The feasibility of a self-management programme (My Life After Stroke; MLAS) for stroke survivors.

PURPOSE: An evidence-based, theory-driven self-management programme "My Life After Stroke" (MLAS) was developed to address the longer-term unmet needs of stroke survivors.This study's aim was to test the acceptability and feasibility of MLAS as well as exploring what outcomes measures to include as part of further testing. METHODS: Stroke registers in four GP practices across Leicester and Cambridge were screened, invite letters sent to eligible stroke survivors and written, informed consent gained. Questionnaires including Southampton Stroke Self-Management Questionnaire (SSSMQ) were completed before and after MLAS.Participants (and carers) attended MLAS (consisting of two individual appointments and four group sessions) over nine weeks, delivered by two trained facilitators. Feedback was gained from participants (after the final group session and final individual appointment) and facilitators. RESULTS: Seventeen of 36 interested stroke survivors participated alongside seven associated carers. 15/17 completed the programme and attendance ranged from 13-17 per session. A positive change of 3.5 of the SSSMQ was observed. Positive feedback was gained from facilitators and 14/15 participants recommended MLAS (one did not respond). CONCLUSIONS: MLAS was a feasible self-management programme for stroke survivors and warrants further testing as part of the Improving Primary Care After Stroke (IPCAS) cluster randomised controlled trial.IMPLICATIONS FOR REHABILITATIONMy Life After Stroke is a self-management programme developed for stroke survivors living in the community.MLAS is feasible and acceptable to stroke survivors.MLAS could be considered to help address the unmet educational and psychological needs of stroke survivors.

Emotional adjustment post-stroke: A qualitative study of an online stroke community.

Understanding of emotional adjustment after stroke is limited. Under one-third of stroke survivors reporting emotional problems receive support. The aim of this study was to explore the process of emotional adjustment post-stroke and investigate the role played by participation in an online stroke community. We applied thematic analysis to 124 relevant posts within 114 discussion threads, written by 39 survivors and 29 carers. The contribution of online community engagement to emotional adjustment was explored using the Social Support Behaviour Code. Stroke survivors share common experiences of emotional adjustment and may not necessarily reach complete acceptance. Positive and negative trajectories of emotional adjustment were identified. Survivors progressed along, or moved between, positive and negative pathways not in a time-dependent manner but in response to "trigger events," such as physical setbacks or anti-depressant treatment, which may occur at any chronological time. An adapted version of Suhr's 1990 Social Support Behaviour Code showed that support provided through the online community took many forms, including advice, teaching, empathy and normalization of concerns. Participation in the stroke community was itself deemed to be a positive "trigger event." There is need to improve awareness of emotional adjustment and their "triggers" amongst stroke survivors, carers and clinicians.

Vaccine uptake in the Irish Travelling community: an audit of general practice records.

Background: Compared to the general population, the Traveller community has substantial health inequalities. Vaccination coverage in Traveller children is estimated to be low and Travellers are at higher risk of vaccine-preventable diseases due to their social circumstances. Methods: Audit of vaccination history of Traveller (n = 214) and non-Traveller (n = 776) children registered at a general practice in England. The Green Book childhood immunization schedule was used as a reference standard. Results: There was significantly lower coverage for Traveller children compared to non-Traveller children for all vaccinations in the routine childhood immunization schedule. The percentage of children completing the schedule at all time points was significantly lower in the Traveller community. Conclusions: Traveller communities have significantly lower uptake of vaccinations, and therefore Travellers' children should be targeted by general practitioners for catch-up vaccination to improve outcomes for individuals and local herd immunity.

Understanding stroke survivors' and informal carers' experiences of and need for primary care and community health services--a systematic review of the qualitative literature: protocol.

INTRODUCTION: Despite the rising prevalence of stroke, no comprehensive model of postacute stroke care exists. Research on stroke has focused on acute care and early supported discharge, with less attention dedicated to longer term support in the community. Likewise, relatively little research has focused on long-term support for informal carers. This review aims to synthesise and appraise extant qualitative evidence on: (1) long-term healthcare needs of stroke survivors and informal carers, and (2) their experiences of primary care and community health services. The review will inform the development of a primary care model for stroke survivors and informal carers. METHODS AND ANALYSIS: We will systematically search 4 databases: MEDLINE, EMBASE, PsycINFO and CINAHL for published qualitative evidence on the needs and experiences of stroke survivors and informal carers of postacute care delivered by primary care and community health services. Additional searches of reference lists and citation indices will be conducted. The quality of articles will be assessed by 2 independent reviewers using a Critical Appraisal Skills Programme (CASP) checklist. Disagreements will be resolved through discussion or third party adjudication. Meta-ethnography will be used to synthesise the literature based on first-order, second-order and third-order constructs. We will construct a theoretical model of stroke survivors' and informal carers' experiences of primary care and community health services. ETHICS AND DISSEMINATION: The results of the systematic review will be disseminated via publication in a peer-reviewed journal and presented at a relevant conference. The study does not require ethical approval as no patient identifiable data will be used.

Treatment of Disseminated Aspergillosis with Posaconazole in 10 Dogs.

BACKGROUND: Few effective treatments for disseminated Aspergillus infections in dogs are available. Posaconazole has potent and broad-spectrum activity against Aspergillus spp., but its use has not yet been sufficiently evaluated in dogs. HYPOTHESIS/OBJECTIVES: The aim of this study was to determine the safety and efficacy of posaconazole for the treatment of naturally occurring disseminated Aspergillus infections in dogs. ANIMALS: Ten client-owned dogs with disseminated aspergillosis. METHODS: Prospective, nonrandomized, noncontrolled study with posaconazole administered to dogs at dosage of 5 mg/kg p.o. q12h. The primary veterinarian or the veterinary specialist caring for the dogs provided patient data. RESULTS: The treatment response for dogs with disseminated disease while receiving posaconazole was defined as clinical remission (n = 4) and clinical improvement (n = 6). There was a high rate of relapse during treatment or after cessation of treatment in both groups, and most dogs died or were euthanized due to progressive disease. Excluding 1 dog concurrently treated with terbinafine that remains alive 5 years after diagnosis, the mean survival time for dogs was 241 days (range 44-516 days). Three other dogs lived >1 year after starting treatment. No clinically relevant adverse events or increases in serum liver enzyme activity occurred during treatment with posaconazole. CONCLUSIONS AND CLINICAL IMPORTANCE: Posaconazole appears to be safe and well-tolerated for treatment of disseminated Aspergillus infections in dogs. Long-term survival >1 year is possible with prolonged treatment, but relapse is common.

Promoting dietary diversity to improve child growth in less-resourced rural settings in Uganda.

BACKGROUND: Analyses of global trends indicate that childhood undernutrition is more prevalent in rural areas, and also that maternal education and decision-making power are among the key factors significantly associated with child growth. METHODS: The present study comprised a controlled longitudinal study aiming to assess the effectiveness of nutrition education with respect to improving growth patterns of young children of less-literate, low income caregivers in a rural subsistence farming community. Caregivers in the intervention group (n = 52) attended a structured nutrition education programme, whereas the control group (n = 45) participated in sewing classes. Weights and lengths/heights were measured for children in the intervention and control groups every month for 1 year to assess changes in growth patterns. Repeated measures analysis of covariance was used to access differences between the two groups over time and across age groups. Variability in growth patterns of individual children and clustering of caregiver effects were controlled for during the statistical analysis. RESULTS: After 12 months, children in the intervention group had significant improvements in weight-for-age compared to the controls [mean (SD): 0.61 (0.15) versus -0.99 (0.16), P = 0.038]. Changes in height-for-age, weight-for-height and mid-upper arm circumference-for-age showed a positive trend for children in the intervention group. Changes in weight-for-height were statistically significant across age groups and negatively related to caregiver's age. CONCLUSIONS: Educating caregivers has the potential to improve young children's nutritional status and growth, especially among less literate populations where households subsist on what they produce.

The cost-effectiveness of supervised exercise for the treatment of intermittent claudication.

BACKGROUND: Supervised exercise (SE) is thought to result in improvements in walking distance and quality of life compared with unsupervised exercise (USE) in people with intermittent claudication. However, the cost-effectiveness of SE is unclear. As a result, many patients are currently unable to access supervised programmes. METHODS: We searched MEDLINE, Embase, Cochrane, and Cinahl databases to identify randomised controlled trials comparing USE with SE in adults with intermittent claudication. A Markov model was developed to estimate costs and quality adjusted life years (QALYs) from an NHS and personal social services perspective. Quality of life was obtained from the included clinical trials. Resource use was modelled on current programmes and unit costs were based on published sources. RESULTS: Depending on estimated rates of compliance, SE was cost-effective in over 75% of model simulations, with an incremental cost-effectiveness ratio of £711 to £1,608 per QALY gained. The model was sensitive to long-term effects of exercise on cardiovascular risk and quality of life. CONCLUSIONS: SE is more cost-effective than USE for the treatment of people with intermittent claudication. Supervised programmes should be made widely available and offered as a first line treatment to people with intermittent claudication.

Nutrition Education to Improve Dietary Intake and Micronutrient Nutriture among Children in Less-Resourced Areas: A Randomised Controlled Intervention in Kabarole District; Western Uganda

Objective: To determine whether nutrition education targeting the child-feeding practices of low-income rural caregivers will reduce anaemia and improve vitamin A nutriture of the young children in their care.Design: A controlled intervention trial; based on experiential learning theory. Forty-six women completed a nine-session nutrition education programme; while controls (n = 43) concurrently engaged in sewing classes. Setting: Two rural farming communities in the Kabarole district; western Uganda. Subjects: Less literate; low-income rural female caregivers and the children in their care (6-48 months). Outcome measures: Caregivers' child-feeding practices and the children's nutritional status were assessed at baseline; one month after intervention (Follow-up 1) and one year from baseline (Follow-up 2). Results: Caregivers in the intervention group reported improved child snacking patterns; food-selection practices; meal adequacy; and food variety. Children in the intervention group recorded lower haemoglobin levels at baseline (9.86 vs. 10.70 g/dl) and caught up with controls at Follow-up 1 (10.06 vs. 10.78 g/dl). However; changes were not sustained. Mean retinol-binding protein improved from 0.68 ?mol/l (95CI: 0.57-0.78) to 0.91 ?mol/l (95CI: 0.78-1.03) among intervention children; but remained approximately the same in controls. Vitamin A nutriture was influenced by infections. Conclusion: Nutrition education significantly improved feeding practices and children's nutritional status. The effectiveness and sustainability of this programme can be enhanced if nutrition education is integrated into other food-production and public health programmes

Nutrition Education to Improve Dietary Intake and Micronutrient Nutriture among Children in Less-Resourced Areas: A Randomised Controlled Intervention in Kabarole District; Western Uganda

Objective:To determine whether nutrition education targeting the child-feeding practices of low-income rural caregivers will reduce anaemia and improve vitamin A nutriture of the young children in their care.Design: A controlled intervention trial; based on experiential learning theory. Forty-six women completed a nine-session nutrition education programme; while controls (n = 43) concurrently engaged in sewing classes. Setting: Two rural farming communities in the Kabarole district; western Uganda. Subjects: Less literate; low-income rural female caregivers and the children in their care (6-48 months). Outcome measures: Caregivers' child-feeding practices and the children's nutritional status were assessed at baseline; one month after intervention (Follow-up 1) and one year from baseline (Follow-up 2). Results: Caregivers in the intervention group reported improved child snacking patterns; food-selection practices; meal adequacy; and food variety. Children in the intervention group recorded lower haemoglobin levels at baseline (9.86 vs. 10.70 g/dl) and caught up with controls at Follow-up 1 (10.06 vs. 10.78 g/dl). However; changes were not sustained. Mean retinol-binding protein improved from 0.68 ?mol/l (95CI: 0.57-0.78) to 0.91 ?mol/l (95CI: 0.78-1.03) among intervention children; but remained approximately the same in controls. Vitamin A nutriture was influenced by infections. Conclusion: Nutrition education significantly improved feeding practices and children's nutritional status. The effectiveness and sustainability of this programme can be enhanced if nutrition education is integrated into other food-production and public health programmes

A brief pain management program compared with physical therapy for low back pain: results from an economic analysis alongside a randomized clinical trial.

OBJECTIVE: Guidelines for the management of acute low back pain in primary care recommend early intervention to address psychosocial risk factors associated with long-term disability. We assessed the cost utility and cost effectiveness of a brief pain management program (BPM) targeting psychosocial factors compared with physical therapy (PT) for primary care patients with low back pain of <12 weeks' duration. METHODS: A total of 402 patients were randomly assigned to BPM or PT. We adopted a health care perspective, examining the direct health care costs of low back pain. Outcome measures were quality-adjusted life years (QALYs) and 12-month change scores on the Roland and Morris disability questionnaire. Resource use data related to back pain were collected at 12-month followup. Cost effectiveness was expressed as incremental ratios, with uncertainty assessed using cost-effectiveness planes and acceptability curves. RESULTS: There were no statistically significant differences in mean health care costs or outcomes between treatments. PT had marginally greater effectiveness at 12 months, albeit with greater health care costs (BPM 142 pounds, PT 195 pounds). The incremental cost-per-QALY ratio was 2,362 pounds. If the UK National Health Service were willing to pay 10,000 pound per additional QALY, there is only a 17% chance that BPM provides the best value for money. CONCLUSION: PT is a cost-effective primary care management strategy for low back pain. However, the absence of a clinically superior treatment program raises the possibility that BPM could provide an additional primary care approach, administered in fewer sessions, allowing patient and doctor preferences to be considered.

Conservative hand therapy treatments in rheumatoid arthritis--a randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of three different physiotherapeutic approaches in the management of the rheumatoid hand. METHODS: In a randomized controlled trial, participants with rheumatoid arthritis (RA) recruited from a rheumatology department in Mid-Staffordshire, UK (February 1999 to January 2001) were randomized to three groups. All received joint protection (JP) information delivered by a therapist at baseline. Group 1 participants received a set of additional hand-strengthening and mobilizing home exercises, group 2 a different set of additional hand-stretching exercises and group 3 the JP information alone. The primary outcome was the Arthritis Impact Measurement Scales II (AIMS II) (upper limb; hand and finger function subscales). Outcomes were assessed at baseline and 1, 3 and 6 months. Analysis was by intention to treat. RESULTS: Sixty-seven participants (mean age 59.6 yr) were recruited: group 1 n = 21, group 2 n = 24 and group 3 n = 22. A 78% follow-up was achieved at 6 months. There was a mean fall (SD) in AIMS II upper limb function 0-6 month change scores in group 1 of 1.00 (1.07). In groups 2 and 3 there was a mean increase in AIMS II scores of 0.18 (1.54) and 0.30 (1.22), respectively. The differences in AIMS change scores between group 1 and groups 2 and 3 were statistically significant (P = 0.007) and remained so after adjustment for multiple testing (P = 0.012). CONCLUSION: Statistically significant improvements in arm function have been demonstrated following a programme of home-strengthening hand exercises in RA patients compared with simple stretches or advice alone.

Comparison of physical treatments versus a brief pain-management programme for back pain in primary care: a randomised clinical trial in physiotherapy practice.

BACKGROUND: Recommendations for the management of low back pain in primary care emphasise the importance of recognising and addressing psychosocial factors at an early stage. We compared the effectiveness of a brief pain-management programme with physiotherapy incorporating manual therapy for the reduction of disability at 12 months in patients consulting primary care with subacute low back pain. METHODS: For this pragmatic, multicentre, randomised clinical trial, eligible participants consulted primary care with non-specific low back pain of less than 12 weeks' duration. They were randomly assigned either a programme of pain management (n=201) or manual therapy (n=201). The primary outcome was change in the score on the Roland and Morris disability questionnaire at 12 months. Analysis was by intention to treat. FINDINGS: Of 544 patients assessed for eligibility, 402 were recruited (mean age 40.6 years) and 329 (82%) reached 12-month follow-up. Mean disability scores were 13.8 (SD 4.8) for the pain-management group and 13.3 (4.9) for the manual-therapy group. The mean decreases in disability scores were 8.8 (6.4) and 8.8 (6.1) at 12 months (difference 0 [95% CI -1.3 to 1.4], p=0.99), and median numbers of physiotherapy visits per patient were three (IQR one to five) and four (two to five), respectively (p=0.001). One adverse reaction (an exacerbation of pain after the initial assessment) was recorded. INTERPRETATION: Brief pain management techniques delivered by appropriately trained clinicians offer an alternative to physiotherapy incorporating manual therapy and could provide a more efficient first-line approach for management of non-specific subacute low back pain in primary care.

Food shopping practices are associated with dietary quality in low-income households.

ABSTRACT Nutrition education for low-income audiences often focuses on building skills in food shopping and food resource management to help families receive the best nutrition from the resources they have available. However, empirical evidence for the effect of food shopping practice on dietary quality has been limited. This article presents new analyses from two studies that found an association between food shopping practices and diet quality. Logistic regression of data from 957 respondents from the 1996 National Food Stamp Program Survey found that food shopping practices were significantly (p

Racial differences in adolescent coping and self-esteem.

Racial differences in coping strategies and self-esteem were examined for 361 male and female adolescents in Grades 7-12. Coping strategies were assessed with the Adolescent Coping Orientation for Problem Experiences (J. M. Patterson & H. I. McCubbin, 1986). Self-esteem was assessed by the Coopersmith Self-Esteem Inventory (S. Coopersmith, 1987). Multivariate analysis revealed racial differences in adolescent coping strategies of ventilating feelings, seeking diversions, developing self-reliance, avoiding problems, seeking spiritual support, investing in close friends, engaging in demanding activities, solving family problems, and relaxing. In particular, African American adolescents reported using diversions, self-reliance, spiritual support, close friends, demanding activities, family problems, and relaxation more frequently than Caucasian adolescents did. Implications for professionals and recommendations for future research are discussed.

Crutch length: effect on energy cost and activity intensity in non-weight-bearing ambulation.

OBJECTIVE: To investigate the effect of forearm crutch length on energy cost in three-point, non-weight-bearing (NWB) ambulation. DESIGN: Double-blind repeated measures design using crutch length as the independent variable. SETTING: Overland walking circuit at a university campus. PARTICIPANTS: Volunteer, convenience sample of 20 subjects consisting of university students and staff without cardiovascular, respiratory, or orthopedic conditions. INTERVENTION: Subjects used a three-point, NWB gait with forearm crutches set to length using conventional guidelines, and at 2.5 cm above and below this value. MAIN OUTCOME MEASURES: Oxygen consumption, carbon dioxide production, heart rate, speed of ambulation, and perceived exertion under steady-state conditions. RESULTS: In terms of oxygen cost, ambulation with crutches set to the length recommended in conventional guidelines was not significantly more energy efficient than ambulation with either the longer or shorter crutches. Using crutches set 2.5 cm longer than conventional guidelines produced the lowest respiratory exchange ratio (Vco2/Vo2) and the lowest ratings of perceived exertion. However, none of these differences reached statistical significance. CONCLUSION: Since exact crutch length was not critical in terms of oxygen cost, walking speed, or perceived exertion during NWB ambulation, the importance of rigidly adhering to specific guidelines for setting crutch length was not substantiated in this study. Clinically, consideration of patient preference regarding crutch length (within 2.5 cm) can be advocated.