019] [Revised: 03/09/2020] [Accepted: 04/09/2020] [Indexed: 11/03/2022]
Abstract
INTRODUCTION/BACKGROUND Accurate prehospital identification of patients who had an acute stroke enables rapid conveyance to specialist units for time-dependent treatments such as thrombolysis and thrombectomy. Misidentification leads to patients who had a 'stroke mimic' (SM) being inappropriately triaged to specialist units. We evaluated the positive predictive value (PPV) of prehospital stroke identification by ambulance clinicians in the North East of England. METHODS This service evaluation linked routinely collected records from a UK regional ambulance service identifying adults with any clinical impression of suspected stroke to diagnostic data from four National Health Service hospital trusts between 1 June 2013 and 31 May 2016. The reference standard for a confirmed stroke diagnosis was inclusion in Sentinel Stroke National Audit Programme data or a hospital diagnosis of stroke or transient ischaemic attack in Hospital Episode Statistics. PPV was calculated as a measure of diagnostic accuracy. RESULTS Ambulance clinicians in North East England identified 5645 patients who had a suspected stroke (mean age 73.2 years, 48% male). At least one Face Arm Speech Test (FAST) symptom was documented for 93% of patients who had a suspected stroke but a positive FAST was only documented for 51%. Stroke, or transient ischaemic attack, was the final diagnosis for 3483 (62%) patients. SM (false positives) accounted for 38% of suspected strokes identified by ambulance clinicians and included a wide range of non-stroke diagnoses including infections, seizures and migraine. DISCUSSION In this large multisite data set, identification of patients who had a stroke by ambulance clinicians had a PPV rate of 62% (95% CI 61 to 63). Most patients who had a suspected stroke had at least one FAST symptom, but failure to document a complete test was common. Training for stroke identification and SM rates need to be considered when planning service provision and capacity.
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Affiliation(s)
- Graham McClelland
- Research and Development, North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, UK .,Institute of Neuroscience (Stroke Research Group), Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Darren Flynn
- Teesside University School of Health and Social Care, Middlesbrough, UK
| | - Helen Rodgers
- Institute of Neuroscience (Stroke Research Group), Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Christopher Price
- Institute of Neuroscience (Stroke Research Group), Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
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14
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Price CI, Shaw L, Dixit A, Graziadio S, Lendrem C, Mitra D, Rodgers H, Sutcliffe L, White P. Asymmetrical Bioimpedance in the Anterior Circulation for Urgent Stratification of suspected Stroke (ABACUS Stroke): study protocol for a diagnostic accuracy study. Diagn Progn Res 2020; 4:2. [PMID: 32110739 PMCID: PMC7033905 DOI: 10.1186/s41512-019-0068-3] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 11/28/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Early identification and treatment of stroke improve outcome. Ischaemic stroke due to large vessel occlusion (LVO) benefits from time-critical thrombectomy but this is only available in highly specialised healthcare services. Cerebral Bioimpedance Asymmetry (CBA) measurement obtained with the portable and rapid Cerebrotech Visor™ System device may be able to identify certain types of stroke including LVO. This test could be deployed pre-hospital and used to immediately direct patients to the most appropriate healthcare service for treatment. This study is evaluating the diagnostic accuracy of CBA measurements obtained from a real-world population of suspected stroke. METHODS Study design: Prospective observational cohort study.Setting: A hyperacute stroke unit and neuroscience centre in North East England.Participants: Adults with a paramedic assigned diagnosis of suspected stroke arriving at hospital within 6 hours of symptom onset.Index Test: Cerebral Bioimpedance Asymmetry measurement performed using the Cerebrotech Visor™ System. Measurement values produce continuous data (range 0 -100); pre-defined threshold for positive state ≥ 10.Reference Standard Tests: Standard CT brain +/- CT/MR angiography, and expert clinician opinion will establish the following clinical outcomes which constitute the suspected stroke population: ischaemic stroke +/- large vessel occlusion; symptomatic severe anterior vessel stenosis; large (≥60ml) and small (<60mls) vessel intracerebral haemorrhage; transient ischaemic attack; stroke mimic conditions; prior territorial stroke.Analyses: Sensitivity, specificity, negative and positive predictive values, area under the Receiver Operating Characteristic curve for identification of i) "complex stroke" (ischaemic stroke with large vessel occlusion or symptomatic severe anterior vessel stenosis or intracerebral haemorrhage ≥60ml or prior territorial stroke) and ii) ischaemic stroke with large vessel occlusion in isolation.Sample size: 124 participants. DISCUSSION The results from this study will determine how accurately CBA measurement using the Cerebrotech Visor™ System can identify key stroke types within the suspected stroke population. Acceptable diagnostic performance would be an important step forwards for access to time-critical treatments. TRIAL REGISTRATION Registered with ISRCTN (identifier: ISRCTN79169844) on 06/08/2018.
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Affiliation(s)
- Christopher I. Price
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Henry Wellcome Building, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
| | - Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Henry Wellcome Building, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
| | - Anand Dixit
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Hospital, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP UK
| | - Sara Graziadio
- NIHR Newcastle In Vitro Diagnostics Co-operative, Room M2.061, William Leech Building, Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
| | - Clare Lendrem
- NIHR Newcastle In Vitro Diagnostics Co-operative, Room M2.061, William Leech Building, Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
| | - Dipayan Mitra
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Hospital, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP UK
| | - Helen Rodgers
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Henry Wellcome Building, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Hospital, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP UK
| | - Lou Sutcliffe
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Henry Wellcome Building, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
| | - Phil White
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Henry Wellcome Building, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Hospital, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP UK
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15
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Wilhelm LO, Gellert P, White M, Araujo-Soares V, Ford GA, Mackintosh JE, Rodgers H, Sniehotta FF, Thomson RG, Dombrowski SU. The Recognition-Response Gap in Acute Stroke: Examining the Relationship between Stroke Recognition and Response in a General Population Survey. J Stroke Cerebrovasc Dis 2020; 29:104499. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104499] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 11/15/2022] Open
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16
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Rodgers H, Bosomworth H, van Wijck F, Krebs HI, Shaw L. Usual care: the big but unmanaged problem of rehabilitation evidence - Authors' reply. Lancet 2020; 395:337-338. [PMID: 32007165 DOI: 10.1016/s0140-6736(19)32543-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 09/20/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Helen Rodgers
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne NE2 4AE, UK; Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Tyneside, UK; Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
| | - Helen Bosomworth
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne NE2 4AE, UK
| | - Frederike van Wijck
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | | | - Lisa Shaw
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne NE2 4AE, UK
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Maubach N, Batten M, Jones S, Chen J, Scholz B, Davis A, Bromley J, Burke B, Tan R, Hurwitz M, Rodgers H, Mitchell I. End‐of‐life care in an Australian acute hospital: a retrospective observational study. Intern Med J 2019; 49:1400-1405. [DOI: 10.1111/imj.14305] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 02/18/2019] [Accepted: 03/19/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Ninya Maubach
- Medical SchoolThe Australian National University Canberra Australian Capital Territory Australia
| | - Monique Batten
- Medical SchoolThe Australian National University Canberra Australian Capital Territory Australia
| | - Scott Jones
- Medical SchoolThe Australian National University Canberra Australian Capital Territory Australia
| | - Judy Chen
- Medical SchoolThe Australian National University Canberra Australian Capital Territory Australia
| | - Brett Scholz
- Medical SchoolThe Australian National University Canberra Australian Capital Territory Australia
| | - Alison Davis
- Medical SchoolThe Australian National University Canberra Australian Capital Territory Australia
- The Canberra Hospital, ACT Health Canberra Australian Capital Territory Australia
| | - Jonathan Bromley
- Medical SchoolThe Australian National University Canberra Australian Capital Territory Australia
- The Canberra Hospital, ACT Health Canberra Australian Capital Territory Australia
| | - Brandon Burke
- Medical SchoolThe Australian National University Canberra Australian Capital Territory Australia
- The Canberra Hospital, ACT Health Canberra Australian Capital Territory Australia
| | - Ren Tan
- The Canberra Hospital, ACT Health Canberra Australian Capital Territory Australia
| | - Mark Hurwitz
- Medical SchoolThe Australian National University Canberra Australian Capital Territory Australia
- The Canberra Hospital, ACT Health Canberra Australian Capital Territory Australia
| | - Helen Rodgers
- The Canberra Hospital, ACT Health Canberra Australian Capital Territory Australia
| | - Imogen Mitchell
- Medical SchoolThe Australian National University Canberra Australian Capital Territory Australia
- The Canberra Hospital, ACT Health Canberra Australian Capital Territory Australia
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Rodgers H, Howel D, Bhattarai N, Cant R, Drummond A, Ford GA, Forster A, Francis R, Hills K, Laverty AM, McKevitt C, McMeekin P, Price CIM, Stamp E, Stevens E, Vale L, Shaw L. Evaluation of an Extended Stroke Rehabilitation Service (EXTRAS): A Randomized Controlled Trial and Economic Analysis. Stroke 2019; 50:3561-3568. [PMID: 31637972 PMCID: PMC7597995 DOI: 10.1161/strokeaha.119.024876] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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] [Indexed: 01/19/2023]
Abstract
Supplemental Digital Content is available in the text. There is limited evidence to guide rehabilitation to meet the longer term needs of stroke survivors. The clinical effectiveness and cost-effectiveness of an extended stroke rehabilitation service (EXTRAS) provided following early supported discharge were determined.
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Affiliation(s)
- Helen Rodgers
- From the Stroke Research Group, Institute of Neuroscience (H.R., G.A.F., R.F., K.H., C.I.M.P., L.S.), Newcastle University, Newcastle upon Tyne, United Kingdom.,Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Tyneside, United Kingdom (H.R., A.-M.L., C.I.M.P.).,Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom (H.R.)
| | - Denise Howel
- Institute of Health and Society Newcastle University, Newcastle upon Tyne, UK (D.H., N.B., E. Stamp, L.V.), Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Nawaraj Bhattarai
- Institute of Health and Society Newcastle University, Newcastle upon Tyne, UK (D.H., N.B., E. Stamp, L.V.), Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Robin Cant
- Lay Investigator, Stroke Research Group, Institute of Neuroscience, Newcastle (R.C.), Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Avril Drummond
- School of Health Sciences, Nottingham University, United Kingdom (A.D.)
| | - Gary A Ford
- From the Stroke Research Group, Institute of Neuroscience (H.R., G.A.F., R.F., K.H., C.I.M.P., L.S.), Newcastle University, Newcastle upon Tyne, United Kingdom.,Medical Sciences Division, University of Oxford, and Oxford University Hospitals NHS Foundation Trust, United Kingdom (G.A.F.)
| | - Anne Forster
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, United Kingdom (A.F.)
| | - Richard Francis
- From the Stroke Research Group, Institute of Neuroscience (H.R., G.A.F., R.F., K.H., C.I.M.P., L.S.), Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Katie Hills
- From the Stroke Research Group, Institute of Neuroscience (H.R., G.A.F., R.F., K.H., C.I.M.P., L.S.), Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Anne-Marie Laverty
- Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Tyneside, United Kingdom (H.R., A.-M.L., C.I.M.P.)
| | - Christopher McKevitt
- School of Population Health and Environmental Sciences, King's College London, United Kingdom (C.M., E. Stevens)
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, United Kingdom (P.M.)
| | - Christopher I M Price
- From the Stroke Research Group, Institute of Neuroscience (H.R., G.A.F., R.F., K.H., C.I.M.P., L.S.), Newcastle University, Newcastle upon Tyne, United Kingdom.,Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Tyneside, United Kingdom (H.R., A.-M.L., C.I.M.P.)
| | - Elaine Stamp
- Institute of Health and Society Newcastle University, Newcastle upon Tyne, UK (D.H., N.B., E. Stamp, L.V.), Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Eleanor Stevens
- School of Population Health and Environmental Sciences, King's College London, United Kingdom (C.M., E. Stevens)
| | - Luke Vale
- Institute of Health and Society Newcastle University, Newcastle upon Tyne, UK (D.H., N.B., E. Stamp, L.V.), Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Lisa Shaw
- From the Stroke Research Group, Institute of Neuroscience (H.R., G.A.F., R.F., K.H., C.I.M.P., L.S.), Newcastle University, Newcastle upon Tyne, United Kingdom
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Rodgers H, Bosomworth H, Krebs HI, van Wijck F, Howel D, Wilson N, Aird L, Alvarado N, Andole S, Cohen DL, Dawson J, Fernandez-Garcia C, Finch T, Ford GA, Francis R, Hogg S, Hughes N, Price CI, Ternent L, Turner DL, Vale L, Wilkes S, Shaw L. Robot assisted training for the upper limb after stroke (RATULS): a multicentre randomised controlled trial. Lancet 2019; 394:51-62. [PMID: 31128926 PMCID: PMC6620612 DOI: 10.1016/s0140-6736(19)31055-4] [Citation(s) in RCA: 203] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 05/07/2019] [Accepted: 05/08/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Loss of arm function is a common problem after stroke. Robot-assisted training might improve arm function and activities of daily living. We compared the clinical effectiveness of robot-assisted training using the MIT-Manus robotic gym with an enhanced upper limb therapy (EULT) programme based on repetitive functional task practice and with usual care. METHODS RATULS was a pragmatic, multicentre, randomised controlled trial done at four UK centres. Stroke patients aged at least 18 years with moderate or severe upper limb functional limitation, between 1 week and 5 years after their first stroke, were randomly assigned (1:1:1) to receive robot-assisted training, EULT, or usual care. Robot-assisted training and EULT were provided for 45 min, three times per week for 12 weeks. Randomisation was internet-based using permuted block sequences. Treatment allocation was masked from outcome assessors but not from participants or therapists. The primary outcome was upper limb function success (defined using the Action Research Arm Test [ARAT]) at 3 months. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN69371850. FINDINGS Between April 14, 2014, and April 30, 2018, 770 participants were enrolled and randomly assigned to either robot-assisted training (n=257), EULT (n=259), or usual care (n=254). The primary outcome of ARAT success was achieved by 103 (44%) of 232 patients in the robot-assisted training group, 118 (50%) of 234 in the EULT group, and 85 (42%) of 203 in the usual care group. Compared with usual care, robot-assisted training (adjusted odds ratio [aOR] 1·17 [98·3% CI 0·70-1·96]) and EULT (aOR 1·51 [0·90-2·51]) did not improve upper limb function; the effects of robot-assisted training did not differ from EULT (aOR 0·78 [0·48-1·27]). More participants in the robot-assisted training group (39 [15%] of 257) and EULT group (33 [13%] of 259) had serious adverse events than in the usual care group (20 [8%] of 254), but none were attributable to the intervention. INTERPRETATION Robot-assisted training and EULT did not improve upper limb function after stroke compared with usual care for patients with moderate or severe upper limb functional limitation. These results do not support the use of robot-assisted training as provided in this trial in routine clinical practice. FUNDING National Institute for Health Research Health Technology Assessment Programme.
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Affiliation(s)
- Helen Rodgers
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK; Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Tyneside, UK; Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
| | - Helen Bosomworth
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | | | - Frederike van Wijck
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Denise Howel
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Nina Wilson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Lydia Aird
- Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Tyneside, UK
| | | | - Sreeman Andole
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - David L Cohen
- London North West Healthcare NHS Trust, Northwick Park Hospital, Harrow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - Tracy Finch
- Nursing, Midwifery and Health, Northumbria University, Newcastle upon Tyne, UK
| | - Gary A Ford
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK; Medical Sciences Division, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard Francis
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Steven Hogg
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | | | - Christopher I Price
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK; Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Tyneside, UK
| | - Laura Ternent
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Duncan L Turner
- School of Health, Sport and Bioscience, University of East London, London, UK
| | - Luke Vale
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Scott Wilkes
- School of Medicine, University of Sunderland, Sunderland, UK
| | - Lisa Shaw
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
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Da-Silva RH, Moore SA, Rodgers H, Shaw L, Sutcliffe L, van Wijck F, Price CI. Wristband Accelerometers to motiVate arm Exercises after Stroke (WAVES): a pilot randomized controlled trial. Clin Rehabil 2019; 33:1391-1403. [PMID: 30845829 DOI: 10.1177/0269215519834720] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [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: 11/17/2022]
Abstract
OBJECTIVE To evaluate the feasibility of a multicentre, observer-blind, pilot randomized controlled trial (RCT) of a wristband accelerometer with activity-dependent vibration alerts to prompt impaired arm use after stroke. DESIGN Parallel-group pilot RCT. SETTING Four English stroke services. PARTICIPANTS Patients 0-3 months post stroke with a new arm deficit. INTERVENTION Participants were randomized to wear a prompting or 'sham' wristband during a four-week self-directed therapy programme with twice-weekly therapy review. MAIN OUTCOMES Recruitment, retention and adherence rates, safety and completion of assessments were reported. Arm recovery was measured by Action Research Arm Test (ARAT) and Motor Activity Log (MAL) without statistical comparison. RESULTS In total, 33 patients were recruited (0.6 per month/site; median time post stroke: 26 days (interquartile range (IQR):15.5-45)). Baseline, four-week and eight-week median (IQR) ARAT for the control group (n = 19) were 15 (2-35), 35 (15-26) and 31 (21-55) and those for the intervention group (n = 14) were 37 (16-45), 57 (29-57) and 57 (37-57), respectively; for MAL Amount of Use, the corresponding values in the control group were 0.2 (0.0-1.2), 1.1 (0.3-2.9) and 1.2 (0.7-2.9) and in the intervention group were 1.4 (0.5-2.6), 3.8 (1.9-4.5) and 3.7 (2.1-4.3). Four participants withdrew from the study. Wristbands were worn for 79% of the recommended time. The intervention and control group participants received a median of 6.0 (IQR: 4.3-8.0) and 7.5 (IQR: 6.8-8.0) therapy reviews. A median of 8 (IQR: 6-10) prompts were delivered per intervention participant/day. Research assessments were completed for 28/29 and 25/28 patients at four and eight weeks. Eight serious adverse events were reported, all unrelated to the intervention. CONCLUSION A multicentre RCT of wristband accelerometers to prompt arm activity early after stroke is feasible. A total sample of 108 participants would be required.
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Affiliation(s)
- Ruth H Da-Silva
- 1 Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Sarah A Moore
- 1 Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Helen Rodgers
- 1 Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Lisa Shaw
- 1 Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Louise Sutcliffe
- 1 Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Frederike van Wijck
- 2 School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Christopher I Price
- 1 Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
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Price CI, Shaw L, Dodd P, Exley C, Flynn D, Francis R, Islam S, Javanbakht M, Lakey R, Lally J, McClelland G, McMeekin P, Rodgers H, Snooks H, Sutcliffe L, Tyrell P, Vale L, Watkins A, Ford GA. Paramedic Acute Stroke Treatment Assessment (PASTA): study protocol for a randomised controlled trial. Trials 2019; 20:121. [PMID: 30755249 PMCID: PMC6373128 DOI: 10.1186/s13063-018-3144-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 04/01/2018] [Accepted: 12/17/2018] [Indexed: 11/10/2022] Open
Abstract
Background Despite evidence from clinical trials that intravenous (IV) thrombolysis is a cost-effective treatment for selected acute ischaemic stroke patients, there remain large variations in the rate of IV thrombolysis delivery between stroke services. This study is evaluating whether an enhanced care pathway delivered by paramedics (the Paramedic Acute Stroke Treatment Assessment (PASTA)) could increase the number of patients who receive IV thrombolysis treatment. Methods Study design: Cluster randomised trial with economic analysis and parallel process evaluation. Setting: National Health Service ambulance services, emergency departments and hyper-acute stroke units within three geographical regions of England and Wales. Randomisation: Ambulance stations within each region are the units of randomisation. According to station allocation, paramedics based at a station deliver the PASTA pathway (intervention) or continue with standard stroke care (control). Study intervention: The PASTA pathway includes structured pre-hospital information collection, prompted pre-notification, structured handover of information in hospital and assistance with simple tasks during the initial hospital assessment. Study-trained intervention group paramedics deliver this pathway to adults within 4 h of suspected stroke onset. Study control: Standard stroke care according to national and local guidelines for the pre-hospital and hospital assessment of suspected stroke. Participants: Participants enrolled in the study are adults with confirmed stroke who were assessed by a study paramedic within 4 h of symptom onset. Primary outcome: Proportion of participants receiving IV thrombolysis. Sample size: 1297 participants provide 90% power to detect a 10% difference in the proportion of patients receiving IV thrombolysis. Discussion The results from this trial will determine whether an enhanced care pathway delivered by paramedics can increase thrombolysis delivery rates. Trial registration ISRCTN registry, ISRCTN12418919. Registered on 5 November 2015. Electronic supplementary material The online version of this article (10.1186/s13063-018-3144-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christopher I Price
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, UK.
| | - Lisa Shaw
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, UK.
| | - Peter Dodd
- Lay investigator. Contact via: Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, UK
| | - Catherine Exley
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - Darren Flynn
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - Richard Francis
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, UK
| | - Saiful Islam
- College of Medicine, Swansea University, Singleton Park, Swansea, SA2 8PP, Wales
| | - Mehdi Javanbakht
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - Rachel Lakey
- Newcastle Clinical Trials Unit, Newcastle University, 1-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, UK
| | - Joanne Lally
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - Graham McClelland
- North East Ambulance Service, Bernicia House, Goldcrest Way, Newburn Riverside, Newcastle upon Tyne, NE15 8NY, UK
| | - Peter McMeekin
- Faculty of Health & Life Sciences, Northumbria University, 2nd floor Northumberland Building, Newcastle upon Tyne, NE1 8ST, UK
| | - Helen Rodgers
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Hospital, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| | - Helen Snooks
- College of Medicine, Swansea University, Singleton Park, Swansea, SA2 8PP, Wales
| | - Louise Sutcliffe
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, UK
| | - Pippa Tyrell
- Stroke Medicine, Clinical Sciences Building, Salford Royal Hospitals' NHS Foundation Trust, Salford, M6 8HD, UK
| | - Luke Vale
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - Alan Watkins
- College of Medicine, Swansea University, Singleton Park, Swansea, SA2 8PP, Wales
| | - Gary A Ford
- Medical Sciences Division, University of Oxford, and Oxford University Hospitals NHS Foundation Trust, Level 3, John Radcliffe Hospital, Oxford, OX3 9DU, UK
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Rodgers H, Shaw L, Bhattarai N, Cant R, Drummond A, Ford GA, Forster A, Francis R, Hills K, Howel D, Laverty AM, McKevitt C, McMeekin P, Price C, Stamp E, Stevens E, Vale L. 137A trial to evaluate an eXTended RehAbilitation service for Stroke patients (EXTRAS): main patient results. Age Ageing 2019. [DOI: 10.1093/ageing/afz001.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- H Rodgers
- Newcastle University
- Northumbria Healthcare NHS Foundation Trust
- Newcastle upon Tyne Hospitals NHS Foundation Trust
| | | | | | | | | | | | | | | | | | | | | | | | | | - C Price
- Newcastle University
- Northumbria Healthcare NHS Foundation Trust
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Rodgers H, Scott O. National Lung Cancer Audit patient booklet impact assessment: an evaluation. Lung Cancer 2019. [DOI: 10.1016/s0169-5002(19)30187-4] [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: 11/17/2022]
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McClelland G, Flynn D, Rodgers H, Price C. 01 Development and validation of a pragmatic prehospital tool to identify stroke MIMIC patients. Arch Emerg Med 2019. [DOI: 10.1136/emermed-2019-999.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundStroke mimics (SM) are non-stroke conditions producing similar symptoms to stroke. Prehospital stroke identification tools prioritise sensitivity over specificity, therefore >25% of prehospital suspected stroke patients are SM. Failure to identify SM Results in inefficient use of ambulances and specialist stroke services. We developed a pragmatic tool for paramedics, using information often available in the prehospital setting, to identify SM amongst suspected stroke patients.MethodsThe initial tool was developed using a systematic literature review to identify SM characteristics, a survey of UK paramedics to explore the acceptability of SM identification and regression analysis of clinical variables documented in ambulance records of suspected stroke patients linked to their primary hospital diagnoses (n=1,650, 40% SM).The initial tool was refined using two focus groups with paramedics (n=3) and hospital clinicians (n=9) and analysis of an expanded prehospital dataset (n=3,797, 41% SM) to produce the final STEAM tool.ResultsSTEAM scores six variables:1 point for Systolic blood pressure <90 mmHg1 point for Temperature >38.5°C with heart rate >90 bpm1 point for seizures or 2 points for seizures with diagnosed Epilepsy1 point for Age <40 years or 2 points for age <30 years1 point for headache with diagnosed Migraine1 point for FAST–veA score of ≥2 on STEAM predicted SM diagnosis in the expanded derivation dataset with 5.5% sensitivity, 99.6% specificity and positive predictive value (PPV) of 91.4%. STEAM was validated using an external dataset (n=1,848, 33% SM) of prehospital suspected stroke patients where STEAM was 5.5% sensitive, 99.4% specific with a PPV of 82.5%.ConclusionsSTEAM uses common clinical characteristics to identify a small number of SM patients with a high level of certainty. The benefits of reducing SM admissions to specialist stroke services should be weighed against delayed admission for the small number of stroke patients identified as a SM.
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Abstract
We evaluated the impact of the centralisation of three acute stroke units into a single hyperacute stroke unit within a large urban and rural NHS trust in North East England in June 2015. We performed retrospective interrupted time series analyses of 4,305 stroke patients admitted between 1 April 2013 and 31 December 2017 utilising data recorded for the Sentinel Stroke National Audit Programme. Centralisation was -associated with reductions in total length of inpatient stay (-4.9 days [95% CI: -8.1 to -1.7]). Time from admission to thrombolysis shortened by 26.0 minutes (95% CI: -40.0 to -12.1), and time from admission to brain imaging for thrombolysed patients improved by 16.2 minutes (95% CI: -22.0 to -10.4). Time from stroke onset to hospital admission, mortality and dependency (as measured by median modified Rankin Scale) were unaffected by centralisation. This study provides further evidence to support the centralisation of acute stroke services in England.
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Affiliation(s)
- Mat Elameer
- Stroke Research Group, Newcastle University, Newcastle-upon-Tyne, UK
| | - Chris Price
- Stroke Research Group, Newcastle University, Newcastle-upon-Tyne, UK
| | - Darren Flynn
- Institute of Health and Society, Newcastle University, Newcastle-upon-Tyne, UK
| | - Helen Rodgers
- Stroke Research Group, Newcastle University, Newcastle-upon-Tyne, UK
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Kengen R, Thoonen E, Daveson K, Loong B, Rodgers H, Beckingham W, Kennedy K, Suwandarathne R, van Haren F. Chlorhexidine washing in intensive care does not reduce bloodstream infections, blood culture contamination and drug-resistant microorganism acquisition: an interrupted time series analysis. CRIT CARE RESUSC 2018; 20:231-240. [PMID: 30153786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Health care-associated infections are a major cause of morbidity and mortality in intensive care patients. The effect of daily washing with chlorhexidine on these infections is controversial. METHODS Single-centre, retrospective, open-label, sequential period, interrupted time series (ITS) analysis in a 31-bed tertiary referral mixed intensive care unit (ICU), comparing daily washing with water and soap (from January 2011 to August 2013) with chlorhexidine washing (from November 2013 to December 2015), after the introduction of a unit-level policy of chlorhexidine washing. All patients in the ICU were included in the study, except: if they were under 18 years of age, if their ICU stay was less than 24 hours (to ensure that all studied patients had at least one exposure to the daily wash intervention), or if patients had a known allergy to chlorhexidine. Outcome measures included: clinically significant positive blood cultures attributable to the ICU stay; contaminated blood cultures; newly acquired multidrug-resistant microorganisms (MDRO) such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE) or multidrug-resistant gram-negative (MRGN) isolates attributable to ICU from clinical and screening cultures; and newly acquired Clostridium difficile infections (CDIs). Incidence rates of these outcomes were calculated per 1000 patient days. MDRO acquisition rates were corrected for background hospital period prevalence rates of MDRO. RESULTS A total of 6634 patients were included in the study. ITS analysis showed no significant level or slope changes in any of the outcome measures after implementation of chlorhexidine washing. The incidence rate of clinically significant positive blood cultures during the chlorhexidine period compared with the water and soap period was 3.6 v 4.7 (P =0.37); blood culture contamination rates were 11.8 v 9.5 (P =0.56); incidence rates of new ICU-associated MDRO acquisitions were 3.22 v 3.69 (P =0.27); incidence rates of new CDI were 2.01 v 0.79 (P =0.16). Outcomes after adjustment for known and potential confounders were similar. CONCLUSIONS In this real-world, long term ICU study, implementation of a unit-level policy of daily washing with chlorhexidine impregnated cloths was not associated with a reduction in the rates of ICU-associated clinically significant positive blood cultures, blood culture contamination, newly acquired MDRO isolates, and CDIs.
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Affiliation(s)
- Roel Kengen
- Intensive Care Unit, Canberra Hospital, Woden, ACT, Australia.
| | - Elcke Thoonen
- Intensive Care Unit, Canberra Hospital, Woden, ACT, Australia
| | - Kathryn Daveson
- Infectious Diseases and Microbiology, Canberra Hospital, Woden, ACT, Australia
| | - Bronwyn Loong
- Research School of Finance, Actuarial Studies and Applied Statistics, Australian National University, Canberra, ACT, Australia
| | - Helen Rodgers
- Intensive Care Unit, Canberra Hospital, Woden, ACT, Australia
| | - Wendy Beckingham
- Infection Prevention and Control, Canberra Hospital, Woden, ACT, Australia
| | - Karina Kennedy
- Infectious Diseases and Microbiology, Canberra Hospital, Woden, ACT, Australia
| | | | - Frank van Haren
- Intensive Care Unit, Canberra Hospital, Woden, ACT, Australia
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Clarke DJ, Burton LJ, Tyson SF, Rodgers H, Drummond A, Palmer R, Hoffman A, Prescott M, Tyrrell P, Brkic L, Grenfell K, Forster A. Why do stroke survivors not receive recommended amounts of active therapy? Findings from the ReAcT study, a mixed-methods case-study evaluation in eight stroke units. Clin Rehabil 2018; 32:1119-1132. [PMID: 29582712 PMCID: PMC6068965 DOI: 10.1177/0269215518765329] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [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: 07/25/2017] [Accepted: 02/24/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To identify why the National Clinical Guideline recommendation of 45 minutes of each appropriate therapy daily is not met in many English stroke units. DESIGN Mixed-methods case-study evaluation, including modified process mapping, non-participant observations of service organisation and therapy delivery, documentary analysis and semi-structured interviews. SETTING Eight stroke units in four English regions. SUBJECTS Seventy-seven patients with stroke, 53 carers and 197 stroke unit staff were observed; 49 patients, 50 carers and 131 staff participants were interviewed. RESULTS Over 1000 hours of non-participant observations and 433 patient-specific therapy observations were undertaken. The most significant factor influencing amount and frequency of therapy provided was the time therapists routinely spent, individually and collectively, in information exchange. Patient factors, including fatigue and tolerance influenced therapists' decisions about frequency and intensity, typically resulting in adaptation of therapy rather than no provision. Limited use of individual patient therapy timetables was evident. Therapist staffing levels were associated with differences in therapy provision but were not the main determinant of intensity and frequency. Few therapists demonstrated understanding of the evidence underpinning recommendations for increased therapy frequency and intensity. Units delivering more therapy had undertaken patient-focused reorganisation of therapists' working practices, enabling them to provide therapy consistent with guideline recommendations. CONCLUSION Time spent in information exchange impacted on therapy provision in stroke units. Reorganisation of therapists' work improved alignment with guidelines.
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Affiliation(s)
- David J Clarke
- Academic Unit of Elderly Care and
Rehabilitation, Leeds Institute of Health Sciences, Bradford Royal Infirmary,
Bradford, UK
| | - Louisa-Jane Burton
- Academic Unit of Elderly Care and
Rehabilitation, Leeds Institute of Health Sciences, Bradford Royal Infirmary,
Bradford, UK
| | - Sarah F Tyson
- School of Health Sciences, Manchester
Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Helen Rodgers
- Stroke Research Group, Institute of
Neuroscience, Newcastle University, Newcastle, UK
| | - Avril Drummond
- Faculty of Medicine and Health Sciences,
University of Nottingham, Nottingham, UK
| | - Rebecca Palmer
- Health Services Research, School of
Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Alex Hoffman
- Sentinel Stroke National Audit
Programme, Royal College of Physicians, London, UK
| | - Matthew Prescott
- Physiotherapy Department, Bradford
Teaching Hospitals NHS Trust, Bradford, UK
| | - Pippa Tyrrell
- Salford Royal NHS Foundation Trust and
Manchester Academic Health Science Centre, The University of Manchester, Manchester,
UK
| | - Lianne Brkic
- Academic Unit of Elderly Care and
Rehabilitation, Leeds Institute of Health Sciences, Bradford Royal Infirmary,
Bradford, UK
- Stroke Research Group, Institute of
Neuroscience, Newcastle University, Newcastle, UK
| | - Katie Grenfell
- Academic Unit of Elderly Care and
Rehabilitation, Leeds Institute of Health Sciences, Bradford Royal Infirmary,
Bradford, UK
| | - Anne Forster
- Academic Unit of Elderly Care and
Rehabilitation, Leeds Institute of Health Sciences, Bradford Royal Infirmary,
Bradford, UK
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Langhorne P, Wu O, Rodgers H, Ashburn A, Bernhardt J. A Very Early Rehabilitation Trial after stroke (AVERT): a Phase III, multicentre, randomised controlled trial. Health Technol Assess 2018; 21:1-120. [PMID: 28967376 DOI: 10.3310/hta21540] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Mobilising patients early after stroke [early mobilisation (EM)] is thought to contribute to the beneficial effects of stroke unit care but it is poorly defined and lacks direct evidence of benefit. OBJECTIVES We assessed the effectiveness of frequent higher dose very early mobilisation (VEM) after stroke. DESIGN We conducted a parallel-group, single-blind, prospective randomised controlled trial with blinded end-point assessment using a web-based computer-generated stratified randomisation. SETTING The trial took place in 56 acute stroke units in five countries. PARTICIPANTS We included adult patients with a first or recurrent stroke who met physiological inclusion criteria. INTERVENTIONS Patients received either usual stroke unit care (UC) or UC plus VEM commencing within 24 hours of stroke. MAIN OUTCOME MEASURES The primary outcome was good recovery [modified Rankin scale (mRS) score of 0-2] 3 months after stroke. Secondary outcomes at 3 months were the mRS, time to achieve walking 50 m, serious adverse events, quality of life (QoL) and costs at 12 months. Tertiary outcomes included a dose-response analysis. DATA SOURCES Patients, outcome assessors and investigators involved in the trial were blinded to treatment allocation. RESULTS We recruited 2104 (UK, n = 610; Australasia, n = 1494) patients: 1054 allocated to VEM and 1050 to UC. Intervention protocol targets were achieved. Compared with UC, VEM patients mobilised 4.8 hours [95% confidence interval (CI) 4.1 to 5.7 hours; p < 0.0001] earlier, with an additional three (95% CI 3.0 to 3.5; p < 0.0001) mobilisation sessions per day. Fewer patients in the VEM group (n = 480, 46%) had a favourable outcome than in the UC group (n = 525, 50%) (adjusted odds ratio 0.73, 95% CI 0.59 to 0.90; p = 0.004). Results were consistent between Australasian and UK settings. There were no statistically significant differences in secondary outcomes at 3 months and QoL at 12 months. Dose-response analysis found a consistent pattern of an improved odds of efficacy and safety outcomes in association with increased daily frequency of out-of-bed sessions but a reduced odds with an increased amount of mobilisation (minutes per day). LIMITATIONS UC clinicians started mobilisation earlier each year altering the context of the trial. Other potential confounding factors included staff patient interaction. CONCLUSIONS Patients in the VEM group were mobilised earlier and with a higher dose of therapy than those in the UC group, which was already early. This VEM protocol was associated with reduced odds of favourable outcome at 3 months cautioning against very early high-dose mobilisation. At 12 months, health-related QoL was similar regardless of group. Shorter, more frequent mobilisation early after stroke may be associated with a more favourable outcome. FUTURE WORK These results informed a new trial proposal [A Very Early Rehabilitation Trial - DOSE (AVERT-DOSE)] aiming to determine the optimal frequency and dose of EM. TRIAL REGISTRATION The trial is registered with the Australian New Zealand Clinical Trials Registry number ACTRN12606000185561, Current Controlled Trials ISRCTN98129255 and ISRCTN98129255. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 54. See the NIHR Journals Library website for further project information. Funding was also received from the National Health and Medical Research Council Australia, Singapore Health, Chest Heart and Stroke Scotland, Northern Ireland Chest Heart and Stroke, and the Stroke Association. In addition, National Health and Medical Research Council fellowship funding was provided to Julie Bernhardt (1058635), who also received fellowship funding from the Australia Research Council (0991086) and the National Heart Foundation (G04M1571). The Florey Institute of Neuroscience and Mental Health, which hosted the trial, acknowledges the support received from the Victorian Government via the Operational Infrastructure Support Scheme.
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Affiliation(s)
- Peter Langhorne
- Academic Section of Geriatric Medicine, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Olivia Wu
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Helen Rodgers
- Institute for Ageing and Health, Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Ann Ashburn
- Rehabilitation Research Unit, Southampton General Hospital, Southampton, UK
| | - Julie Bernhardt
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia.,University of Melbourne, Parkville, VIC, Australia
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De Brún A, Flynn D, Ternent L, Price CI, Rodgers H, Ford GA, Rudd M, Lancsar E, Simpson S, Teah J, Thomson RG. A novel design process for selection of attributes for inclusion in discrete choice experiments: case study exploring variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke. BMC Health Serv Res 2018; 18:483. [PMID: 29929523 PMCID: PMC6013945 DOI: 10.1186/s12913-018-3305-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [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: 10/26/2017] [Accepted: 06/18/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND A discrete choice experiment (DCE) is a method used to elicit participants' preferences and the relative importance of different attributes and levels within a decision-making process. DCEs have become popular in healthcare; however, approaches to identify the attributes/levels influencing a decision of interest and to selection methods for their inclusion in a DCE are under-reported. Our objectives were: to explore the development process used to select/present attributes/levels from the identified range that may be influential; to describe a systematic and rigorous development process for design of a DCE in the context of thrombolytic therapy for acute stroke; and, to discuss the advantages of our five-stage approach to enhance current guidance for developing DCEs. METHODS A five-stage DCE development process was undertaken. Methods employed included literature review, qualitative analysis of interview and ethnographic data, expert panel discussions, a quantitative structured prioritisation (ranking) exercise and pilot testing of the DCE using a 'think aloud' approach. RESULTS The five-stage process reported helped to reduce the list of 22 initial patient-related factors to a final set of nine variable factors and six fixed factors for inclusion in a testable DCE using a vignette model of presentation. CONCLUSIONS In order for the data and conclusions generated by DCEs to be deemed valid, it is crucial that the methods of design and development are documented and reported. This paper has detailed a rigorous and systematic approach to DCE development which may be useful to researchers seeking to establish methods for reducing and prioritising attributes for inclusion in future DCEs.
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Affiliation(s)
- Aoife De Brún
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK. .,School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland.
| | - Darren Flynn
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Laura Ternent
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher I Price
- NIHR Newcastle Biomedical Research Centre based at Newcastle upon Tyne Hospitals NHS Trust and Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Helen Rodgers
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK.,Northumbria Healthcare NHS Foundation Trust, Ashington, UK
| | - Gary A Ford
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Matthew Rudd
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK.,Northumbria Healthcare NHS Foundation Trust, Ashington, UK
| | - Emily Lancsar
- Department of Health Services Research and Policy, Research School of Population Health, Australian National University, Canberra, Australia
| | | | - John Teah
- The Stroke Association, Gateshead, UK
| | - Richard G Thomson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
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Hodkin EF, Lei Y, Humby J, Glover IS, Choudhury S, Kumar H, Perez MA, Rodgers H, Jackson A. Automated FES for Upper Limb Rehabilitation Following Stroke and Spinal Cord Injury. IEEE Trans Neural Syst Rehabil Eng 2018; 26:1067-1074. [PMID: 29752242 PMCID: PMC6051484 DOI: 10.1109/tnsre.2018.2816238] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 02/20/2018] [Accepted: 03/01/2018] [Indexed: 11/07/2022]
Abstract
Neurorehabilitation aims to induce beneficial neural plasticity in order to restore function following injury to the nervous system. There is an increasing evidence that appropriately timed functional electrical stimulation (FES) can promote associative plasticity, but the dosage is critical for lasting functional benefits. Here, we present a novel approach to closed-loop control of muscle stimulation for the rehabilitation of reach-to-grasp movements following stroke and spinal cord injury (SCI). We developed a simple, low-cost device to deliver assistive stimulation contingent on users' self-initiated movements. The device allows repeated practice with minimal input by a therapist, and is potentially suitable for home use. Pilot data demonstrate usability by people with upper limb weakness following SCI and stroke, and participant feedback was positive. Moreover, repeated training with the device over 1-2 weeks led to functional benefits on a general object manipulation assessment. Thus, automated FES delivered by this novel device may provide a promising and readily translatable therapy for upper limb rehabilitation for people with stroke and SCI.
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31
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Da-Silva RH, van Wijck F, Shaw L, Rodgers H, Balaam M, Brkic L, Ploetz T, Jackson D, Ladha K, Price CI. Prompting arm activity after stroke: A clinical proof of concept study of wrist-worn accelerometers with a vibrating alert function. J Rehabil Assist Technol Eng 2018; 5:2055668318761524. [PMID: 31191927 PMCID: PMC6453063 DOI: 10.1177/2055668318761524] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 05/19/2017] [Accepted: 01/11/2018] [Indexed: 11/20/2022] Open
Abstract
Background Frequent practice of functional movements after stroke may optimise motor
recovery; however, it is challenging for patients to remember to integrate
an impaired limb into daily activities. We report the activity responses of
stroke patients receiving a vibrating alert delivered by a tri-axial
accelerometer wristband to prompt movement of the impaired arm if hourly
activity levels fell. Methods Adults with upper limb impairment ≤28 days post-stroke wore the device for
four weeks. Therapists and patients reviewed movement activity data twice
weekly to agree ongoing rehabilitation activities and programme the
wristband with a personalised prompt threshold (median baseline
activity + 5%, 25% or 50%). Results: Seven patients completed the programme (five males;
mean ± standard deviation (age) 64 ± 5 years; days post-stroke 13 ± 7;
baseline/four-week Action Research Arm Test median (Interquartile range
(IQR)) 39 (8, 44)/56 (11, 57)). Wristbands were worn for 89% of programme
duration. A total of 1,288 prompts were delivered, with a median of four
(IQR 3,7) prompts per patient per day. Mean activity increases following a
prompt ranged from 11% to 29%. Conclusions Feedback delivered by a programmable accelerometer increased impaired arm
activity. Improvements are required in device reliability before conducting
a pragmatic clinical trial to examine the impact upon recovery.
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Affiliation(s)
- Ruth H Da-Silva
- 1Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Frederike van Wijck
- 2School of Health and Life Science, Glasgow Caledonian University, Glasgow, UK
| | - Lisa Shaw
- 1Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Helen Rodgers
- 1Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Madeline Balaam
- 3School of Computing Science, Newcastle University, Newcastle upon Tyne, UK
| | - Lianne Brkic
- 1Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Thomas Ploetz
- 3School of Computing Science, Newcastle University, Newcastle upon Tyne, UK
| | - Dan Jackson
- 3School of Computing Science, Newcastle University, Newcastle upon Tyne, UK
| | - Karim Ladha
- 3School of Computing Science, Newcastle University, Newcastle upon Tyne, UK
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Rowe FJ, Hanna K, Evans JR, Noonan CP, Garcia‐Finana M, Dodridge CS, Howard C, Jarvis KA, MacDiarmid SL, Maan T, North L, Rodgers H. Interventions for eye movement disorders due to acquired brain injury. Cochrane Database Syst Rev 2018; 3:CD011290. [PMID: 29505103 PMCID: PMC6494416 DOI: 10.1002/14651858.cd011290.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Acquired brain injury can cause eye movement disorders which may include: strabismus, gaze deficits and nystagmus, causing visual symptoms of double, blurred or 'juddery' vision and reading difficulties. A wide range of interventions exist that have potential to alleviate or ameliorate these symptoms. There is a need to evaluate the effectiveness of these interventions and the timing of their implementation. OBJECTIVES We aimed to assess the effectiveness of any intervention and determine the effect of timing of intervention in the treatment of strabismus, gaze deficits and nystagmus due to acquired brain injury. We considered restitutive, substitutive, compensatory or pharmacological interventions separately and compared them to control, placebo, alternative treatment or no treatment for improving ocular alignment or motility (or both). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (containing the Cochrane Eyes and Vision Trials Register) (2017, Issue 5), MEDLINE Ovid, Embase Ovid, CINAHL EBSCO, AMED Ovid, PsycINFO Ovid, Dissertations & Theses (PQDT) database, PsycBITE (Psychological Database for Brain Impairment Treatment Efficacy), ISRCTN registry, ClinicalTrials.gov, Health Services Research Projects in Progress (HSRProj), National Eye Institute Clinical Studies Database and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). The databases were last searched on 26 June 2017. No date or language restrictions were used in the electronic searches for trials. We manually searched the Australian Orthoptic Journal, British and Irish Orthoptic Journal, and ESA, ISA and IOA conference proceedings. We contacted researchers active in this field for information about further published or unpublished studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) of any intervention for ocular alignment or motility deficits (or both) due to acquired brain injury. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies and extracted data. We used standard methods expected by Cochrane. We employed the GRADE approach to interpret findings and assess the quality of the evidence. MAIN RESULTS We found five RCTs (116 participants) that were eligible for inclusion. These trials included conditions of acquired nystagmus, sixth cranial nerve palsy and traumatic brain injury-induced ocular motility defects. We did not identify any relevant studies of restitutive interventions.We identified one UK-based trial of a substitutive intervention, in which botulinum toxin was compared with observation in 47 people with acute sixth nerve palsy. At four months after entry into the trial, people given botulinum toxin were more likely to make a full recovery (reduction in angle of deviation within 10 prism dioptres), compared with observation (risk ratio 1.19, 95% CI 0.96 to 1.48; low-certainty evidence). These same participants also achieved binocular single vision. In the injection group only, there were 2 cases of transient ptosis out of 22 participants (9%), and 4 participants out of 22 (18%) with transient vertical deviation; a total complication rate of 24% per injection and 27% per participant. All adverse events recovered. We judged the certainty of evidence as low, downgrading for risk of bias and imprecision. It was not possible to mask investigators or participants to allocation, and the follow-up between groups varied.We identified one USA-based cross-over trial of a compensatory intervention. Oculomotor rehabilitation was compared with sham training in 12 people with mild traumatic brain injury, at least one year after the injury. We judged the evidence from this study to be very low-certainty. The study was small, data for the sham training group were not fully reported, and it was unclear if a cross-over study design was appropriate as this is an intervention with potential to have a permanent effect.We identified three cross-over studies of pharmacological interventions for acquired nystagmus, which took place in Germany and the USA. These studies investigated two classes of pharmacological interventions: GABAergic drugs (gabapentin, baclofen) and aminopyridines (4-aminopyridines (AP), 3,4-diaminopyridine (DAP)). We judged the evidence from all three studies as very low-certainty because of small numbers of participants (which led to imprecision) and risk of bias (they were cross-over studies which did not report data in a way that permitted estimation of effect size).One study compared gabapentin (up to 900 mg/day) with baclofen (up to 30 mg/day) in 21 people with pendular and jerk nystagmus. The follow-up period was two weeks. This study provides very low-certainty evidence that gabapentin may work better than baclofen in improving ocular motility and reducing participant-reported symptoms (oscillopsia). These effects may be different in pendular and jerk nystagmus, but without formal subgroup analysis it is unclear if the difference between the two types of nystagmus was chance finding. Quality of life was not reported. Ten participants with pendular nystagmus chose to continue treatment with gabapentin, and one with baclofen. Two participants with jerk nystagmus chose to continue treatment with gabapentin, and one with baclofen. Drug intolerance was reported in one person receiving gabapentin and in four participants receiving baclofen. Increased ataxia was reported in three participants receiving gabapentin and two participants receiving baclofen.One study compared a single dose of 3,4-DAP (20 mg) with placebo in 17 people with downbeat nystagmus. Assessments were made 30 minutes after taking the drug. This study provides very low-certainty evidence that 3,4-DAP may reduce the mean peak slow-phase velocity, with less oscillopsia, in people with downbeat nystagmus. Three participants reported transient side effects of minor perioral/distal paraesthesia.One study compared a single dose of 4-AP with a single dose of 3,4-DAP (both 10 mg doses) in eight people with downbeat nystagmus. Assessments were made 45 and 90 minutes after drug administration. This study provides very low-certainty evidence that both 3,4-DAP and 4-AP may reduce the mean slow-phase velocity in people with downbeat nystagmus. This effect may be stronger with 4-AP. AUTHORS' CONCLUSIONS The included studies provide insufficient evidence to inform decisions about treatments specifically for eye movement disorders that occur following acquired brain injury. No information was obtained on the cost of treatment or measures of participant satisfaction relating to treatment options and effectiveness. It was possible to describe the outcome of treatment in each trial and ascertain the occurrence of adverse events.
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Affiliation(s)
- Fiona J Rowe
- University of LiverpoolDepartment of Health Services ResearchWaterhouse Building (B211)1‐3 Brownlow StreetLiverpoolUKL69 3GL
| | - Kerry Hanna
- University of LiverpoolDepartment of Health Services ResearchWaterhouse Building (B211)1‐3 Brownlow StreetLiverpoolUKL69 3GL
| | - Jennifer R Evans
- London School of Hygiene & Tropical MedicineCochrane Eyes and Vision, ICEHKeppel StreetLondonUKWC1E 7HT
| | - Carmel P Noonan
- Aintree University Hospitals NHS Foundation TrustDepartment of OphthalmologyLower LaneLiverpoolUKL9 7AL
| | - Marta Garcia‐Finana
- University of LiverpoolBiostatisticsBlock F, Waterhouse Bld1‐5 Brownlow StreetLiverpoolUKL69 3GL
| | - Caroline S Dodridge
- Oxford University Hospitals NHS TrustOrthopticsOxford Eye Hospital, John Radcliffe Hospital, Headley WayOxfordUKOX3 9DU
| | - Claire Howard
- Salford Royal NHS Foundation TrustOrthopticsStott LaneSalfordManchesterUKM6 8HD
| | - Kathryn A Jarvis
- University of LiverpoolOccupational TherapyBrownlow HillLiverpoolUKL69 3GB
| | - Sonia L MacDiarmid
- Warrington and Halton Hospitals NHS Foundation TrustDepartment of OrthopticsLovely LaneWarringtonUKWA5 2QQ
| | - Tallat Maan
- Pennine Care NHS Foundation TrustCommunity Eye Service225 Old StreetAshton‐under‐LyneUKOL6 7SR
| | - Lorraine North
- Frimley Park NHS Foundation TrustOrthopticsPortsmouth RoadFrimleySurreyUKGU16 7UJ
| | - Helen Rodgers
- Newcastle UniversityInstitute of NeuroscienceNewcastleUKNE2 4HH
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Rodgers H, Scott O, Beckett P, Navani N, Dickinson R. Development of the first patient-level National Lung Cancer Audit 2016 key findings for patient and carers. Lung Cancer 2018. [DOI: 10.1016/s0169-5002(18)30148-x] [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: 11/25/2022]
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Hansen CK, Christensen A, Rodgers H, Havsteen I, Kruuse C, Christensen H. Does the Primary Imaging Modality-Computed Tomography or Magnetic Resonance Imaging-Influence Stroke Physicians' Certainty on Whether or Not to Give Thrombolysis to Randomized Acute Stroke Patients? J Stroke Cerebrovasc Dis 2017; 27:926-935. [PMID: 29198901 DOI: 10.1016/j.jstrokecerebrovasdis.2017.10.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 03/10/2017] [Revised: 10/26/2017] [Accepted: 10/29/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Door-to-needle time of 20 minutes to stroke patients with intravenous tissue plasminogen activator (iv-tPA) is feasible when computed tomography (CT) is used as first-line of brain imaging. Magnetic resonance imaging (MRI)-based assessment is more time-consuming but superior in detecting acute ischemia. The certainty with which stroke physicians prescribe or refrain from giving iv-tPA treatment to CT- versus MRI-examined patients has not previously been studied. The aim of the present study was to determine the effect of a primary imaging strategy of CT or MRI on clinicians' certainty to prescribe or refrain from giving iv-tPA to patients with suspected acute stroke. METHOD Consecutive patients with suspected stroke were quasi-randomized to either CT- or MRI-based assessment before potential iv-tPA treatment. The influence of (1) the clinical findings and (2) the image findings, and (3) the certainty with which the stroke physician prescribed or refrained from giving iv-tPA treatment were assessed with visual analog scales (VAS). Predictors of treatment certainty were identified with a random-effect model. RESULTS Four-hundred forty-four consecutive patients were quasi-randomized. MRI influenced the final treatment decision more than CT (P = .002). Compared with CT-examined patients (mean VAS score 8.6, SD ±1.6) stroke physicians were significantly more certain when prescribing or refraining from giving iv-tPA to MRI-examined patients (mean VAS score 9.0, SD ±1.2) (P = .014). No differences in modified Rankin scale or mortality were detected at 3 months in CT- versus MRI-examined iv-tPA-treated patients. CONCLUSIONS Stroke physicians were significantly more certain when prescribing iv-tPA to MRI-examined stroke patients, and MRI influences the final treatment decision significantly more compared with CT, although no difference in mortality and functional outcome at 3 months was detected between CT- and MRI-examined patients treated with iv-tPA.
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Affiliation(s)
- Christine Krarup Hansen
- Department of Neurology, Bispebjerg-Frederiksberg-Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Anders Christensen
- Department of Radiology, Bispebjerg-Frederiksberg-Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Helen Rodgers
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle, United Kingdom
| | - Inger Havsteen
- Department of Radiology, Bispebjerg-Frederiksberg-Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Christina Kruuse
- Department of Neurology, Neurovascular Research Unit, Herlev-Gentofte-Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Hanne Christensen
- Department of Neurology, Bispebjerg-Frederiksberg-Hospital, University of Copenhagen, Copenhagen, Denmark
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McClelland G, Rodgers H, Flynn D, Price C. PP14 Development of a prehospital assessment to identify stroke mimic conditions. Arch Emerg Med 2017. [DOI: 10.1136/emermed-2017-207114.14] [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: 11/04/2022]
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Rodgers H, Shaw L, Bosomworth H, Aird L, Alvarado N, Andole S, Cohen DL, Dawson J, Eyre J, Finch T, Ford GA, Hislop J, Hogg S, Howel D, Hughes N, Krebs HI, Price C, Rochester L, Stamp E, Ternent L, Turner D, Vale L, Warburton E, van Wijck F, Wilkes S. Robot Assisted Training for the Upper Limb after Stroke (RATULS): study protocol for a randomised controlled trial. Trials 2017; 18:340. [PMID: 28728602 PMCID: PMC5520386 DOI: 10.1186/s13063-017-2083-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [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: 10/15/2016] [Accepted: 07/04/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Loss of arm function is a common and distressing consequence of stroke. We describe the protocol for a pragmatic, multicentre randomised controlled trial to determine whether robot-assisted training improves upper limb function following stroke. METHODS/DESIGN Study design: a pragmatic, three-arm, multicentre randomised controlled trial, economic analysis and process evaluation. SETTING NHS stroke services. PARTICIPANTS adults with acute or chronic first-ever stroke (1 week to 5 years post stroke) causing moderate to severe upper limb functional limitation. Randomisation groups: 1. Robot-assisted training using the InMotion robotic gym system for 45 min, three times/week for 12 weeks 2. Enhanced upper limb therapy for 45 min, three times/week for 12 weeks 3. Usual NHS care in accordance with local clinical practice Randomisation: individual participant randomisation stratified by centre, time since stroke, and severity of upper limb impairment. PRIMARY OUTCOME upper limb function measured by the Action Research Arm Test (ARAT) at 3 months post randomisation. SECONDARY OUTCOMES upper limb impairment (Fugl-Meyer Test), activities of daily living (Barthel ADL Index), quality of life (Stroke Impact Scale, EQ-5D-5L), resource use, cost per quality-adjusted life year and adverse events, at 3 and 6 months. Blinding: outcomes are undertaken by blinded assessors. Economic analysis: micro-costing and economic evaluation of interventions compared to usual NHS care. A within-trial analysis, with an economic model will be used to extrapolate longer-term costs and outcomes. Process evaluation: semi-structured interviews with participants and professionals to seek their views and experiences of the rehabilitation that they have received or provided, and factors affecting the implementation of the trial. SAMPLE SIZE allowing for 10% attrition, 720 participants provide 80% power to detect a 15% difference in successful outcome between each of the treatment pairs. Successful outcome definition: baseline ARAT 0-7 must improve by 3 or more points; baseline ARAT 8-13 improve by 4 or more points; baseline ARAT 14-19 improve by 5 or more points; baseline ARAT 20-39 improve by 6 or more points. DISCUSSION The results from this trial will determine whether robot-assisted training improves upper limb function post stroke. TRIAL REGISTRATION ISRCTN, identifier: ISRCTN69371850 . Registered 4 October 2013.
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Affiliation(s)
- Helen Rodgers
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
- Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, Rake Lane, North Shields, Tyne and Wear NE29 8NH UK
| | - Lisa Shaw
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
| | - Helen Bosomworth
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
| | - Lydia Aird
- Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, Rake Lane, North Shields, Tyne and Wear NE29 8NH UK
| | - Natasha Alvarado
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX UK
| | - Sreeman Andole
- Barking, Havering and Redbridge University Hospitals NHS Trust Queen’s Hospital, Rom Valley Way, Romford, Essex RM7 0AG UK
| | - David L. Cohen
- North West London Hospitals NHS Trust, Northwick Park Hospital, Watford Road, Harrow, HA1 3UJ UK
| | - Jesse Dawson
- University of Glasgow, Queen Elizabeth University Hospital, 1342 Govan Road, Govan, Glasgow, G51 4TF UK
| | - Janet Eyre
- Department of Child Health, Institute of Neuroscience, Newcastle University, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP UK
| | - Tracy Finch
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX UK
| | - Gary A. Ford
- Medical Sciences Division, University of Oxford, and Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU UK
- Oxford Academic Health Science Network, Magdalen Centre North Oxford Science Business Park, Oxford, OX4 4GA UK
| | - Jennifer Hislop
- Health Economics Group, Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX UK
| | - Steven Hogg
- Contact via: Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
| | - Denise Howel
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX UK
| | - Niall Hughes
- NHS Greater Glasgow and Clyde, Queen Elizabeth University Hospital, 1342 Govan Road, Govan, Glasgow, G51 4TF UK
| | - Hermano Igo Krebs
- Massachusetts Institute of Technology, 77 Massachusetts Avenue, 3-137, Cambridge, MA 02139 USA
| | - Christopher Price
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
- Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, Wansbeck General Hospital, Woodhorn Lane, Ashington, Northumberland NE63 9JJ UK
| | - Lynn Rochester
- Institute of Neuroscience, Newcastle University, Clinical Ageing Research Unit, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL UK
| | - Elaine Stamp
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX UK
| | - Laura Ternent
- Health Economics Group, Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX UK
| | - Duncan Turner
- University of East London, School of Health, Sport and Biosciences, Stratford Campus, Water Lane, Stratford, London, E15 4LZ UK
| | - Luke Vale
- Health Economics Group, Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX UK
| | - Elizabeth Warburton
- Cambridge University Health Partners (Addenbrooke’s Hospital), R3 Neurosciences, Addenbrooke’s Hospital, Hills Road, Box 83, Cambridge, CB2 2QQ UK
| | - Frederike van Wijck
- Institute for Applied Health Research and School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA UK
| | - Scott Wilkes
- Department of Pharmacy, Health and Wellbeing, Faculty of Applied Sciences, Science Complex, University of Sunderland, City Campus, Chester Road, Sunderland, SR1 3SD UK
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Bryant JM, Grogono DM, Rodriguez-Rincon D, Everall I, Brown KP, Moreno P, Verma D, Hill E, Drijkoningen J, Gilligan P, Esther CR, Noone PG, Giddings O, Bell SC, Thomson R, Wainwright CE, Coulter C, Pandey S, Wood ME, Stockwell RE, Ramsay KA, Sherrard LJ, Kidd TJ, Jabbour N, Johnson GR, Knibbs LD, Morawska L, Sly PD, Jones A, Bilton D, Laurenson I, Ruddy M, Bourke S, Bowler IC, Chapman SJ, Clayton A, Cullen M, Daniels T, Dempsey O, Denton M, Desai M, Drew RJ, Edenborough F, Evans J, Folb J, Humphrey H, Isalska B, Jensen-Fangel S, Jönsson B, Jones AM, Katzenstein TL, Lillebaek T, MacGregor G, Mayell S, Millar M, Modha D, Nash EF, O'Brien C, O'Brien D, Ohri C, Pao CS, Peckham D, Perrin F, Perry A, Pressler T, Prtak L, Qvist T, Robb A, Rodgers H, Schaffer K, Shafi N, van Ingen J, Walshaw M, Watson D, West N, Whitehouse J, Haworth CS, Harris SR, Ordway D, Parkhill J, Floto RA. Emergence and spread of a human-transmissible multidrug-resistant nontuberculous mycobacterium. Science 2017; 354:751-757. [PMID: 27846606 DOI: 10.1126/science.aaf8156] [Citation(s) in RCA: 355] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 09/23/2016] [Indexed: 12/20/2022]
Abstract
Lung infections with Mycobacterium abscessus, a species of multidrug-resistant nontuberculous mycobacteria, are emerging as an important global threat to individuals with cystic fibrosis (CF), in whom M. abscessus accelerates inflammatory lung damage, leading to increased morbidity and mortality. Previously, M. abscessus was thought to be independently acquired by susceptible individuals from the environment. However, using whole-genome analysis of a global collection of clinical isolates, we show that the majority of M. abscessus infections are acquired through transmission, potentially via fomites and aerosols, of recently emerged dominant circulating clones that have spread globally. We demonstrate that these clones are associated with worse clinical outcomes, show increased virulence in cell-based and mouse infection models, and thus represent an urgent international infection challenge.
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Affiliation(s)
- Josephine M Bryant
- Wellcome Trust Sanger Institute, Hinxton, UK.,University of Cambridge Department of Medicine, MRC-Laboratory of Molecular Biology, Cambridge, UK
| | - Dorothy M Grogono
- University of Cambridge Department of Medicine, MRC-Laboratory of Molecular Biology, Cambridge, UK.,Cambridge Centre for Lung Infection, Papworth Hospital, Cambridge, UK
| | - Daniela Rodriguez-Rincon
- University of Cambridge Department of Medicine, MRC-Laboratory of Molecular Biology, Cambridge, UK
| | | | - Karen P Brown
- University of Cambridge Department of Medicine, MRC-Laboratory of Molecular Biology, Cambridge, UK.,Cambridge Centre for Lung Infection, Papworth Hospital, Cambridge, UK
| | - Pablo Moreno
- EMBL European Bioinformatics Institute, Hinxton, UK
| | - Deepshikha Verma
- Mycobacteria Research Laboratory, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins CO, USA
| | - Emily Hill
- Mycobacteria Research Laboratory, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins CO, USA
| | - Judith Drijkoningen
- University of Cambridge Department of Medicine, MRC-Laboratory of Molecular Biology, Cambridge, UK
| | - Peter Gilligan
- University of North Carolina School of Medicine, NC, USA
| | | | - Peadar G Noone
- University of North Carolina School of Medicine, NC, USA
| | | | - Scott C Bell
- QIMR Berghofer Medical Research Institute, Brisbane, Australia.,School of Medicine, The University of Queensland, Australia.,The Prince Charles Hospital, Brisbane, Australia
| | - Rachel Thomson
- Gallipoli Medical Research Centre, University of Queensland, Brisbane, Australia
| | - Claire E Wainwright
- School of Medicine, The University of Queensland, Australia.,Lady Cilento Children's Hospital, Brisbane
| | - Chris Coulter
- Queensland Mycobacterial Reference Laboratory, Brisbane, Australia
| | - Sushil Pandey
- Queensland Mycobacterial Reference Laboratory, Brisbane, Australia
| | - Michelle E Wood
- QIMR Berghofer Medical Research Institute, Brisbane, Australia.,School of Medicine, The University of Queensland, Australia.,The Prince Charles Hospital, Brisbane, Australia
| | - Rebecca E Stockwell
- QIMR Berghofer Medical Research Institute, Brisbane, Australia.,School of Medicine, The University of Queensland, Australia
| | - Kay A Ramsay
- QIMR Berghofer Medical Research Institute, Brisbane, Australia.,School of Medicine, The University of Queensland, Australia
| | | | - Timothy J Kidd
- Centre for Experimental Medicine, Queen's University Belfast, UK.,School of Chemistry and Biomolecular sciences, The University of Queensland, Australia
| | - Nassib Jabbour
- Queensland University of Technology, Brisbane, Australia.,International Laboratory for Air Quality and Health, Queensland University of Technology, Brisbane, Australia
| | - Graham R Johnson
- International Laboratory for Air Quality and Health, Queensland University of Technology, Brisbane, Australia
| | - Luke D Knibbs
- School of Public Health, The University of Queensland, Brisbane, Australia
| | - Lidia Morawska
- International Laboratory for Air Quality and Health, Queensland University of Technology, Brisbane, Australia
| | - Peter D Sly
- Child Health Research Centre, The University of Queensland, Brisbane, Australia
| | - Andrew Jones
- Royal Brompton and Harefield NHS Foundation Trust, UK
| | - Diana Bilton
- Royal Brompton and Harefield NHS Foundation Trust, UK
| | | | | | - Stephen Bourke
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | | | | | | | - Mairi Cullen
- University Hospital of South Manchester NHS Foundation Trust, UK
| | - Thomas Daniels
- University Hospital of South Manchester NHS Foundation Trust, UK
| | - Owen Dempsey
- Aberdeen Royal Infirmary, NHS Grampian, Scotland, UK
| | | | - Maya Desai
- Birmingham Children's Hospital NHS Foundation Trust, UK
| | | | | | | | - Jonathan Folb
- The Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - Helen Humphrey
- University Hospital Southampton NHS Foundation Trust, UK
| | - Barbara Isalska
- University Hospital of South Manchester NHS Foundation Trust, UK
| | | | - Bodil Jönsson
- Department of Infectious Medicine, Institute of Biomedicine, University of Gothenburg, Sweden
| | - Andrew M Jones
- University Hospital of South Manchester NHS Foundation Trust, UK
| | - Terese L Katzenstein
- Copenhagen Cystic Fibrosis Center, Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Troels Lillebaek
- International reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark
| | - Gordon MacGregor
- Gartnavel Hospital, Glasgow, NHS Greater Glasgow and Clyde, Scotland, UK
| | | | | | | | - Edward F Nash
- Heart of England NHS Foundation Trust, Birmingham, UK
| | | | | | | | | | | | | | - Audrey Perry
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - Tania Pressler
- Copenhagen Cystic Fibrosis Center, Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Laura Prtak
- The Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - Tavs Qvist
- Copenhagen Cystic Fibrosis Center, Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Ali Robb
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | | | | | - Nadia Shafi
- Cambridge Centre for Lung Infection, Papworth Hospital, Cambridge, UK
| | - Jakko van Ingen
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Martin Walshaw
- Liverpool Heart and Chest Hospital NHS Foundation Trust, UK
| | | | - Noreen West
- Sheffield Children's NHS Foundation Trust, UK
| | | | - Charles S Haworth
- Cambridge Centre for Lung Infection, Papworth Hospital, Cambridge, UK
| | | | - Diane Ordway
- Mycobacteria Research Laboratory, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins CO, USA
| | | | - R Andres Floto
- University of Cambridge Department of Medicine, MRC-Laboratory of Molecular Biology, Cambridge, UK.,Cambridge Centre for Lung Infection, Papworth Hospital, Cambridge, UK
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McClelland G, Flynn D, Rodgers H, Price C. A survey of UK paramedics’ views about their stroke training, current practice and the identification of stroke mimics. Br Paramed J 2017. [DOI: 10.29045/14784726.2017.2.1.4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Abstract
Stroke units reduce death and disability through the provision of specialist multidisciplinary care for diagnosis, emergency treatments, normalisation of homeostasis, prevention of complications, rehabilitation and secondary prevention. All stroke patients can benefit from provision of high-quality basic medical care and some need high impact specific treatments, such as thrombolysis, that are often time dependent. A standard patient pathway should include assessment of neurological impairment, vascular risk factors, swallowing, fluid balance and nutrition, cognitive function, communication, mood disorders, continence, activities of daily living and rehabilitation goals. Good communication and shared decision making with patients and their families are key to high-quality stroke care. Patients with mild or moderate disability, who are medically stable, can continue rehabilitation at home with early supported discharge teams rather than needing a prolonged stay in hospital. National clinical guidelines and prospective audits are integral to monitoring and developing stroke services in the UK.
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Affiliation(s)
- Helen Rodgers
- Newcastle University and honorary consultant stroke physician, Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Chris Price
- Newcastle University and honorary consultant stroke physician, Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, UK
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Bulic D, Bennett M, Rodgers H, Nourse M, Rubie P, Looi JC, Van Haren F. Delirium After Mechanical Ventilation in Intensive Care Units: The Cognitive and Psychosocial Assessment (CAPA) Study Protocol. JMIR Res Protoc 2017; 6:e31. [PMID: 28246074 PMCID: PMC5426842 DOI: 10.2196/resprot.6660] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 01/03/2017] [Accepted: 01/05/2017] [Indexed: 11/13/2022] Open
Abstract
Background In the intensive care unit (ICU), critical illness delirium occurs in the context of multiple comorbidities, multi-organ failure, and invasive management techniques, such as mechanical ventilation, sedation, and lack of sleep. Delirium is characterized by an acute confusional state defined by fluctuating mental status, inattention, and either disorganized thinking or an altered level of consciousness. The long-term cognitive and psychosocial function of patients that experience delirium in the ICU is of crucial interest because preliminary data suggest a strong association between ICU-related delirium and long-term cognitive impairment. Objective The aim of this study is to explore the relationship between delirium in the ICU and adverse outcomes by following mechanically ventilated patients for one year following their discharge from the ICU and collecting data on their long-term cognition and psychosocial function. Methods This study will be conducted by enrolling patients in two tertiary ICUs in Australia. We aim to recruit 200 patients who have been mechanically ventilated for more than 24 hours. Data will be collected at the following three time points: (1) at discharge where they will be administered the Mini-Mental State Examination (MMSE); (2) at 6 months after discharge from the ICU discharge where the Impact of Events Scale Revised (IES-R) and the Telephone Inventory for Cognitive Status (TICS) tests will be administered; and (3) at 12 months after discharge from the ICU where the patients will be administered the TICS and IES-R tests, as well as the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE). The IQCODE will be administered to their “person responsible” or the significant other of the patient. Results Long-term cognition and psychosocial function will be the primary outcome of this study. Mortality will also be investigated as a secondary outcome. Active enrollment will take place until the end of September 2016 and data collection will conclude at the end of September 2017. The analysis and results are expected to be available by March 2018. Conclusion Delirium during mechanical ventilation has been linked to longer ICU and hospital stays, higher financial burdens, increased risks of long-term cognitive impairment (ie, dementia), poor functional outcomes and quality of life, and decreased survival. However, delirium during mechanical ventilation in the ICU is not well understood. This study will advance our knowledge of the comprehensive, long-term effects of delirium on cognitive and psychosocial function. Trial Registration Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12616001116415; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371216 (Archived by WebCite at http://www.webcitation.org/ 6nfDkGTcW)
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Affiliation(s)
- Daniella Bulic
- University of New South Wales, Faculty of Medicine, University of New South Wales, Randwick, Australia
| | - Michael Bennett
- University of New South Wales, Faculty of Medicine, University of New South Wales, Randwick, Australia.,Prince of Wales Hospital, Anaesthetic Department, Prince of Wales Hospital, Randwick, Australia
| | - Helen Rodgers
- Canberra Hospital, Intensive Care Research Department, Canberra Hospital, Garran, Australia
| | - Mary Nourse
- Canberra Hospital, Intensive Care Research Department, Canberra Hospital, Garran, Australia
| | - Patrick Rubie
- Prince of Wales Hospital, Anaesthetic Department, Prince of Wales Hospital, Randwick, Australia
| | - Jeffrey Cl Looi
- Academic Unit of Psychiatry and Addiction Medicine, Medical School, Australian National University, Canberra, Australia.,Faculty of Medicine, Melbourne Neuropsychiatry Centre, Department of Psychiatry, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Frank Van Haren
- Canberra Hospital, Intensive Care Research Department, Canberra Hospital, Garran, Australia.,Medical School, College of Medicine, Biology & Environment, Australian National University, Canberra, Australia
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Flynn D, Francis R, Robalino S, Lally J, Snooks H, Rodgers H, McClelland G, Ford GA, Price C. A review of enhanced paramedic roles during and after hospital handover of stroke, myocardial infarction and trauma patients. BMC Emerg Med 2017; 17:5. [PMID: 28228127 PMCID: PMC5322648 DOI: 10.1186/s12873-017-0118-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [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: 06/01/2016] [Accepted: 02/17/2017] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Ambulance paramedics play a critical role expediting patient access to emergency treatments. Standardised handover communication frameworks have led to improvements in accuracy and speed of information transfer but their impact upon time-critical scenarios is unclear. Patient outcomes might be improved by paramedics staying for a limited time after handover to assist with shared patient care. We aimed to categorize and synthesise data from studies describing development/extension of the ambulance-based paramedic role during and after handover for time-critical conditions (trauma, stroke and myocardial infarction). METHODS We conducted an electronic search of published literature (Jan 1990 to Sep 2016) by applying a structured strategy to eight bibliographic databases. Two reviewers independently assessed eligible studies of paramedics, emergency medical (or ambulance) technicians that reported on the development, evaluation or implementation of (i) generic or specific structured handovers applied to trauma, stroke or myocardial infarction (MI) patients; or (ii) paramedic-initiated care processes at handover or post-handover clinical activity directly related to patient care in secondary care for trauma, stroke and MI. Eligible studies had to report changes in health outcomes. RESULTS We did not identify any studies that evaluated the health impact of an emergency ambulance paramedic intervention following arrival at hospital. A narrative review was undertaken of 36 studies shortlisted at the full text stage which reported data relevant to time-critical clinical scenarios on structured handover tools/protocols; protocols/enhanced paramedic skills to improve handover; or protocols/enhanced paramedic skills leading to a change in in-hospital transfer location. These studies reported that (i) enhanced paramedic skills (diagnosis, clinical decision making and administration of treatment) might supplement handover information; (ii) structured handover tools and feedback on handover performance can impact positively on paramedic behaviour during clinical communication; and (iii) additional roles of paramedics after arrival at hospital was limited to 'direct transportation' of patients to imaging/specialist care facilities. CONCLUSIONS There is insufficient published evidence to make a recommendation regarding condition-specific handovers or extending the ambulance paramedic role across the secondary/tertiary care threshold to improve health outcomes. However, previous studies have reported non-clinical outcomes which suggest that structured handovers and enhanced paramedic actions after hospital arrival might be beneficial for time-critical conditions and further investigation is required.
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Affiliation(s)
- Darren Flynn
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX United Kingdom
| | - Richard Francis
- Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Shannon Robalino
- Research Design Service - North East, Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Joanne Lally
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX United Kingdom
| | - Helen Snooks
- College of Medicine, Swansea University, Wales, United Kingdom
| | - Helen Rodgers
- Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Graham McClelland
- North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Gary A. Ford
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Christopher Price
- Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, United Kingdom
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MacIsaac RL, Ali M, Taylor-Rowan M, Rodgers H, Lees KR, Quinn TJ. Use of a 3-Item Short-Form Version of the Barthel Index for Use in Stroke: Systematic Review and External Validation. Stroke 2017; 48:618-623. [PMID: 28154094 DOI: 10.1161/strokeaha.116.014789] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 12/12/2016] [Accepted: 12/19/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE There may be a potential to reduce the number of items assessed in the Barthel Index (BI), and shortened versions of the BI have been described. We sought to collate all existing short-form BI (SF-BI) and perform a comparative validation using clinical trial data. METHODS We performed a systematic review across multidisciplinary electronic databases to find all published SF-BI. Our validation used the VISTA (Virtual International Stroke Trials Archive) resource. We describe concurrent validity (agreement of each SF-BI with BI), convergent and divergent validity (agreement of each SF-BI with other outcome measures available in the data set), predictive validity (association of prognostic factors with SF-BI outcomes), and content validity (item correlation and exploratory factor analyses). RESULTS From 3546 titles, we found 8 articles describing 6 differing SF-BI. Using acute trial data (n=8852), internal reliability suggested redundancy in BI (Cronbach α, 0.96). Each SF-BI demonstrated a strong correlation with BI, modified Rankin Scale, National Institutes of Health Stroke Scale (all ρ≥0.83; P<0.001). Using rehabilitation trial data (n=332), SF-BI demonstrated modest correlation with quality of life measures Stroke Impact Scale and 5 domain EuroQOL (ρ≥0.50, P<0.001). Prespecified prognostic factors were associated with SF-BI outcomes (all P<0.001). Our factor analysis described a 3 factor structure, and item reduction suggested an optimal 3-item SF-BI comprising bladder control, transfer, and mobility items in keeping with 1 of the 3-item SF-BI previously described in the literature. CONCLUSIONS There is redundancy in the original BI; we have demonstrated internal and external validity of a 3-item SF-BI that should be simple to use.
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Affiliation(s)
- Rachael L MacIsaac
- From the Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (R.L.M., M.A., M.T.-R., K.R.L., T.J.Q.); and Stroke Research Group Institute for Neuroscience and Institute for Ageing, Newcastle University, United Kingdom (H.R.)
| | - Myzoon Ali
- From the Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (R.L.M., M.A., M.T.-R., K.R.L., T.J.Q.); and Stroke Research Group Institute for Neuroscience and Institute for Ageing, Newcastle University, United Kingdom (H.R.)
| | - Martin Taylor-Rowan
- From the Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (R.L.M., M.A., M.T.-R., K.R.L., T.J.Q.); and Stroke Research Group Institute for Neuroscience and Institute for Ageing, Newcastle University, United Kingdom (H.R.)
| | - Helen Rodgers
- From the Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (R.L.M., M.A., M.T.-R., K.R.L., T.J.Q.); and Stroke Research Group Institute for Neuroscience and Institute for Ageing, Newcastle University, United Kingdom (H.R.)
| | - Kennedy R Lees
- From the Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (R.L.M., M.A., M.T.-R., K.R.L., T.J.Q.); and Stroke Research Group Institute for Neuroscience and Institute for Ageing, Newcastle University, United Kingdom (H.R.)
| | - Terence J Quinn
- From the Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (R.L.M., M.A., M.T.-R., K.R.L., T.J.Q.); and Stroke Research Group Institute for Neuroscience and Institute for Ageing, Newcastle University, United Kingdom (H.R.).
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43
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De Brún A, Flynn D, Ternent L, Price CI, Rodgers H, Ford GA, Rudd M, Lancsar E, Simpson S, Teah J, Thomson RG. Factors that influence clinicians' decisions to offer intravenous alteplase in acute ischemic stroke patients with uncertain treatment indication: Results of a discrete choice experiment. Int J Stroke 2017; 13:74-82. [PMID: 28134031 DOI: 10.1177/1747493017690755] [Citation(s) in RCA: 7] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Treatment with intravenous alteplase for eligible patients with acute ischemic stroke is underused, with variation in treatment rates across the UK. This study sought to elucidate factors influencing variation in clinicians' decision-making about this thrombolytic treatment. Methods A discrete choice experiment using hypothetical patient vignettes framed around areas of clinical uncertainty was conducted with UK-based clinicians. Mixed logit regression analyses were conducted on the data. Results A total of 138 clinicians completed the discrete choice experiment. Seven patient factors were individually predictive of increased likelihood of immediately offering IV alteplase (compared to reference levels in brackets): stroke onset time 2 h 30 min [50 min]; pre-stroke dependency mRS 3 [mRS 4]; systolic blood pressure 185 mm/Hg [140 mm/Hg]; stroke severity scores of NIHSS 5 without aphasia, NIHSS 14 and NIHSS 23 [NIHSS 2 without aphasia]; age 85 [68]; Afro-Caribbean [white]. Factors predictive of withholding treatment with IV alteplase were: age 95 [68]; stroke onset time of 4 h 15 min [50 min]; severe dementia [no memory problems]; SBP 200 mm/Hg [140 mm/Hg]. Three clinician-related factors were predictive of an increased likelihood of offering IV alteplase (perceived robustness of the evidence for IV alteplase; thrombolyzing more patients in the past 12 months; and high discomfort with uncertainty) and one with a decreased likelihood (high clinician comfort with treating patients outside the licensing criteria). Conclusions Both patient- and clinician-related factors have a major influence on the use of alteplase to treat patients with acute ischemic stroke. Clinicians' views of the evidence, comfort with uncertainty and treating patients outside the license criteria are important factors to address in programs that seek to reduce variation in care quality regarding treatment with IV alteplase. Further research is needed to further understand the differences in clinical decision-making about treating patients with acute ischemic stroke with IV alteplase.
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Affiliation(s)
- Aoife De Brún
- 1 Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Darren Flynn
- 1 Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Laura Ternent
- 1 Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher I Price
- 2 Northumbria Healthcare NHS Foundation Trust, Ashington, UK.,3 Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Helen Rodgers
- 3 Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Gary A Ford
- 4 Oxford University Hospitals NHS Trust, Oxford, UK
| | - Matthew Rudd
- 2 Northumbria Healthcare NHS Foundation Trust, Ashington, UK
| | - Emily Lancsar
- 5 Centre for Health Economics, Monash University, Melbourne, Australia
| | - Stephen Simpson
- 6 The Stroke Association, Gateshead, Newcastle upon Tyne, UK
| | - John Teah
- 6 The Stroke Association, Gateshead, Newcastle upon Tyne, UK
| | - Richard G Thomson
- 1 Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
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Thomson RG, De Brún A, Flynn D, Ternent L, Price CI, Rodgers H, Ford GA, Rudd M, Lancsar E, Simpson S, Teah J. Factors that influence variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke: results of a discrete choice experiment. Health Serv Deliv Res 2017. [DOI: 10.3310/hsdr05040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BackgroundIntravenous thrombolysis for patients with acute ischaemic stroke is underused (only 80% of eligible patients receive it) and there is variation in its use across the UK. Previously, variation might have been explained by structural differences; however, continuing variation may reflect differences in clinical decision-making regarding the eligibility of patients for treatment. This variation in decision-making could lead to the underuse, or result in inappropriate use, of thrombolysis.ObjectivesTo identify the factors which contribute to variation in, and influence, clinicians’ decision-making about treating ischaemic stroke patients with intravenous thrombolysis.MethodsA discrete choice experiment (DCE) using hypothetical patient vignettes framed around areas of clinical uncertainty was conducted to better understand the influence of patient-related and clinician-related factors on clinical decision-making. An online DCE was developed following an iterative five-stage design process. UK-based clinicians involved in final decision-making about thrombolysis were invited to take part via national professional bodies of relevant medical specialties. Mixed-logit regression analyses were conducted.ResultsA total of 138 clinicians responded and opted to offer thrombolysis in 31.4% of cases. Seven patient factors were individually predictive of the increased likelihood of offering thrombolysis (compared with reference levels in brackets): stroke onset time of 2 hours 30 minutes (50 minutes); pre-stroke dependency modified Rankin Scale score (mRS) of 3 (mRS4); systolic blood pressure (SBP) of 185 mmHg (140 mmHg); stroke severity scores of National Institutes of Health Stroke Scale (NIHSS) 5 without aphasia, NIHSS 14 and NIHSS 23 (NIHSS 2 without aphasia); age 85 years (65 years); and Afro-Caribbean (white). Factors predictive of not offering thrombolysis were age 95 years; stroke onset time of 4 hours 15 minutes; severe dementia (no memory problems); and SBP of 200 mmHg. Three clinician-related factors were predictive of an increased likelihood of offering thrombolysis (perceived robustness of the evidence for thrombolysis; thrombolysing more patients in the past 12 months; and high discomfort with uncertainty) and one factor was predictive of a decreased likelihood of offering treatment (clinicians’ being comfortable treating patients outside the licensing criteria).LimitationsWe anticipated a sample size of 150–200. Nonetheless, the final sample of 138 is good considering that the total population of eligible UK clinicians is relatively small. Furthermore, data from the Royal College of Physicians suggest that our sample is representative of clinicians involved in decision-making about thrombolysis.ConclusionsThere was considerable heterogeneity among respondents in thrombolysis decision-making, indicating that clinicians differ in their thresholds for treatment across a number of patient-related factors. Respondents were significantly more likely to treat 85-year-old patients than patients aged 68 years and this probably reflects acceptance of data from Third International Stroke Trial that report benefit for patients aged > 80 years. That respondents were more likely to offer thrombolysis to patients with severe stroke than to patients with mild stroke may indicate uncertainty/concern about the risk/benefit balance in treatment of minor stroke. Findings will be disseminated via peer-review publication and presentation at national/international conferences, and will be linked to training/continuing professional development (CPD) programmes.Future workThe nature of DCE design means that only a subset of potentially influential factors could be explored. Factors not explored in this study warrant future research. Training/CPD should address the impact of non-medical influences on decision-making using evidence-based strategies.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Richard G Thomson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Aoife De Brún
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Darren Flynn
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Laura Ternent
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher I Price
- Stroke Unit, Wansbeck General Hospital, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
- Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, UK
| | - Helen Rodgers
- Stroke Unit, Wansbeck General Hospital, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
- Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, UK
| | - Gary A Ford
- Oxford University Hospitals NHS Trust, Oxford, UK
| | - Matthew Rudd
- Stroke Unit, Wansbeck General Hospital, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
- Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, UK
| | - Emily Lancsar
- Centre for Health Economics, Monash University, Melbourne, VIC, Australia
| | | | - John Teah
- The Stroke Association, Gateshead, UK
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White PM, Lenthall R, McConachie N, Bhalla A, James M, Dinsmore J, Rodgers H, Rowland-Hill C. Commentary on: Implementing mechanical thrombectomy for acute ischaemic stroke in the UK. Clin Radiol 2016; 72:123-125. [PMID: 27989377 DOI: 10.1016/j.crad.2016.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 11/07/2016] [Accepted: 11/07/2016] [Indexed: 10/20/2022]
Affiliation(s)
- P M White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK; British Society of Neuroradiologists, UK; UK Neurointerventional Group, UK.
| | - R Lenthall
- British Society of Neuroradiologists, UK; Department of Neuroradiology, Queen's Medical Centre, Nottingham, UK
| | - N McConachie
- Department of Neuroradiology, Queen's Medical Centre, Nottingham, UK; UK Neurointerventional Group, UK
| | - A Bhalla
- Stroke Medicine, Guys and St Thomas Hospital, London, UK; British Association of Stroke Physicians, UK
| | - M James
- British Association of Stroke Physicians, UK; Stroke Medicine, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - J Dinsmore
- Department of Anaesthesia, St George's Hospital, London, UK; Neuro Anaesthesia & Critical Care Society of Great Britain and Ireland, UK
| | - H Rodgers
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK; British Association of Stroke Physicians, UK
| | - C Rowland-Hill
- British Society of Neuroradiologists, UK; Neuroradiology Department, Hull and East Yorkshire Hospitals NHS Trust, UK
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Moore SA, Da Silva R, Balaam M, Brkic L, Jackson D, Jamieson D, Ploetz T, Rodgers H, Shaw L, van Wijck F, Price C. Wristband Accelerometers to motiVate arm Exercise after Stroke (WAVES): study protocol for a pilot randomized controlled trial. Trials 2016; 17:508. [PMID: 27769310 PMCID: PMC5073848 DOI: 10.1186/s13063-016-1628-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [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: 08/04/2016] [Accepted: 09/23/2016] [Indexed: 11/23/2022] Open
Abstract
Background Loss of upper limb function affects up to 85 % of acute stroke patients. Recovery of upper limb function requires regular intensive practise of specific upper limb tasks. To enhance intensity of practice interventions are being developed to encourage patients to undertake self-directed exercise practice. Most interventions do not translate well into everyday activities and stroke patients continue to find it difficult remembering integration of upper limb movements into daily activities. A wrist-worn device has been developed that monitors and provides ‘live’ upper limb activity feedback to remind patients to use their stroke arm in daily activities (The CueS wristband). The aim of this trial is to assess the feasibility of a multi-centre, observer blind, pilot randomised controlled trial of the CueS wristband in clinical stroke services. Methods/design This pilot randomised controlled feasibility trial aims to recruit 60 participants over 15 months from North East England. Participants will be within 3 months of stroke which has caused new reduced upper limb function and will still be receiving therapy. Each participant will be randomised to an intervention or control group. Intervention participants will wear a CueS wristband (between 8 am and 8 pm) providing “live” feedback towards pre-set movement goals through a simple visual display and vibration prompts whilst undertaking a 4-week upper limb therapy programme (reviewed twice weekly by an occupational/physiotherapist). Control participants will also complete the 4-week upper limb therapy programme but will wear a ‘sham’ CueS wristband that monitors upper limb activity but provides no feedback. Outcomes will determine study feasibility in terms of recruitment, retention, adverse events, adherence and collection of descriptive clinical and accelerometer motor performance data at baseline, 4 weeks and 8 weeks. Discussion The WAVES study will address an important gap in the evidence base by reporting the feasibility of undertaking an evaluation of emerging and affordable technology to encourage impaired upper limb activity after stroke. The study will establish whether the study protocol can be supported by clinical stroke services, thereby informing the design of a future multi-centre randomised controlled trial of clinical and cost-effectiveness. Trial registration ISRCTN:82306027. Registered 12 July 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1628-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarah A Moore
- Institute of Neuroscience (Stroke Research Group), Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, England, UK
| | - Ruth Da Silva
- Institute of Neuroscience (Stroke Research Group), Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, England, UK
| | - Madelaine Balaam
- School of Computing Science (Open Lab), Newcastle University, Newcastle upon Tyne, NE1 7RU, England, UK
| | - Lianne Brkic
- Institute of Neuroscience (Stroke Research Group), Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, England, UK
| | - Dan Jackson
- School of Computing Science (Open Lab), Newcastle University, Newcastle upon Tyne, NE1 7RU, England, UK
| | - Dan Jamieson
- School of Computing Science (Open Lab), Newcastle University, Newcastle upon Tyne, NE1 7RU, England, UK
| | - Thomas Ploetz
- School of Computing Science (Open Lab), Newcastle University, Newcastle upon Tyne, NE1 7RU, England, UK
| | - Helen Rodgers
- Institute of Neuroscience (Stroke Research Group), Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, England, UK
| | - Lisa Shaw
- Institute of Neuroscience (Stroke Research Group), Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, England, UK
| | - Frederike van Wijck
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland, UK
| | - Christopher Price
- Institute of Neuroscience (Stroke Research Group), Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, England, UK.
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Shaw L, Ford GA, Exley C, Flynn D, McMeekin P, Rodgers H, Snooks H, Tyrell P, Vale L, Price C. PARAMEDIC ACUTE STROKE TREATMENT ASSESSMENT (PASTA) TRIAL. Arch Emerg Med 2016. [DOI: 10.1136/emermed-2016-206139.32] [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: 11/03/2022]
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Brkic L, Shaw L, van Wijck F, Francis R, Price C, Forster A, Langhorne P, Watkins C, Rodgers H. Repetitive arm functional tasks after stroke (RAFTAS): a pilot randomised controlled trial. Pilot Feasibility Stud 2016; 2:50. [PMID: 27965867 PMCID: PMC5154114 DOI: 10.1186/s40814-016-0088-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [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: 10/14/2015] [Accepted: 07/28/2016] [Indexed: 11/30/2022] Open
Abstract
Background Repetitive functional task practise (RFTP) is a promising treatment to improve upper limb recovery following stroke. We report the findings of a study to determine the feasibility of a multi-centre randomised controlled trial to evaluate this intervention. Methods A pilot randomised controlled trial recruited patients with new reduced upper limb function within 14 days of acute stroke from three stroke units. Participants were randomised to receive a four week upper limb RFTP therapy programme consisting of goal setting, independent activity practise, and twice weekly therapy reviews in addition to usual post stroke rehabilitation, or usual post stroke rehabilitation. The recruitment rate; adherence to the RFTP therapy programme; usual post stroke rehabilitation received; attrition rate; data quality; success of outcome assessor blinding; adverse events; and the views of study participants and therapists about the intervention were recorded. Results Fifty five eligible patients were identified, 4-6 % of patients screened at each site. Twenty four patients participated in the pilot study. Two study sites met the recruitment target of 1–2 participants per month. The median number of face to face therapy sessions received was 6 [IQR 3–8]. The median number of daily repetitions of activities recorded was 80 [IQR 39–80]. Data about usual post stroke rehabilitation were available for 18/24 (75 %). Outcome data were available for 22/24 (92 %) at one month and 20/24 (83 %) at three months. Outcome assessors were unblinded to participant group allocation for 11/22 (50 %) at one month and 6/20 (30 %) at three months. Four adverse events were considered serious as they resulted in hospitalisation. None were related to study treatment. Feedback from patients and therapists about the RFTP programme was mainly positive. Conclusions A multi-centre randomised controlled trial to evaluate an upper limb RFTP therapy programme provided early after stroke is feasible and acceptable to patients and therapists, but there are issues which need to be addressed when designing a Phase III study. A Phase III study will need to monitor and report not only recruitment and attrition but also adherence to the intervention, usual post stroke rehabilitation received, and outcome assessor blinding. Trial registration International Standard Randomised Controlled Trials Number (ISRCTN) 58527251
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Affiliation(s)
- Lianne Brkic
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
| | - Lisa Shaw
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
| | - Frederike van Wijck
- Institute for Applied Health Research and School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA UK
| | - Richard Francis
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
| | - Christopher Price
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
| | - Anne Forster
- Academic Unit of Elderly Care and Rehabilitation, Bradford Royal Infirmary, University of Leeds and Bradford Institute for Health Research, Duckworth Lane, Bradford, BD9 6RJ UK
| | - Peter Langhorne
- Academic Section of Geriatric Medicine, Royal Infirmary, Floor 2, New Lister Building, Glasgow, G31 2ER UK
| | - Caroline Watkins
- Clinical Practice Research Unit, School of Nursing and Caring Sciences, University of Central Lancashire, Brook 419, Preston, PR1 2HE UK
| | - Helen Rodgers
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
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Reid DB, Chapple LS, O'Connor SN, Bellomo R, Buhr H, Chapman MJ, Davies AR, Eastwood GM, Ferrie S, Lange K, McIntyre J, Needham DM, Peake SL, Rai S, Ridley EJ, Rodgers H, Deane AM. The effect of augmenting early nutritional energy delivery on quality of life and employment status one year after ICU admission. Anaesth Intensive Care 2016; 44:406-12. [PMID: 27246942 DOI: 10.1177/0310057x1604400309] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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: 11/17/2022]
Abstract
Augmenting energy delivery during the acute phase of critical illness may reduce mortality and improve functional outcomes. The objective of this sub-study was to evaluate the effect of early augmented enteral nutrition (EN) during critical illness, on outcomes one year later. We performed prospective longitudinal evaluation of study participants, initially enrolled in The Augmented versus Routine approach to Giving Energy Trial (TARGET), a feasibility study that randomised critically ill patients to 1.5 kcal/ml (augmented) or 1.0 kcal/ml (routine) EN administered at the same rate for up to ten days, who were alive at one year. One year after randomisation Short Form-36 version 2 (SF-36v2) and EuroQol-5D-5L quality of life surveys, and employment status were assessed via telephone survey. At one year there were 71 survivors (1.5 kcal/ml 38 versus 1.0 kcal/ml 33; P=0.55). Thirty-nine (55%) patients consented to this follow-up study and completed the surveys (n = 23 and 16, respectively). The SF-36v2 physical and mental component summary scores were below normal population means but were similar in 1.5 kcal/ml and 1.0 kcal/ml groups (P=0.90 and P=0.71). EuroQol-5D-5L data were also comparable between groups (P=0.70). However, at one-year follow-up, more patients who received 1.5 kcal/ml were employed (7 versus 2; P=0.022). The delivery of 1.5 kcal/ml for a maximum of ten days did not affect self-rated quality of life one year later.
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Affiliation(s)
- D B Reid
- Intensive Care Registrar, Royal Adelaide Hospital, Adelaide, South Australia
| | - L S Chapple
- Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, Queensland
| | - S N O'Connor
- Research Manager, Intensive Care Unit, Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, South Australia
| | - R Bellomo
- Intensive Care Consultant, Austin Hospital, Melbourne, Victoria
| | - H Buhr
- Research Manager, Intensive Care Service, Royal Prince Alfred Hospital, Sydney, New South Wales
| | - M J Chapman
- Director of Research, Department of Intensive Care Medicine, Royal Adelaide Hospital, Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia
| | - A R Davies
- Research Fellow, Department of Epidemiology and Preventative Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria
| | - G M Eastwood
- Research Manager, Department of Intensive Care, Austin Hospital, Melbourne, Victoria
| | - S Ferrie
- Critical Care Dietitian, Intensive Care Service, Royal Prince Alfred Hospital, Sydney, New South Wales
| | - K Lange
- Biostatistician, Discipline of Medicine, University of Adelaide, Adelaide, South Australia
| | - J McIntyre
- Research Coordinator, Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, South Australia
| | - D M Needham
- Medical Director, Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, USA
| | - S L Peake
- Senior Intensive Care Clinician, Discipline of Acute Care Medicine, University of Adelaide, Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, South Australia
| | - S Rai
- Intensive Care Specialist, The Canberra Hospital, Canberra, Australian Capital Territory
| | - E J Ridley
- Nutrition Program Manager, Department of Epidemiology and Preventative Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria
| | - H Rodgers
- Research Coordinator, The Canberra Hospital, Canberra, Australian Capital Territory
| | - A M Deane
- Department of Intensive Care Medicine, Royal Adelaide Hospital, Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia
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Abstract
BACKGROUND The Stroke Impact Scale (SIS) is a stroke-specific, quality of life measure recommended for research and clinical practice. Completion rates are suboptimal and could relate to test burden. We derived and validated a short form SIS (SF-SIS). METHODS AND RESULTS We examined data from the Virtual International Stroke Trial Archive, generating derivation and validation populations. We derived an SF-SIS by selecting 1 item per domain of SIS, choosing items most highly correlated with total domain score. Our validation described agreement of SF-SIS with original SIS and the SIS-16 and correlation with Barthel Index, modified Rankin Scale, National Institutes of Health Stroke Scale, and Euro-QoL 5 dimensions visual analog scales. We assessed discriminative validity (associations between SF-SIS and factors known to influence outcome [age, physiological parameters, and comorbidity]). We assessed face validity and acceptability by sharing the SF-SIS with a focus group of stroke survivors and multidisciplinary stroke healthcare staff. From 5549 acute study patients (mean age 68.5 [SD 13] years, mean SIS 64 [SD 32]) and 332 rehabilitation patients (mean age 65.7 [SD 11] years, mean SIS 61 [SD 11]), we derived an 8-item SF-SIS that demonstrated good agreement with original SIS and good correlation with our chosen functional and quality of life measures (all ρ>0.70, P<0.0001). Significant associations were seen with our chosen predictors of stroke outcome in the acute group (P<0.0001). The focus group agreed with the choice of items for SF-SIS across 7 of 8 domains. CONCLUSIONS Using multiple, complementary methods, we have derived an SF-SIS and demonstrated content, convergent, and discriminant validity. This shortened SIS should allow collection of robust quality of life data with less associated test burden.
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Affiliation(s)
- Rachael MacIsaac
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
| | - Myzoon Ali
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
| | - Michele Peters
- Nuffield Department of Population Health, University of Oxford, UK
| | - Coralie English
- School of Health Sciences, University of Newcastle, Australia
| | - Helen Rodgers
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | | | - Kennedy R Lees
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
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