Talking about recovery after stroke: How do we do it, and can we do it better?

Background: Survivors of stroke and their families report dissatisfaction with the information they receive about the expected timing and extent of recovery. Aim: To develop an in-depth understanding of current practice in providing and receiving information about recovery in stroke units and explore patients’, carers’ and professionals’ experiences and views, to inform development of a complex intervention to improve provision. Methods: Current practice was explored using focused ethnographic case studies in two stroke units, including non-participant observations, interviews with patients, carers and professionals, and documentary analysis. Systematic literature reviews identified and synthesised existing literature relating to patients’, carers’ and professionals’ views and experiences, and the effectiveness of existing strategies to improve provision. This work informed intervention development underpinned by behaviour change theory, with mixed-methods survey employed to gather professionals’ feedback on identified strategies. Results: A complex range of factors influenced the consistency, quality, and delivery of information about recovery, including the hospital and stroke unit environment, multidisciplinary team (MDT) working, the uncertainties of stroke recovery, and individual differences in patients’ and carers’ abilities and needs. Patients and carers reported mixed experiences of receiving information, and desired delivery to be positive, honest, proactive, and compassionate. Identified barriers to provision included professionals’ perceived lack of skills and confidence and insufficient knowledge of the benefits. No strategies to deliver recovery information that had been proven effective in improving patient and carer outcomes could be identified from existing literature. Professionals perceived practical advice and demonstrations of communication skills, MDT support, and patient and carer accounts as feasible and effective strategies to address these barriers. Discussion: Communication of information about recovery in stroke units continues to be sub-optimal and presents significant challenges for professionals. Further research is required to continue development of an intervention to support professionals to provide information more effectively

Service users' views of the assessment process in stroke rehabilitation

Objective: To investigate the service users’ (stroke survivors and care-givers) experiences and views of the rehabilitation assessment process. Design: Qualitative data analysis from three focus groups using a content analysis to identify the major themes. Setting: Participants were recruited from stroke support groups and community rehabilitation services in a large UK city. Subjects: Seventeen community-dwelling stroke survivors who had completed their rehabilitation within the previous year and six care-givers. Results: Five themes emerged: understanding the purpose of the assessment; repetition of assessments; feedback about assessments and progress; format of feedback and barriers to feedback. While all participants reported undergoing assessment, some felt their purpose was not always explained and resented unexplained repetitions of tests. Some participants reported a positive experience, but most wanted more information about their progress and predictions of recovery. They wanted regular, consistent, objective information presented in layman’s terms; verbally and in writing. Some carers reported difficulty accessing information particularly as a result of confidentiality policies. While some participants accepted these short-comings, others considered them due to staff’s disinterest or ineptitude, which undermined their trust in the team. Conclusions: Stroke service users require clear information about the purpose of assessments and regular, consistent, objective feedback about their progress using layman’s language both verbally and in writing. </jats:sec

Finishing the euchromatic sequence of the human genome

The sequence of the human genome encodes the genetic instructions for human physiology, as well as rich information about human evolution. In 2001, the International Human Genome Sequencing Consortium reported a draft sequence of the euchromatic portion of the human genome. Since then, the international collaboration has worked to convert this draft into a genome sequence with high accuracy and nearly complete coverage. Here, we report the result of this finishing process. The current genome sequence (Build 35) contains 2.85 billion nucleotides interrupted by only 341 gaps. It covers ∼99% of the euchromatic genome and is accurate to an error rate of ∼1 event per 100,000 bases. Many of the remaining euchromatic gaps are associated with segmental duplications and will require focused work with new methods. The near-complete sequence, the first for a vertebrate, greatly improves the precision of biological analyses of the human genome including studies of gene number, birth and death. Notably, the human enome seems to encode only 20,000-25,000 protein-coding genes. The genome sequence reported here should serve as a firm foundation for biomedical research in the decades ahead

Investigation of hospital discharge cases and SARS-CoV-2 introduction into Lothian care homes

Background The first epidemic wave of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in Scotland resulted in high case numbers and mortality in care homes. In Lothian, over one-third of care homes reported an outbreak, while there was limited testing of hospital patients discharged to care homes. Aim To investigate patients discharged from hospitals as a source of SARS-CoV-2 introduction into care homes during the first epidemic wave. Methods A clinical review was performed for all patients discharges from hospitals to care homes from 1st March 2020 to 31st May 2020. Episodes were ruled out based on coronavirus disease 2019 (COVID-19) test history, clinical assessment at discharge, whole-genome sequencing (WGS) data and an infectious period of 14 days. Clinical samples were processed for WGS, and consensus genomes generated were used for analysis using Cluster Investigation and Virus Epidemiological Tool software. Patient timelines were obtained using electronic hospital records. Findings In total, 787 patients discharged from hospitals to care homes were identified. Of these, 776 (99%) were ruled out for subsequent introduction of SARS-CoV-2 into care homes. However, for 10 episodes, the results were inconclusive as there was low genomic diversity in consensus genomes or no sequencing data were available. Only one discharge episode had a genomic, time and location link to positive cases during hospital admission, leading to 10 positive cases in their care home. Conclusion The majority of patients discharged from hospitals were ruled out for introduction of SARS-CoV-2 into care homes, highlighting the importance of screening all new admissions when faced with a novel emerging virus and no available vaccine

SARS-CoV-2 Omicron is an immune escape variant with an altered cell entry pathway

Vaccines based on the spike protein of SARS-CoV-2 are a cornerstone of the public health response to COVID-19. The emergence of hypermutated, increasingly transmissible variants of concern (VOCs) threaten this strategy. Omicron (B.1.1.529), the fifth VOC to be described, harbours multiple amino acid mutations in spike, half of which lie within the receptor-binding domain. Here we demonstrate substantial evasion of neutralization by Omicron BA.1 and BA.2 variants in vitro using sera from individuals vaccinated with ChAdOx1, BNT162b2 and mRNA-1273. These data were mirrored by a substantial reduction in real-world vaccine effectiveness that was partially restored by booster vaccination. The Omicron variants BA.1 and BA.2 did not induce cell syncytia in vitro and favoured a TMPRSS2-independent endosomal entry pathway, these phenotypes mapping to distinct regions of the spike protein. Impaired cell fusion was determined by the receptor-binding domain, while endosomal entry mapped to the S2 domain. Such marked changes in antigenicity and replicative biology may underlie the rapid global spread and altered pathogenicity of the Omicron variant

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

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