In search of consensus on aphasia management.

Morag Bixley and colleagues discuss their analysis of current UK aphasia practice

Aphasia management in an acute setting, what are we doing and why?

TITLE OF PAPER: APHASIA MANAGEMENT IN AN ACUTE SETTING, WHAT ARE WE DOING AND WHY? KEYWORDS: THERAPY, RATIONALES, EXPERTS • WHY THE STUDY WAS UNDERTAKEN The Specific Interest Group in Aphasia Therapy has been involved with two projects looking into what Speech and Language Therapists (SLTs) do for people with aphasia in the acute setting. In the first phase of their research Bixley et al (2011) collated the different activities reported by 86 SLTs from 55 different adult trusts. This research suggested that therapist activity could be divided into five categories. A follow up study (Bixley et al, 2013) asked SLTs to confirm these groups, estimate the amount of time spent on each activity and provide a rationale for why this therapy intervention was important. Twenty two therapists confirmed that their activities could be categorised into the five different types. Eight of these therapists were able to estimate the amount of time spent on each type of activity. These activities were: 1) Assessment - 32% 2) Multidisciplinary team working (MDT) - 26% 3) Therapy choices - 23% 4) SLT administration - 13% and 5) Support training and education (STE) - 6%. This paper expands on this research by presenting a grounded theme analysis of the rationales for intervention for people with aphasia in the acute setting. • HOW THE STUDY WAS DONE Therapists were asked to complete a short questionnaire that had been distributed opportunistically through the SIG network. Twenty two SLTs from 14 different NHS trusts participated in this research. Twenty one participants (95%) estimated that they spent an average of 43% of their time in work providing aphasia management. Typically they worked in departments of three therapists providing 17 sessions of acute aphasia care. Eleven therapists (50%) had less than five years SLT experience and typically were on pay scale 5 or 6. Four very experienced therapists (18%) who had worked for ten to twenty years were paid at band 8. • WHAT WAS FOUND AND IMPLICATIONS FOR FUTURE POLICY AND PRACTICE Rationales were provided for each of the five management options. Assessment: Words used to describe reasons for assessment activities (basis, develop, establish, estimate, focus, gain, guide, indicate, inform, make, plan, provide and suggest) indicate that assessment is an active, ongoing, reflective process. Assessment was linked to both therapist belief and recommended practice (Royal College of Physicians, 2012 and National Institute for Health and Clinical Excellence, 2013). MDT: Therapists reported that the role of MDT working was goal setting for the benefit of the client management. However some therapists were not employed as part of an MDT and found it difficult to influence this decision making process. Therapy: SLTs thought that impairment, functional and psychological therapies were equally important. They acknowledged that this was challenging in the acute sector where clients were discharged quickly and were not always well enough to engage fully with rehabilitation. 19/22 therapists (86%) suggested they would like more time to provide SLT input. This paper presents a consensus of current SLT expert opinion. Despite the small sample size this research could be used to guide targets for future SLT intervention in the acute sector and it could be used as a focus for discussion about intervention choices within the SLT profession. REFERENCES Bixley, M., Blagdon, B., Dean, M., Langley, J. & Stanton, D. (2013) Best practice for aphasia in the acute sector: a consensus of expert opinions. British Aphasiology Society Biennial International Conference Book of Abstracts, 8-9. Bixley, M., Blagdon, B., Dean, M., Langley, J. & Stanton, D. (2011) In search of consensus on aphasia management. Royal College of Speech and Language Therapists Bulletin, October, 18-20. Intercollegiate Stroke Working Party. (2012) National clinical guideline for stroke, 4th edition. London: Royal College of Physicians. National Institute For Health And Clinical Excellence. (2013) Stroke rehabilitation: 2nd guideline consultation

Antiinflammatory Therapy with Canakinumab for Atherosclerotic Disease

Background: Experimental and clinical data suggest that reducing inflammation without affecting lipid levels may reduce the risk of cardiovascular disease. Yet, the inflammatory hypothesis of atherothrombosis has remained unproved. Methods: We conducted a randomized, double-blind trial of canakinumab, a therapeutic monoclonal antibody targeting interleukin-1β, involving 10,061 patients with previous myocardial infarction and a high-sensitivity C-reactive protein level of 2 mg or more per liter. The trial compared three doses of canakinumab (50 mg, 150 mg, and 300 mg, administered subcutaneously every 3 months) with placebo. The primary efficacy end point was nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. RESULTS: At 48 months, the median reduction from baseline in the high-sensitivity C-reactive protein level was 26 percentage points greater in the group that received the 50-mg dose of canakinumab, 37 percentage points greater in the 150-mg group, and 41 percentage points greater in the 300-mg group than in the placebo group. Canakinumab did not reduce lipid levels from baseline. At a median follow-up of 3.7 years, the incidence rate for the primary end point was 4.50 events per 100 person-years in the placebo group, 4.11 events per 100 person-years in the 50-mg group, 3.86 events per 100 person-years in the 150-mg group, and 3.90 events per 100 person-years in the 300-mg group. The hazard ratios as compared with placebo were as follows: in the 50-mg group, 0.93 (95% confidence interval [CI], 0.80 to 1.07; P = 0.30); in the 150-mg group, 0.85 (95% CI, 0.74 to 0.98; P = 0.021); and in the 300-mg group, 0.86 (95% CI, 0.75 to 0.99; P = 0.031). The 150-mg dose, but not the other doses, met the prespecified multiplicity-adjusted threshold for statistical significance for the primary end point and the secondary end point that additionally included hospitalization for unstable angina that led to urgent revascularization (hazard ratio vs. placebo, 0.83; 95% CI, 0.73 to 0.95; P = 0.005). Canakinumab was associated with a higher incidence of fatal infection than was placebo. There was no significant difference in all-cause mortality (hazard ratio for all canakinumab doses vs. placebo, 0.94; 95% CI, 0.83 to 1.06; P = 0.31). Conclusions: Antiinflammatory therapy targeting the interleukin-1β innate immunity pathway with canakinumab at a dose of 150 mg every 3 months led to a significantly lower rate of recurrent cardiovascular events than placebo, independent of lipid-level lowering. (Funded by Novartis; CANTOS ClinicalTrials.gov number, NCT01327846.

Characterisation of fabric deformation mechanisms during preform manufacture

SIGLEAvailable from British Library Document Supply Centre-DSC:DXN020955 / BLDSC - British Library Document Supply CentreGBUnited Kingdo

Best practice for aphasia in the acute sector: a consensus of expert opinions

Background Information Historically Speech and Language Therapy (SLT) intervention has been guided by a, sometimes bewildering, plethora of standards and guidelines. Publications such as those written by the Royal College of Physicians (2012), the National Institute for Health and Clinical Excellence (2013) and Bowen et al (2012), guide our input within the acute setting. In 2011, the SIG Aphasia Therapy published the results of a survey into the practices of 86 SLTs who worked in 55 different adult SLT trusts (Bixley et al, 2011). The results of the 2011 study suggested that 172 different and appropriate management options could be sorted into five categories. This current study was designed to investigate whether the hypothesised categories in the original research described current working practices. Method Twenty two therapists, from 14 different NHS trusts, responded to a questionnaire that was distributed opportunistically through the SIG network. Thirteen (59%) had less than five years SLT experience and typically were on pay scale 5, 6 or 7. Four very experienced therapists (18%) who had worked for ten to twenty years were paid at band 8. Ten (45%) were employed full time. Fourteen (64%) worked in posts split between acute stroke units and the community. On average, the twenty two SLTs worked in departments of three therapists providing 17 sessions of acute aphasia care per week. Twenty one SLTs (95%) estimated that they spent on average 43% of their time in work providing aphasia management. Results All twenty two therapists confirmed the five categories and twenty five intervention aims derived from the original research and eight therapists were able to estimate the time spent on each type of activity. Definitions were: 1) Assessment (32%) informal, formal, case history, outcome, screening, mental capacity 2) Multidisciplinary team working (MDT) (26%) writing guidelines and documentation, joint sessions, attending discharge and MDT meetings, goal setting 3) Therapy choices (23%) language therapy, establishing functional communication, low tech AAC, providing accessible environment, group work, computer therapy, outings 4) SLT administration (13%) plan discharge liaise and refer onwards, prioritise and make resources, write notes and keep statistics 5) Support training and education (STE) (6%) client, family, assistant practitioners, MDT. Discussion This description of SLT management choices adds a classification system and a level of detail that is not available elsewhere in the literature. Detail and differentiation about SLT intervention is important in much the same way different doses of a drug affect pharmacological outcomes. Our findings confirm that assessment, STE and conversation therapy should be located firmly within the basic remit of SLT. Significantly 52/86 therapists (60%) in our initial investigation and 19/22 (86%) therapists in our follow up research suggested that they did not have enough time to provide therapy for people with aphasia in the acute setting. References BIXLEY, M., BLAGDON, B., DEAN, M., LANGLEY, J. & STANTON, D. (2011) In search of consensus on aphasia management. Royal College of Speech and Language Therapists Bulletin, 2011, October, 18-20. BOWEN, A., HESKETH, A., PATCHICK, E., YOUNG, A., DAVIES, L., VAIL, A., LONG, A.F., WATKINS, C., PEARL, G., LAMBON RALPH, M. A. & TYRELL, P. Effectiveness of enhanced communication therapy in the first four months after a stroke for aphasia and dysarthria: a randomised controlled trial. British Medical Journal, 2012, 345, 1-15. INTERCOLLEGIATE STROKE WORKING PARTY. (2012) National clinical guideline for stroke, 4th edition. London: Royal College of Physicians. NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE. (2013) Stroke rehabilitation: 2nd guideline consultation