Occupational therapy to improve outdoor mobility after stroke

People who have suffered a stroke can become housebound and miserable because they cannot access suitable transport. They can have difficulty getting to the shops, doctors and hospital and this can have an effect on their quality of life. Occupational therapists routinely aim to help these people overcome their outdoor mobility problems by providing information and verbal instructions but these interventions do not appear to be effective. The aim of this research was to design and evaluate a new occupational therapy outdoor mobility intervention. The intervention was modeled on travel training that is provided for other conditions and the outdoor mobility experiences and needs of people with stroke. Qualitative semi structured interviews were used to investigate 24 peoples experiences of both using transport and their outdoor mobility after they had suffered a stroke. It was found that people wanted to travel for a variety of reasons; shopping, work, getting to the doctors, social reasons, meeting friends, visiting family and just for the sake of traveling. People were prevented from traveling because of physical difficulties such as stepping onto the bus, psychological problems such as confidence and environmental barriers such as the weather or lack of information. The results were used to define the main components of an Occupational Therapy Outdoor Mobility Intervention. A randomised controlled trial was used to evaluate the effects of this Occupational Therapy Outdoor Mobility Intervention (OTOMI) by comparing it to the routine occupational therapy intervention. Participants with stroke in the last 36 months were recruited from primary care services and randomly allocated to receive either the OTOMI or the routine occupational therapy. Participants in the OTOMI received up to seven individualised occupational therapy sessions. The sessions aimed to increase confidence, encourage use of different types of transport and provided tailor-made information. Outcomes were measured by postal assessment 4 and 10 months after recruitment. The primary outcome measure was a yes/ no question, Do you get out of the house as much as you would like? Secondary outcomes included the number of journeys, mood, performance of activities of daily living and leisure. 168 participants who had had a stroke in the last 36 months were recruited into the study over eighteen months, 82 in the control group and 86 to the OTOMI group. 10 people were unable to provide follow-up information at the four month assessment and 21 people at the ten month assessment. Intention-to-treat analyses were undertaken. For the principal outcome measure, participants who were dead at the point of assessment were allocated the worst outcome, and for others lost to follow up their baseline or last recorded responses were used. For the other analyses all missing values were imputed using baseline values. Participants in the treatment group were more likely to get out of their house as often as they wanted at 4 months (RR 1.72,95% CI 1.25 to 2.37) and at 10 months (RR 1.74,95 Cl 1.24 to 2.44). The treatment group recorded more journeys outdoors in the month prior to assessment at 4 months (intervention group median 37, control group median 14, Mann-Whitney p<0.01) and at 10 months (intervention group median 42, control group median 14, Mann-Whitney: p<0.01). At 4 months the NEADL mobility scores were significantly higher in the intervention group, but there were no significant differences in the other secondary outcomes. There were no significant differences in these measures at 10 months. The interview study demonstrated that participating in outdoor mobility is a major problem for people who have had a stroke. The randomised controlled trial demonstrated that a relatively simple and feasible, individualized, properly organised, focused and adequately resourced occupational therapy outdoor mobility intervention can increase participation in outdoor mobility activities, allowing people to get out of the house as much as they wish

The association of specific executive functions and falls risk in people with mild cognitive impairment and early-stage dementia

Background/Aims: Impairment in executive function is associated with a heightened risk for falls in people with mild cognitive impairment (MCI) and dementia. The purpose of this study was to determine which aspects of executive function are associated with falls risk. Methods: Forty-two participants with a mean age of 81.6 years and a diagnosis of MCI or mild dementia completed five different executive function tests from the computerised CANTAB test battery and a comprehensive falls risk assessment. Results: A hierarchical regression analysis showed that falls risk was significantly associated with spatial memory abilities and inhibition of a pre-potent response. Conclusion: The concept of executive function may be too general to provide meaningful results in a research or clinical context, which should focus on spatial memory and inhibition of a pre-potent response

Community falls prevention for people who call an emergency ambulance after a fall: randomised controlled trial

Objective To evaluate whether a service to prevent falls in the community would help reduce the rate of falls in older people who call an emergency ambulance when they fall but are not taken to hospital

The SARS-CoV-2 Spike protein has a broad tropism for mammalian ACE2 proteins.

SARS Coronavirus 2 (SARS-CoV-2) emerged in late 2019, leading to the Coronavirus Disease 2019 (COVID-19) pandemic that continues to cause significant global mortality in human populations. Given its sequence similarity to SARS-CoV, as well as related coronaviruses circulating in bats, SARS-CoV-2 is thought to have originated in Chiroptera species in China. However, whether the virus spread directly to humans or through an intermediate host is currently unclear, as is the potential for this virus to infect companion animals, livestock, and wildlife that could act as viral reservoirs. Using a combination of surrogate entry assays and live virus, we demonstrate that, in addition to human angiotensin-converting enzyme 2 (ACE2), the Spike glycoprotein of SARS-CoV-2 has a broad host tropism for mammalian ACE2 receptors, despite divergence in the amino acids at the Spike receptor binding site on these proteins. Of the 22 different hosts we investigated, ACE2 proteins from dog, cat, and cattle were the most permissive to SARS-CoV-2, while bat and bird ACE2 proteins were the least efficiently used receptors. The absence of a significant tropism for any of the 3 genetically distinct bat ACE2 proteins we examined indicates that SARS-CoV-2 receptor usage likely shifted during zoonotic transmission from bats into people, possibly in an intermediate reservoir. Comparison of SARS-CoV-2 receptor usage to the related coronaviruses SARS-CoV and RaTG13 identified distinct tropisms, with the 2 human viruses being more closely aligned. Finally, using bioinformatics, structural data, and targeted mutagenesis, we identified amino acid residues within the Spike-ACE2 interface, which may have played a pivotal role in the emergence of SARS-CoV-2 in humans. The apparently broad tropism of SARS-CoV-2 at the point of viral entry confirms the potential risk of infection to a wide range of companion animals, livestock, and wildlife

Acute medical unit comprehensive geriatric assessment intervention study (AMIGOS)

<p>Abstract</p> <p>Background</p> <p>Many older people presenting to Acute Medical Units (AMU) are discharged after only a short stay (< 72 hours), yet many re-present to hospital or die within 1 year. Comprehensive Geriatric Assessment may improve patient outcomes for this group.</p> <p>Method</p> <p>Participants</p> <p>Patients aged > 70 years and scoring positive on a risk screening tool ('Identification of Seniors At Risk') who are discharged within 72 hours of attending an AMU with a medical crisis, recruited prior to discharge. Sample size is 400. Carers of participants will also be recruited.</p> <p>Intervention</p> <p>Assessment on the AMU and further out-patient management by a specialist physician in geriatric medicine. Assessment and further management will follow the principles of Comprehensive Geriatric Assessment, providing advice and support to primary care services.</p> <p>Design</p> <p>Multi-centre, individual patient randomised controlled trial comparing intervention with usual care.</p> <p>Outcome measurement</p> <p>Follow up is by postal questionnaire 90 days after randomisation, and data will be entered into the study database by a researcher blind to allocation. The primary outcome is the number of days spent at home (for those admitted from home), or days spent in the same care home (if admitted from a care home). Secondary outcomes include mortality, institutionalisation, health and social care resource use, and scaled outcome measures, including quality of life, disability, mental well-being. Carer strain and well being will also be measured at 90 days.</p> <p>Analyses</p> <p>Comparisons of outcomes and costs, and a cost utility analysis between the intervention and control groups will be carried out.</p> <p>Trial Registration</p> <p>ISRCTN: <a href="http://www.controlled-trials.com/ISRCTN21800480">ISRCTN21800480</a></p

Developing the principles of chair based exercise for older people: a modified Delphi study

Background Chair based exercise (CBE) is suggested to engage older people with compromised health and mobility in an accessible form of exercise. A systematic review looking at the benefits of CBE for older people identified a lack of clarity regarding a definition, delivery, purpose and benefits. This study aimed to utilise expert consensus to define CBE for older people and develop a core set of principles to guide practice and future research. Methods The framework for consensus was constructed through a team workshop identifying 42 statements within 7 domains. A four round electronic Delphi study with multi-disciplinary health care experts was undertaken. Statements were rated using a 5 point Likert scale of agreement and free text responses. A threshold of 70% agreement was used to determine consensus. Free text responses were analysed thematically. Between rounds a number of strategies (e.g., amended wording of statements, generation and removal of statements) were used to move towards consensus. Results 16 experts agreed on 46 statements over four rounds of consultation (Round 1: 22 accepted, 3 removed, 5 new and 17 modified; Round 2: 16 accepted, 0 removed, 4 new and 6 modified; Round 3: 4 accepted, 2 removed, 0 new and 4 modified; Round 4: 4 accepted, 0 removed, 0 new, 0 modified). Statements were accepted in all seven domains: the definition of CBE (5), intended users (3), potential benefits (8), structure (12), format (8), risk management (7) and evaluation (3). The agreed definition of CBE had five components: 1. CBE is primarily a seated exercise programme; 2. The purpose of using a chair is to promote stability in both sitting and standing; 3. CBE should be considered as part of a continuum of exercise for frail older people where progression is encouraged; 4. CBE should be used flexibly to respond to the changing needs of frail older people; and 5. Where possible CBE should be used as a starting point to progress to standing programmes. Conclusions Consensus has been reached on a definition and a set of principles governing CBE for older people; this provides clarity for implementation and future research about CBE

Evaluation of the guide to action care home fall prevention programme in care homes for older people: A multi-centre, single blinded, cluster randomised controlled trial (FINCH)

BackgroundFalls in care home residents are common, unpleasant, costly and difficult to prevent. Trial DesignThe objective was to evaluate the clinical and cost effectiveness of the Guide to Action for Falls Prevention Care Homes, GtACH) in which care home staff were trained and supported in the systematic use of a multi-domain decision support tool and identify issues affecting subsequent implementation. A two-arm parallel design, multi-centre, cluster randomised controlled trial of the GtACH programme and usual falls prevention in older care home residents was conducted with embedded process evaluation and economic evaluation. MethodThe study was conducted in care homes from ten UK sites. The primary trial outcome was the rate of falls per resident participant occurring during the 90-day period between 91 days and 180 days post-randomisation. The primary outcome for the cost effectiveness analysis was the cost per fall averted and for the cost utility analysis was the incremental cost per QALY. Secondary outcomes included the rate of falls over days 0-90 and 181-360 post randomisation, activity levels, dependency, and fractures. Care homes were randomised on a 1:1 basis to the GtACH programme or usual care, via a secure web-based randomisation service. Research assistants (RAs), resident participants and staff informants were blind to allocation at recruitment. RAs were blind to allocation at follow up. Data from NHS Digital were extracted blindly. The number of falls per resident was compared between groups using a negative binomial regression model (GEE).Results84 care homes were randomised, 39 to GtACH and 45 to usual care. 1657 residents consented and provided baseline measures, mean age 85 years, 32% men. GtACH training was delivered to 1051 staff (71% of eligible staff) over 146 group sessions. Primary RCT outcome data were available for 630 of the GtACH participants and 712 usual care participants. The primary RCT outcome result showed an unadjusted Incidence Rate Ratio (IRR) of 0.57 (95% CI 0.45-0.71, p<0.01) in favour of the GtACH programme. Fall rates were also lower in the GtACH group in the period 0-90 days, but there were no other differences between groups in the secondary outcomes. Care home staff valued the training, the systematic strategies and the specialist peer support, but there was limited incorporation of the GtACH documentation into routine care home practice. No adverse events were recorded. The incremental cost per DEMQoL-based QALY was £20,889.42 and £4,543.69 per EQ-5D based QALY. Mean falls were 1.889 (sd 3.662) in the GtACH arm and 2.747 (sd 7.414) in the usual care arm. Therefore, 0.858 falls were averted. The base case incremental cost per fall averted was £190.62ConclusionThe GtACH programme significantly reduced the rate of falls in the study care homes, without restricting residents’ activity levels or increasing their dependency and was cost effective at current thresholds in the UK NHS. Widespread implementation of the programme is justified. Trial registrationTrial registration number: ISRCTN34353836. Protocol V6 14 November 2017Funding DetailsThe National Institute for Health Research (NIHR) HTA programm

A multidomain decision support tool to prevent falls in older people: the FinCH cluster RCT

BackgroundFalls in care home residents are common, unpleasant, costly and difficult to prevent.ObjectivesThe objectives were to evaluate the clinical effectiveness and cost-effectiveness of the Guide to Action for falls prevention in Care Homes (GtACH) programme.DesignA multicentre, cluster, parallel, 1 : 1 randomised controlled trial with embedded process evaluation and economic evaluation. Care homes were randomised on a 1 : 1 basis to the GtACH programme or usual care using a secure web-based randomisation service. Research assistants, participating residents and staff informants were blind to allocation at recruitment; research assistants were blind to allocation at follow-up. NHS Digital data were extracted blindly.SettingOlder people’s care homes from 10 UK sites.ParticipantsOlder care home residents.InterventionThe GtACH programme, which includes care home staff training, systematic use of a multidomain decision support tool and implementation of falls prevention actions, compared to usual falls prevention care.OutcomesThe primary trial outcome was the rate of falls per participating resident occurring during the 90-day period between 91 and 180 days post randomisation. The primary outcome for the cost-effectiveness analysis was the cost per fall averted, and the primary outcome for the cost–utility analysis was the incremental cost per quality adjusted life-year. Secondary outcomes included the rate of falls over days 0–90 and 181–360 post randomisation, activity levels, dependency and fractures. The number of falls per resident was compared between arms using a negative binomial regression model (generalised estimating equation).ResultsA total of 84 care homes were randomised: 39 to the GtACH arm and 45 to the control arm. A total of 1657 residents consented and provided baseline measures (mean age 85 years, 32% men). GtACH programme training was delivered to 1051 staff (71% of eligible staff) over 146 group sessions. Primary outcome data were available for 630 GtACH participants and 712 control participants. The primary outcome result showed an unadjusted incidence rate ratio of 0.57 (95% CI 0.45 to 0.71; p < 0.01) in favour of the GtACH programme. Falls rates were lower in the GtACH arm in the period 0–90 days. There were no other differences between arms in the secondary outcomes. Care home staff valued the training, systematic strategies and specialist peer support, but the incorporation of the GtACH programme documentation into routine care home practice was limited. No adverse events were recorded. The incremental cost was £20,889.42 per Dementia Specific Quality of Life-based quality-adjusted life-year and £4543.69 per quality-adjusted life-year based on the EuroQol-5 dimensions, five-level version. The mean number of falls was 1.889 (standard deviation 3.662) in the GtACH arm and 2.747 (standard deviation 7.414) in the control arm. Therefore, 0.858 falls were averted. The base-case incremental cost per fall averted was £190.62.ConclusionThe GtACH programme significantly reduced the falls rate in the study care homes without restricting residents’ activity levels or increasing their dependency, and was cost-effective at current thresholds in the NHS.Future workFuture work should include a broad implementation programme, focusing on scale and sustainability of the GtACH programme.LimitationsA key limitation was the fact that care home staff were not blinded, although risk was small because of the UK statutory requirement to record falls in care homes.Trial registrationThis trial is registered as ISRCTN34353836.FundingThis 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. 26, No. 9. See the NIHR Journals Library website for further project information

Support and Assessment for Fall Emergency Referrals (SAFER 1): Cluster Randomised Trial of Computerised Clinical Decision Support for Paramedics

Objective: To evaluate effectiveness, safety and cost-effectiveness of Computerised Clinical Decision Support (CCDS) for paramedics attending older people who fall. Design: Cluster trial randomised by paramedic; modelling. Setting: 13 ambulance stations in two UK emergency ambulance services. Participants: 42 of 409 eligible paramedics, who attended 779 older patients for a reported fall. Interventions: Intervention paramedics received CCDS on Tablet computers to guide patient care. Control paramedics provided care as usual. One service had already installed electronic data capture. Main Outcome Measures: Effectiveness: patients referred to falls service, patient reported quality of life and satisfaction, processes of care. Safety: Further emergency contacts or death within one month. Cost-Effectiveness Costs and quality of life. We used findings from published Community Falls Prevention Trial to model cost-effectiveness. Results: 17 intervention paramedics used CCDS for 54 (12.4%) of 436 participants. They referred 42 (9.6%) to falls services, compared with 17 (5.0%) of 343 participants seen by 19 control paramedics [Odds ratio (OR) 2.04, 95% CI 1.12 to 3.72]. No adverse events were related to the intervention. Non-significant differences between groups included: subsequent emergency contacts (34.6% versus 29.1%; OR 1.27, 95% CI 0.93 to 1.72); quality of life (mean SF12 differences: MCS −0.74, 95% CI −2.83 to +1.28; PCS −0.13, 95% CI −1.65 to +1.39) and non-conveyance (42.0% versus 36.7%; OR 1.13, 95% CI 0.84 to 1.52). However ambulance job cycle time was 8.9 minutes longer for intervention patients (95% CI 2.3 to 15.3). Average net cost of implementing CCDS was £208 per patient with existing electronic data capture, and £308 without. Modelling estimated cost per quality-adjusted life-year at £15,000 with existing electronic data capture; and £22,200 without. Conclusions: Intervention paramedics referred twice as many participants to falls services with no difference in safety. CCDS is potentially cost-effective, especially with existing electronic data capture

New genetic loci link adipose and insulin biology to body fat distribution.

Body fat distribution is a heritable trait and a well-established predictor of adverse metabolic outcomes, independent of overall adiposity. To increase our understanding of the genetic basis of body fat distribution and its molecular links to cardiometabolic traits, here we conduct genome-wide association meta-analyses of traits related to waist and hip circumferences in up to 224,459 individuals. We identify 49 loci (33 new) associated with waist-to-hip ratio adjusted for body mass index (BMI), and an additional 19 loci newly associated with related waist and hip circumference measures (P < 5 × 10(-8)). In total, 20 of the 49 waist-to-hip ratio adjusted for BMI loci show significant sexual dimorphism, 19 of which display a stronger effect in women. The identified loci were enriched for genes expressed in adipose tissue and for putative regulatory elements in adipocytes. Pathway analyses implicated adipogenesis, angiogenesis, transcriptional regulation and insulin resistance as processes affecting fat distribution, providing insight into potential pathophysiological mechanisms