Exploring stroke survivors' and physiotherapists' views of self-management after stroke : a qualitative study in the UK

Objectives Stroke is a sudden-onset condition with long-term consequences. Self-management could help address long-term consequences of stroke. Stroke survivors' and health professionals' views of self-management may vary, limiting the successful introduction of self-management strategies. This paper explores stroke survivors' and physiotherapists' views of self-management, focusing on what self-management means, and factors perceived to enable and hinder self-management after stroke, to draw out implications for policy, practice and future research.Design Qualitative study using semistructured interviews and a thematic analysis approach.Setting Stroke unit and community stroke-rehabilitation services in London, UK.Participants 13 stroke survivors (8 men and 5 women; aged 53–89 years) admitted to a London stroke unit. 13 physiotherapists: 8 working in an inpatient stroke unit and 5 in community rehabilitation.Results Key differences were evident in how self-management was understood between these groups. Stroke survivors were unfamiliar with the term self-management, but most could provide their own definition and relate to the term, and understood it as care of the self: ‘doing things for yourself’ and ‘looking after yourself’. They did not recognise self-management as part of their care, but valued therapists as encouraging experts in supporting their recovery after stroke. Physiotherapists commonly understood self-management as a process in which stroke survivors were expected to take an active role in their rehabilitation and manage their recovery and health, with different understandings of self-management among physiotherapists shaped by the context in which they worked. They reported that individual, social and organisational factors enable and hinder self-management after stroke, with individual and organisational barriers particularly evident in the early stages.Conclusions If self-management support approaches are to be used, further work is required to explore the language and strategies used by professionals to support self-management, and the barriers to supporting self-management at different time points after stroke

Ink from longfin inshore squid, Doryteuthis pealeii, as a chemical and visual defense against two predatory fishes, summer flounder, Paralichthys dentatus, and sea catfish, Ariopsis felis

Author Posting. © Marine Biological Laboratory, 2013. This article is posted here by permission of Marine Biological Laboratory for personal use, not for redistribution. The definitive version was published in Biological Bulletin 225 (2013): 152-160.Chemical and visual defenses are used by many organisms to avoid being approached or eaten by predators. An example is inking molluscs—including gastropods such as sea hares and cephalopods such as squid, cuttlefish, and octopus—which release a colored ink upon approach or attack. Previous work showed that ink can protect molluscs through a combination of chemical, visual, and other effects. In this study, we examined the effects of ink from longfin inshore squid, Doryteuthis pealeii, on the behavior of two species of predatory fishes, summer flounder, Paralichthys dentatus, and sea catfish, Ariopsis felis. Using a cloud assay, we found that ink from longfin inshore squid affected the approach phase of predation by summer flounder, primarily through its visual effects. Using a food assay, we found that the ink affected the consummatory and ingestive phase of predation of both sea catfish and summer flounder, through the ink's chemical properties. Fractionation of ink showed that most of its deterrent chemical activity is associated with melanin granules, suggesting that either compounds adhering to these granules or melanin itself are the most biologically active. This work provides the basis for a comparative approach to identify deterrent molecules from inking cephalopods and to examine neural mechanisms whereby these chemicals affect behavior of fish, using the sea catfish as a chemosensory model.Our project was supported by National Science Foundation grant IOS-1036742 and REU supplements IOS-1338385, IOS 1234038, and IOS-1130244; by The Plum Foundation John E. Dowling Fellowship Fund and the Colwin Endowed Summer Research Fellowship Fund from the Marine Biological Laboratory; and by a Second Century Initiative graduate fellowship from Georgia State University

Comparison of Provision of Stroke Care in Younger and Older Patients: Findings from the South London Stroke Register

Background. Evidence-based stroke care should be available to all patients. However, evidence exists of inequalities according to age. This study compared access to care for younger adults to that for over 65s. Methods. Using population-based data from 4229 patients with first-ever stroke between 1995 and 2010, associations between age and 21 care indicators were investigated using multivariable logistic regression. Results. Age was not associated with stroke unit admission for ischaemic stroke (P = 0.666). Younger PICH patients were least likely to be admitted to stroke units (P = 0.001), instead treated on neurosurgical or ICU wards. Younger age was also associated with admission to neurosurgery or ICU after SAH (P = 0.006), increased occupational or physiotherapy at 1 year (P = 0.043), and contact with a GP 3 months after stroke (P < 0.001). Conclusion. Younger patients have equal or greater access to evidence-based care. However, there is a need to ensure that services meet the needs of this group

Declining 1-year case-fatality of stroke and increasing coverage of vascular risk management: population-based cohort study

Background The authors estimated trends in 1-year case-fatality of stroke in relation to changes in vascular risk management from 1997 to 2005.Methods A cohort study was implemented using data for 407 family practices in the UK General Practice Research Database, including subjects with first acute strokes between 1997 and 2005. One-year case-fatality was estimated by year and sex. Rate ratios were estimated using Poisson regression.Results There were 19 143 women and 16 552 men who had first acute strokes between 1997 and 2005. In women, the 1-year case-fatality declined from 41.2% in 1997 to 29.2% in 2005. In men, the decline was from 29.2% in 1997 to 22.2% in 2005. The proportion of general practices that prescribed antihypertensive drugs to two-thirds or more of new patients with stroke increased from 6% in 1997 to 48% in 2005, for statins from 1% to 39% and for antiplatelet drugs from 11% to 39%. The rate ratio for 1-year mortality in 2005, compared with 1997--1998, adjusted for age group, sex, prevalent coronary heart disease, prevalent hypertension and deprivation quintile was 0.79 (0.74 to 0.86, p<0.001). After adjustment for antihypertensive, statin and antiplatelet prescribing, the rate ratio was 1.29 (1.17 to 1.42).Conclusions Reducing 1-year case-fatality after acute stroke may be partly explained by increased prescribing of antihypertensive, statin and antiplatelet drugs to patients with recent strokes. However, these analyses did not include measures of possible changes over time in stroke severity or acute stroke management

Socioeconomic deprivation and provision of acute and long-term care after stroke: the South London Stroke Register cohort study

Background and aims Socioeconomic deprivation (SED) is associated with increased mortality after stroke, however, its associations with stroke care remains uncertain. We assessed the SED impacts on acute and long-term stroke care, and examined their ethnic differences and secular trends. Methods We used data from 4202 patients with first-ever stroke (mean age 70.1 years, 50.4% male, 20.4% black), collected by a population-based stroke register in South London, England from 1995 to 2010. Carstairs deprivation score was measured for each patient, taking the 1st as the least deprived and the 2nd to 5th quintiles as SED, and was related to 20 indicators of care in multivariate logistic regression models. Results Patients with SED had 29% and 35% statistically significant reductions in odds of being admitted to hospital and having swallow tests, respectively. The multivariate adjusted odds ratio (OR) for receiving five indicators of acute stroke care was 0.81 (95% CI 0.72 to 0.92). It was 0.76 (0.58 to 0.99) in black patients and 0.82 (0.71 to 0.96) in white patients; and 0.70 (0.58 to 0.84) in patients with stroke occurring before 2001 and 0.89 (0.75 to 1.05) since 2001. SED was further associated with receipt of some stroke care during 5 years of follow-up, including atrial fibrillation medication (0.63, 0.48 to 0.83), and in black patients physiotherapy and occupational therapy (0.32, 0.11 to 0.92). Conclusions Stroke healthcare inequalities in England exist for some important indicators, although overall it has improved over time. The impact of SED may be stronger in black patients than in white patients. Further efforts are required to achieve stroke care equality.National Institute for Health Research Programme Grant (RP-PG-0407-10184

Effect of Moringa oleifera Lam. leaf powder on the pharmacokinetics of nevirapine in HIV-infected adults: a one sequence cross-over study

Moringa oleifera Lam., an herb commonly consumed by HIV-infected people on antiretroviral therapy, inhibits cytochrome P450 3A4, 1A2 and 2D6 activity in vitro; and may alter the pharmacokinetics (PK) of antiretroviral drugs metabolized via the same pathways. However, in vitro drug interaction activity may not translate to a clinically significant effect. Therefore, the effect of moringa leaf powder on the PK of nevirapine in HIV-infected people was investigated. Adult patients at steady-state dosing with nevirapine were admitted for 12-h intensive PK sampling following a 21-day herbal medicine washout. Blood sampling was repeated after 14 days of nevirapine and moringa (1.85 g leaf powder/day) co-administration. Nevirapine plasma concentrations were determined by liquid chromatography-tandem mass spectrometry. To assess the effect of moringa on nevirapine PK, the change in nevirapine area under the plasma concentration–time curve (AUC) was determined. The mean difference in pre- and post-moringa nevirapine, maximum concentration (Cmax) and concentration at 12 h (C12h) were also calculated. The PK parameters were compared by assessing the post/pre geometric mean ratios (GMRs) and associated 90% confidence intervals (CIs). Pharmacokinetics analyses were performed on the results from 11 participants for whom complete data were obtained. The post/pre GMRs and associated 90% CIs for nevirapine were 1.07 (1.00–1.14) for the AUC; 1.06 (0.98–1.16) for Cmax and 1.03 (0.92–1.16) for C12h. Co-administration of Moringa oleifera Lam. leaf powder at the traditional dose did not significantly alter the steady-state PK of nevirapine. Trial registration number NCT01410058 (ClinicalTrials.gov

Provision of acute stroke care and associated factors in a multiethnic population: prospective study with the South London Stroke Register

Objectives To investigate time trends in receipt of effective acute stroke care and to determine the factors associated with provision of care

Shaping innovations in long-term care for stroke survivors with multimorbidity through stakeholder engagement

BACKGROUND:Stroke, like many long-term conditions, tends to be managed in isolation of its associated risk factors and multimorbidity. With increasing access to clinical and research data there is the potential to combine data from a variety of sources to inform interventions to improve healthcare. A 'Learning Health System' (LHS) is an innovative model of care which transforms integrated data into knowledge to improve healthcare. The objective of this study is to develop a process of engaging stakeholders in the use of clinical and research data to co-produce potential solutions, informed by a LHS, to improve long-term care for stroke survivors with multimorbidity. METHODS:We used a stakeholder engagement study design informed by co-production principles to engage stakeholders, including service users, carers, general practitioners and other health and social care professionals, service managers, commissioners of services, policy makers, third sector representatives and researchers. Over a 10 month period we used a range of methods including stakeholder group meetings, focus groups, nominal group techniques (priority setting and consensus building) and interviews. Qualitative data were recorded, transcribed and analysed thematically. RESULTS:37 participants took part in the study. The concept of how data might drive intervention development was difficult to convey and understand. The engagement process led to four priority areas for needs for data and information being identified by stakeholders: 1) improving continuity of care; 2) improving management of mental health consequences; 3) better access to health and social care; and 4) targeting multiple risk factors. These priorities informed preliminary design interventions. The final choice of intervention was agreed by consensus, informed by consideration of the gap in evidence and local service provision, and availability of robust data. This shaped a co-produced decision support tool to improve secondary prevention after stroke for further development. CONCLUSIONS:Stakeholder engagement to identify data-driven solutions is feasible but requires resources. While a number of potential interventions were identified, the final choice rested not just on stakeholder priorities but also on data availability. Further work is required to evaluate the impact and implementation of data-driven interventions for long-term stroke survivors

The economic and innovation contribution of universities: a regional perspective

Universities and other higher education institutions (HEIs) have come to be regarded as key sources of knowledge utilisable in the pursuit of economic growth. Although there have been numerous studies assessing the economic and innovation impact of HEIs, there has been little systematic analysis of differences in the relative contribution of HEIs across regions. This paper provides an exploration of some of these differences in the context of the UK’s regions. Significant differences are found in the wealth generated by universities according to regional location and type of institution. Universities in more competitive regions are generally more productive than those located in less competitive regions. Also, traditional universities are generally more productive than their newer counterparts, with university productivity positively related to knowledge commercialisation capabilities. Weaker regions tend to be more dependent on their universities for income and innovation, but often these universities under-perform in comparison to counterpart institutions in more competitive regions. It is argued that uncompetitive regions lack the additional knowledge infrastructure, besides universities, that are more commonly a feature of more competitive regions