Michael Power

Early supported discharge services for stroke patients: a meta-analysis of individual patients' data

BACKGROUNDnStroke patients conventionally undergo a substantial part of their rehabilitation in hospital. Services have been developed that offer patients early discharge from hospital with rehabilitation at home (early supported discharge [ESD]). We have assessed the effects and costs of such services.nnnMETHODSnWe did a meta-analysis of data from individual patients who took part in randomised trials that recruited patients with stroke in hospital to receive either conventional care or any ESD service intervention that provided rehabilitation and support in a community setting with the aim of shortening the duration of hospital care. The primary outcome was death or dependency at the end of scheduled follow-up.nnnFINDINGSnOutcome data were available for 11 trials (1597 patients). ESD services were mostly provided by specialist multidisciplinary teams to a selected group (median 41%) of stroke patients admitted to hospital. There was a reduced risk of death or dependency equivalent to six (95% CI one to ten) fewer adverse outcomes for every 100 patients receiving an ESD service (p=0.02). The hospital stay was 8 days shorter for patients assigned ESD services than for those assigned conventional care (p<0.0001). There were also significant improvements in scores on the extended activities of daily living scale and in the odds of living at home and reporting satisfaction with services. The greatest benefits were seen in the trials evaluating a coordinated multidisciplinary ESD team and in stroke patients with mild to moderate disability.nnnINTERPRETATIONnAppropriately resourced ESD services provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as shortening hospital stays.

A Consensus on Stroke Early Supported Discharge

Background and Purpose— Research evidence supporting Early Supported Discharge (ESD) services has been summarized in a Cochrane Systematic Review. Trials have shown that ESD can reduce long-term dependency and admission to institutional care and reduce the length of hospital stay. No adverse impact on the mood or well-being of patients or carers has been reported. With the implementation of many national and international stroke initiatives, we felt it timely to reach consensus about ESD among trialists who contributed to the review. Methods— We used a modified Delphi approach with 10 ESD trialists. An agreed list of statements about ESD was generated from the Cochrane review and three rounds of consultation completed. ESD trialists rated statements regarding team composition, model of team work, intervention, and success. Results— Consensus of opinion (>75% agreement) was obtained on 47 of the 56 statements. Multidisciplinary, specialist stroke ESD teams should plan and co-ordinate both discharge from hospital and provide rehabilitation in the community. Specific eligibility criteria (safety, practicality, medical stability, and disability) need to be followed to ensure this service is provided for mild to moderate stroke patients who can benefit from ESD. Length of stay in hospital, patient and carer outcome measures and cost, need to be routinely audited. Conclusions— We have created a consensus document that can be used by commissioners and service providers in implementing ESD services. Our aim is to promote the use of recommendations derived from research findings to facilitate successful implementation of stroke services nationally and internationally.

Randomized Controlled Trial of an Early Discharge Rehabilitation Service The Belfast Community Stroke Trial

Background and Purpose— To compare a community-based multidisciplinary stroke team (CST) approach with hospital-based rehabilitation in terms of hospital stay, functioning, quality of life, and service use and costs. Methods— Stroke patients who met pre-agreed criteria were allocated randomly to the CST service (n=59) or to usual inpatient rehabilitation and follow-up care (n=54). Assessments were completed at randomization and 12 months later. Caregiver strain and satisfaction (n=55) were also assessed. Cost data were collected for a subsample of 38 patients. Results— Almost 80% of surviving patients (n=691) were discharged home and a small number (n=55) were readmitted. Approximately 17% (113/649) were randomized. There were no statistically significant differences in hospital duration, costs, or outcome measures at baseline and 12 months except for higher satisfaction reported by CST patients. Overall, both groups recorded improvement in most domains over time. Carers reported a high level of satisfaction although the level of strain among carers is cause for concern. The community group (n=18) cost less than the hospital group (n=20). Conclusions— A mixed model of hospital-based and community-based rehabilitation services is likely to lead to increased patient choice and satisfaction and a potential reduction in bed pressures for less severe stroke patients.

Suitability of the WHOQOL-BREF and WHOQOL-OLD for Spanish older adults

Background: People are living longer and healthier than at any other time point in history. Therefore, in the last decade, international interest has focussed on the study of quality of life (QoL) in older people. Our aim was to study the psychometric properties of the generic QoL measure WHOQOL-BREF (WHOQOL, World Health Organization Quality of Life) and specific older adult module WHOQOL-OLD in a sample of 286 Spanish elderly. Methods: Participants were 60 years and older from community centres, primary care centres, family associations and nursing homes. The following information was collected: demographics, self-perception of health, depressive symptoms (Geriatric Depression Scale, GDS-30), functional status (SF-12) and QoL (WHOQOL-BREF and WHOQOL-OLD). Analysis was performed using classic psychometric techniques with SPSS v15.0. Results: We found no ceiling and floor effects, and missing data was low. The internal consistency measured by Cronbachs alpha was 0.90 for the WHOQOL-BREF total scale and 0.80 for the WHOQOL-OLD. A priori expected associations were found between WHOQOL-BREF and WHOQOL-OLD with the SF-12 and the GDS-30, indicating good construct validity. WHOQOL-BREF and WHOQOL-OLD domain scores differentiated between participants with lower and higher level of education, and between groups of older people (healthy vs. unhealthy; non-depressed vs. depressed; non-carers vs. carers and non-residents vs. residents). Conclusions: The WHOQOL-BREF and WHOQOL-OLD questionnaires demonstrate acceptable psychometric performance in a convenience sample of Spanish older people. They are valuable measures of QoL for use with older people.

Emotion Coupling and Regulation in Anorexia Nervosa

OBJECTIVEnThe present study sought to investigate emotion regulation strategies in people with anorexia nervosa (AN) and whether the theoretical concept of emotion coupling between anger and disgust could help to explain some of the specific eating disorder symptomatology in people with AN.nnnMETHODnThis emotion coupling hypothesis was tested using a mood induction procedure within laboratory conditions, where individuals with AN (n = 22) were matched with control participants (n = 19). Participants completed a bank of different measures prior to the study, and these included measures of eating pathology, core beliefs about the self and others, and emotion regulation strategies. Within the experimental part of this study, anger, disgust and body size estimation were measured prior to and after an anger induction procedure (i.e., a repeated measures design).nnnRESULTSnPeople with AN demonstrated a significantly more internal-dysfunctional way to regulate their emotional states, when compared with matched controls. Within the emotional coupling part of the study, participants showed a significant increase in levels of disgust and body size estimation following an anger induction when compared with matched controls.nnnDISCUSSIONnThe significance of these results was considered in the light of the new Schematic, Propositional, Analogical and Associative Representation Systems in eating disorders model.

The 2010 British Association of Stroke Physicians Survey of interventional treatments for stroke in the United Kingdom

Introduction The UK National Stroke Strategy (Department of Health 2007) states that patients should have access to a stroke service with neurointerventional capacity. This survey was conducted by the Clinical Standards Committee of the British Association of Stroke Physicians to get a snapshot of the availability of interventional treatments for stroke in the United Kingdom. Methods Questionnaires covering availability of endovascular treatments for stroke, e.g. intra-arterial thrombolysis and mechanical thrombectomy, were emailed to all British Association of Stroke Physicians members in October 2010. Where more than one response was received from the same hospital, the data were only entered once. If there was a discrepancy between different respondents for the same hospital, details were cross-checked with the respondents to ensure accuracy. Results Responses were received from 58 hospitals in England, Scotland, Wales, and Northern Ireland. Intra-arterial thrombolysis and/or mechanical thrombectomy were available in 23 hospitals. Of these, three had not performed any procedures in 2010. Twenty centres had conducted a mean (range) of eight (2–20) procedures during the 10-month period. Thirty-five hospitals were not offering endovascular treatments. Sixteen of these were not referring patients to centres which could provide interventional treatments. Hospitals offering endovascular treatments had a mean (range) of 5·2 (2–12) stroke physicians, 2·3 (0–4) interventional neuroradiologists, and 3·6 (0–9) noninterventional neuroradiologists. Only two hospitals providing interventions had four or more interventional neuroradiologists. Conclusions Only a small number of hospitals in the United Kingdom provide interventional treatments for stroke. Almost 50% of hospitals not providing interventions had no processes in place for referral to providers.

What Basic Emotions Are Experienced in Bipolar Disorder

AIMSnThe aims of this study were to investigate the basic emotions experienced within and between episodes of bipolar disorder and, more specifically, to test the predictions made by the Schematic, Propositional, Analogical and Associative Representation Systems (SPAARS) model that mania is predominantly characterized by the coupling of happiness with anger whereas depression (unipolar and bipolar) primarily comprises a coupling between sadness and disgust.nnnDESIGNnA cross-sectional design was employed to examine the differences within and between the bipolar, unipolar and control groups in the emotional profiles. Data were analysed using one-way ANOVAs.nnnMETHODnPsychiatric diagnoses in the clinical groups were confirmed using the Structured Clinical Interview for DSM-IV (SCID). It was not administered in the control group. Current mood state was measured using the Beck Depression Inventory-II, the State-Trait Anxiety Inventory and the Bech-Rafaelsen Mania Scale. The Basic Emotions Scale was used to explore the emotional profiles.nnnRESULTSnThe results confirmed the predictions made by the SPAARS model about emotions in mania and depression. Outwith these episodes, individuals with bipolar disorder experienced elevated levels of disgust.nnnDISCUSSIONnEvidence was found in support of the proposal of SPAARS that there are five basic emotions, which form the basis for both normal emotional experience and emotional disorders. Disgust is an important feature of bipolar disorder. Strengths and limitations are discussed, and suggestions for future research are explored.

A Randomised Controlled Trial of IPT Versus CBT in Primary Care

A randomized controlled trial is reported in which three treatments were compared for the management of depression in Primary Care. The treatments were Treatment As Usual (TAU) carried out by the General Practitioners, Cognitive-Behaviour Therapy (CBT) or Interpersonal Psychotherapy (IPT). Measurements of depressive symptomatology were taken at Baseline (Time1), at end of treatment (Time2), and at 5-month follow-up (Time3). An initial analysis of the longitudinal data revealed that there were a significant number of missing values, especially in the Time3 follow-up for the TAU group. That is, the missing data were not missing at random within the dataset, which is one of the considerations for usual procedures for replacement of missing values (RMV). The paper presents, therefore, the outcome of different approaches to RMV and their consequences for conclusions about the relative efficacy of the treatment conditions. The results showed that clients in all conditions improved significantly, with at least some analyses showing superiority of IPT and CBT at end of treatment Time 2. However, by the follow-up clients in all conditions performed equally well.