An occupational therapy intervention for residents with stroke-related disabilities in UK care homes (OTCH):Cluster randomised controlled trial with economic evaluation

Background: Care home residents with stroke-related disabilities have significant activity limitations. Phase II trial results suggested a potential benefit of occupational therapy (OT) in maintaining residents’ capacity to engage in functional activity. Objective: Evaluate clinical and cost effectiveness of a targeted course of OT in maintaining functional activity and reducing further health risks from inactivity for UK care home residents living with stroke-related disabilities. Design: Pragmatic, parallel-group, cluster randomised controlled trial with economic evaluation. Cluster randomisation occurred at the care home level. Homes were stratified according to trial administrative centre, and type of care provided (nursing or residential) and randomised 1:1 to either the intervention or control arm. Setting: 228 care homes local to 11 trial administrative centres across England and Wales. Participants: 1042 care home residents with a history of stroke or transient ischaemic attack, including residents with communication and cognitive impairments, not receiving end of life care. 114 care homes (n=568 residents) were allocated to the intervention arm; 114 homes (n=474 residents) to the control arm. Randomisation of participating homes occurred between May 2010 and March 2012. Intervention: Personalised three-month course of OT delivered by qualified therapists. Care workers participated in training workshops to support personal activities of daily living. The control condition consisted of usual care for residents. Main outcome measures: Primary outcome at the participant level: Barthel Index of Activities of Daily Living at three months. Secondary outcomes at the participant level: Barthel Index scores at six and twelve months post-randomisation, and the Rivermead Mobility Index, Geriatric Depression Scale-15, and EuroQol EQ-5D-3L questionnaire at all time-points. An economic evaluation examined the incremental cost per quality-adjusted life year (QALY) gain, costs were estimated from the perspective of the NHS and personal social services. Results: Participants mean age= 82.9 years, 665/1042 (64%) were female. 2538 OT sessions were delivered to 498 participants in the intervention group (mean visits/participant =5.1, SD=3.0). No adverse events attributable to the intervention were recorded. The primary outcome showed no significant differences between groups. The adjusted mean difference in the Barthel Index score between groups was 0.19 points higher in the intervention arm (95% CI -0.33 to 0.70, p=0.48, adjusted ICC 0.09). Secondary outcome measures showed no significant differences at all time-points. Mean incremental cost of the OTCH intervention was £438.78 (CI £-360.89 to £1238.46), and the incremental QALY gain was 0.009 (CI -0.030 to 0.048). Conclusion: A three-month individualised course of OT, showed no benefit in maintaining functional activity in an older care home population with stroke-related disabilities. Limitations: A high proportion of participants with very severe activity-based limitations and cognitive impairment have limited capacity to engage in therapy. Future work: There is an urgent need to reduce health-related complications caused by inactivity, and create more of an enabling built environment within care homes. Trial registration: Current controlled trials ISRCTN00757750

Viruses exacerbating chronic pulmonary disease: the role of immune modulation

Chronic pulmonary diseases are a major cause of morbidity and mortality and their impact is expected to increase in the future. Respiratory viruses are the most common cause of acute respiratory infections and it is increasingly recognized that respiratory viruses are a major cause of acute exacerbations of chronic pulmonary diseases such as asthma, chronic obstructive pulmonary disease and cystic fibrosis. There is now increasing evidence that the host response to virus infection is dysregulated in these diseases and a better understanding of the mechanisms of abnormal immune responses has the potential to lead to the development of new therapies for virus-induced exacerbations. The aim of this article is to review the current knowledge regarding the role of viruses and immune modulation in chronic pulmonary diseases and discuss avenues for future research and therapeutic implications

Social and practical strategies described by people living at home with stroke.

People with stroke are often referred to in negative terms. The phrase 'stroke victim' suggests that they are regarded as passive and deserving of pity, whilst 'the burden of care' implicates them negatively as an encumbrance to others. Much of the literature focuses on how stroke devastates peoples' lives, again casting the person with the stroke as an inactive victim of the illness, and subsequently a passive recipient of care. Against this background we aimed to find out whether people with stroke and their families take positive actions in response to the condition, and if so, to explore the nature of these actions. In-depth interviews were conducted with a consecutive sample of 40 people admitted to hospital in the East End of London, 10 months after their stroke. People with stroke were found to play an active and creative role in managing the aftermath of their illness. They (i) mobilized informal social support; (ii) created new ways of doing things; (iii) took things more slowly; (iv) began the process of relearning; (v) exercized; and (vi) 'covered up'. Families were found to be a major resource. These findings challenge the view of people with stroke as 'victims', who bring about a 'burden of care', and suggest that the majority of work after stroke is conducted not by clinicians or by formal carers, but by the person with the stroke and their families, at home. This needs to be recognized and respected by formal carers, who should base their interventions around the systems and routines established by families

Stroke mimics in the pre-hospital setting

Accurate identification of stroke patients is essential to ensure appropriate and timely treatment. Stroke mimics —patients initially suspected to have suffered a stroke who are subsequently diagnosed with a condition other than stroke —are estimated to account for 5 –33% of suspected stroke patients conveyed by paramedics to a hospital stroke unit. The prevalence of stroke mimics in London has not been investigated although pan-London hospital data suggests that one quarter of all patients admitted to hyper-acute stroke units (HASUs) are stroke mimics. Participants were recruited as part of a larger study investigating whether the use of the Recognition of Stroke in the Emergency Room (ROSIER) tool by ambulance crews improved pre-hospital stroke recognition. Only patients indicated by the ROSIER to have potentially suffered a stroke and conveyed to a participating HASU (n=256) were included. A final diagnosis of stroke was received by 160 patients (“strokes”) while 96 patients received a final diagnosis of nonstroke (“mimics”), resulting in a stroke mimic rate of 38%. Mimics received a wide range of diagnoses, including seizure, syncope, brain tumour, non-organic stroke/symptoms, sepsis, somatisation, and migraine. Compared to strokes, mimics had a lower total ROSIER score, displayed fewer stroke-related symptoms, and presented with more symptoms not indicative of a stroke (e.g. loss of consciousness/syncope, seizure). The stroke mimic rate is higher than reported by previous studies and pan-London hospital data. It is unlikely this higher rate is due to the use of the ROSIER since the speci ficity of the ROSIER is equal to the FAST in the pre-hospital setting (Fothergill et al, submitted). Stroke recognition in the prehospital setting needs to be improved in order to reduce the number of non-strokes falsely identi fied as stroke and to ensure these patients are taken to the appropriate facility for treatment. https://emj.bmj.com/content/emermed/32/5/e8.2.full.pdf This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/emermed-2015-204880.2

Does Use of the Recognition Of Stroke In the Emergency Room stroke assessment tool enhance stroke recognition by ambulance clinicians

Background and Purpose—UK ambulance services assess patients with suspected stroke using the Face Arm Speech Test (FAST). The Recognition Of Stroke In the Emergency Room (ROSIER) tool has been shown superior to the FAST in identifying strokes in emergency departments but has not previously been tested in the ambulance setting. We investigated whether ROSIER use by ambulance clinicians can improve stroke recognition. Methods—Ambulance clinicians used the ROSIER in place of the FAST to assess patients with suspected stroke. As the ROSIER includes all FAST elements, we calculated a FAST score from the ROSIER to enable comparisons between the two tools. Ambulance clinicians’ provisional stroke diagnoses using the ROSIER and calculated FAST were compared with stroke consultants’ diagnosis. We used stepwise logistic regression to compare the contribution of individual ROSIER and FAST items and patient demographics to the prediction of consultants’ diagnoses. Results—Sixty-four percent of strokes and 78% of non strokes identified by ambulance clinicians using the ROSIER were subsequently confirmed by a stroke consultant. There was no difference in the proportion of strokes correctly detected by the ROSIER or FAST with both displaying excellent levels of sensitivity. The ROSIER detected marginally more non stroke cases than the FAST, but both demonstrated poor specificity. Facial weakness, arm weakness, seizure activity, age, and sex predicted consultants’ diagnosis of stroke. Conclusions—The ROSIER was not better than the FAST for prehospital recognition of stroke. A revised version of the FAST incorporating assessment of seizure activity may improve stroke identification and decision making by ambulance clinicians.Peer reviewe