Stroke units: The implementation of a complex intervention

This article reports on selected findings from an action research study that looked at the lessons learnt from setting up a new in-patient stroke service in a London teaching hospital. Key participants in the design and evaluation of this 2-year study included members of the multi-professional stroke team and support staff within the unit, the hospital management team and representatives of patients and carers. Mixed methods (focus groups, indepth interviews, audits, documentary analysis, participant observation field notes) were used to generate data. Findings demonstrated positive change overtime with four main themes emerging from the process: building a team; developing practice-based knowledge and skills in stroke; valuing the central role of the nurse in stroke care; and creating an organisational climate for supporting change. The interplay of these non-linear, but interrelated factors is supported by complexity theory, which includes exploration of how the sum of a whole can be more than its constituent parts. Findings are likely to be of interest to practitioners, managers and policy makers interested in supporting change in a learning organisation

A cross sectional study of the prevalence, risk factors and population attributable fractions for limb and body lesions in lactating sows on commercial farms in England

Background: Lesions on sows' limbs and bodies are an abnormality that might impact on their welfare. The prevalence of and risks for limb and body lesions on lactating sows on commercial English pig farms were investigated using direct observation of the sows and their housing. Results: The prevalence of lesions on the limbs and body were 93% (260/279) and 20% (57/288) respectively. The prevalence of limb and body lesions was significantly lower in outdoor-housed sows compared with indoor-housed sows. Indoor-housed sows had an increased risk of wounds (OR 6.8), calluses (OR 8.8) and capped hock (OR 3.8) on their limbs when housed on fully slatted floors compared with solid concrete floors. In addition, there was an increased risk of bursitis (OR 2.7), capped hock (OR 2.3) and shoulder lesions (OR 4.8) in sows that were unwilling to rise to their feet. There was a decreased risk of shoulder lesions (OR 0.3) and lesions elsewhere on the body (OR 0.2) in sows with more than 20 cm between their tail and the back of the crate compared with sows with less than 10 cm. Conclusion: The sample of outdoor housed sows in this study had the lowest prevalence of limb and body lesions. In lactating sows housed indoors there was a general trend for an increased risk of limb and body lesions in sows housed on slatted floors compared with those housed on solid concrete floors with bedding. Sows that were less responsive to human presence and sows that had the least space to move within their crates had an additional increased risk of lesions

Contemporary splinting practice in the UK for adults with neurological dysfunction: A cross-sectional survey

This article is made available through the Brunel Open Access Publishing Fund.Aim: To explore the contemporary splinting practice of UK occupational therapists and physiotherapists for adults with neurological dysfunction. Method: Cross-sectional online survey of members of the Association of Chartered Physiotherapists in Neurology and College of Occupational Therapists Specialist Section Neurological Practice. Results: Four hundred and twenty therapists completed the survey. Contracture management is the most common rationale for therapists splinting adults with neurological dysfunction. Other shared therapeutic goals of splinting include maintaining muscle and joint alignment, spasticity management, function, pain management and control of oedema. Considerable clinical uncertainty was uncovered in practice particularly around wearing regimens of splints. Most therapists have access to locally-derived splinting guidelines, which may contribute to this diversity of practice. Conclusions: This study provides a unique insight into aspects of contemporary splinting practice among UK therapists, who belong to a specialist neurological professional network and work in a number of different health-care settings with adults who have a neurological condition. Study findings show a wide variation in splinting practice, thereby indicating a potential need for national guidance to assist therapists in this area of clinical uncertainty. Further research is required to establish best practice parameters for splinting in neurological rehabilitation

An epidemiological study of foot, limb and body lesions and lameness in pigs

A cross sectional study of 103 indoor and outdoor British pig farms was carried out in 2003-2004. Over 12,000 pigs aged from 3 days up to multiparious breeding sows were examined. Prevalence of foot, limb and body lesions and lameness was recorded using clear case definitions. Detailed data were also collected on the pen or paddock that the pigs were housed in with particular reference to the floor design, material and condition. Associations between prevalence of disease and the environment the pig was housed in were analysed using multilevel regression models. Post-mortem examination of a small sample of foot and limb lesions was carried out to better understand the pathology. There was a lower prevalence of body and limb lesions in pigs of all ages, and foot lesions in preweaning piglets, housed outdoors compared with indoors. However, there was little difference in the prevalence of foot lesions and lameness in gilts and pregnant sows kept indoors compared with outdoors. In most pigs housed indoors, there was a trend for an increased risk of limb and body lesions and lameness in pigs housed on hard and slatted floors compared with solid concrete floors with bedding. Although, in contrast to this the prevalence of wounds on the limbs in piglets was lower on slatted floors compared with solid concrete floors. The associations between foot lesions and indoor floor type varied with the age of the pig and the type of lesion. In piglets, sole bruising was associated with housing on slatted floors while sole erosion was associated with housing on solid concrete floors without bedding. In gilts and sows, heel flaps were associated with housing on slatted floors while toe erosion was associated with solid floors with deep bedding. In conclusion, this study has provided the most accurate estimates of the prevalence of foot, limb, body lesions and lameness in the English pig herd to date and generated useful hypotheses regarding the aetiology of these lesions. To further understand this topic cohort and intervention studies are now needed

Secondary prevention of stroke: Using the experiences of patients and carers to inform the development of an educational resource

Copyright @ The Author 2008. This article is available open access through the publisher’s website at the link below.Background. Patients who have had one stroke are at increased risk of another. Secondary prevention strategies that address medical risk factors and promote healthy lifestyles can reduce the risk. However, concordance with secondary prevention strategies is poor and there has been little research into patient and carer views. Objectives. To explore the experiences of patients and carers of receiving secondary prevention advice and use these to inform the development of an educational resource. Methods. A total of 38 participants (25 patients and 13 carers) took part in the study which used an action research approach. Focus groups and interviews were undertaken with patients and carers who had been discharged from hospital after stroke (between 3 and 24 months previously). Framework analysis was used to examine the data and elicit action points to develop an educational resource. Results. Participants’ main concern was their desire for early access to information. They commented on their priorities for what information or support they needed, the difficulty of absorbing complex information whilst still an in-patient and how health professionals’ use of language was often a barrier to understanding. They discussed the facilitators and barriers to making lifestyle changes. The educational resource was developed to include specific advice for medical and lifestyle risk factors and an individual action plan. Conclusion. An educational resource for secondary prevention of stroke was developed using a participatory methodology. Our findings suggest that this resource is best delivered in a one-to-one manner, but further work is needed to identify its potential utility.Peninsula Primary Care Research Networ

Some Modern New Poets

Catching up with recent poetry publications is always a lesson in contingency. Some poets – in the cases of John Wilkinson and Peter Gizzi – have published again since September, outdating the books closest to my chair. Some books only came to my attention once summer was already over. There are many poets that I simply haven’t got to. And yet there might be a mercy in these accidents: reading somewhat haphazardly allows one to draw up a bad map of the contemporary landscape, one which can be built upon in the months to come. Of the many symbols that might appear in the legend of that map, a poem's proximity to or distance from provinces of the poetic repertoire which might be thought of as traditional (such as fixed form, metre, and rhyme) has been a constant point of reference.Junior Research Fellowship at Peterhouse, Cambridg

An epidemiological study of foot, limb and body lesions and lameness in pigs

A cross sectional study of 103 indoor and outdoor British pig farms was carried out in 2003-2004. Over 12,000 pigs aged from 3 days up to multiparious breeding sows were examined. Prevalence of foot, limb and body lesions and lameness was recorded using clear case definitions. Detailed data were also collected on the pen or paddock that the pigs were housed in with particular reference to the floor design, material and condition. Associations between prevalence of disease and the environment the pig was housed in were analysed using multilevel regression models. Post-mortem examination of a small sample of foot and limb lesions was carried out to better understand the pathology. There was a lower prevalence of body and limb lesions in pigs of all ages, and foot lesions in preweaning piglets, housed outdoors compared with indoors. However, there was little difference in the prevalence of foot lesions and lameness in gilts and pregnant sows kept indoors compared with outdoors. In most pigs housed indoors, there was a trend for an increased risk of limb and body lesions and lameness in pigs housed on hard and slatted floors compared with solid concrete floors with bedding. Although, in contrast to this the prevalence of wounds on the limbs in piglets was lower on slatted floors compared with solid concrete floors. The associations between foot lesions and indoor floor type varied with the age of the pig and the type of lesion. In piglets, sole bruising was associated with housing on slatted floors while sole erosion was associated with housing on solid concrete floors without bedding. In gilts and sows, heel flaps were associated with housing on slatted floors while toe erosion was associated with solid floors with deep bedding. In conclusion, this study has provided the most accurate estimates of the prevalence of foot, limb, body lesions and lameness in the English pig herd to date and generated useful hypotheses regarding the aetiology of these lesions. To further understand this topic cohort and intervention studies are now needed.EThOS - Electronic Theses Online ServiceGreat Britain. Dept. for Environment, Food & Rural Affairs (DEFRA)University of Warwick (UoW)GBUnited Kingdo

Developing theory and practice: Creation of a Community of Practice through Action Research produced excellence in stroke care

Much emphasis is placed on expert knowledge such as evidence based stroke guidelines, but not enough attention is paid to the processes that are required to translate this into delivery of everyday good care. This paper highlights the worth of creating a Community of Practice (CoP) as a means to achieve this. Drawing on findings from a study conducted 2000 - 2002 of the processes involved in establishment of a nationally lauded high quality Stroke Unit, it demonstrates how successful development of a new service was linked to creation of a CoP. Recent literature suggests CoPs have a key role in the implementation of evidence-based practice; this study supports this claim whilst revealing for the first time the practical knowledge and skills required to develop this style of working. Findings also indicate that the participatory and democratic characteristics of Action Research are congruent with the collaborative approach required for the development of a CoP. The study is an exemplar of how practitioner researchers can capture learning from changing practice, thus contributing to evidence-based healthcare with theoretical as well as practical knowledge. Findings are relevant to those developing stroke services globally but also to those interested in evidence-based practice. (198

Incidence, time course and predictors of impairments relating to caring for the profoundly affected arm after stroke: A systematic review

Background and purpose - A significant number of stroke survivors will not recover the use of their affected arm. A proportion will experience pain, stiffness and difficulty with basic care activities. The purpose of the review was to identify predictors of difficulty caring for the profoundly affected arm and establish the incidence and time-course of the related impairments of pain, spasticity and contracture. Method - Data sources: Databases (PubMED, MEDLINE, AMED, EMBASE, CINAHL and the Cochrane Controlled Trials Register) were searched from inception to December 2013. Additional studies were identified from citation tracking. Review methods: Independent reviewers used pre-defined criteria to identify eligible studies. Quality assessment and risk of bias were assessed using the McMasters Assessment Tool. A narrative evidence synthesis was performed. Results - Thirty-nine articles reporting 34 studies were included. No studies formally measured difficulty caring for the arm, but related impairments were common. Incidence of spasticity in those with weakness ranged from 33% to 78%, shoulder pain affected 22% to 90% and contracture was present in at least 50%. Spasticity and pain appear within 1 week of stroke, and contracture within two weeks. Impairments continued to develop over at least 3–6 months. The most frequent predictors of spasticity and contracture were weakness and reduced motor control, and the risk of pain is most commonly predicted by reduced sensation, shoulder subluxation, weakness and stroke severity. Discussion - There is no published evidence on predicting the likelihood of difficulty caring for the arm following stroke. However, the related impairments of spasticity, pain and contracture are common. Given the time-course of development, clinicians may need not only to intervene early but also be prepared to act over a longer time period. Further research is needed to examine difficulty caring for the arm and the relationship with associated impairments to enable researchers and clinicians to develop targeted interventions