Economic Evaluation of Exercise or Cognitive and Social Enrichment Activities for Improved Cognition After Stroke.

Importance: Cognitive impairment is prevalent in survivors of stroke, affecting approximately 30% of individuals. Physical exercise and cognitive and social enrichment activities can enhance cognitive function in patients with chronic stroke, but their cost-effectiveness compared with a balance and tone program is uncertain. Objective: To conduct a cost-effectiveness and cost-utility analysis of multicomponent exercise or cognitive and social enrichment activities compared with a balance and tone program. Design, Setting, and Participants: This economic evaluation used a Canadian health care systems perspective and the Vitality study, a randomized clinical trial aimed at improving cognition after stroke with a 6-month intervention and a subsequent 6-month follow-up (ie, 12 months). The economic evaluation covered the duration of the Vitality trial, between June 6, 2014, and February 26, 2019. Participants were community-dwelling adults aged 55 years and older who experienced a stroke at least 12 months prior to study enrollment in the Vancouver metropolitan area, British Columbia, Canada. Data were analyzed from June 1, 2022, to March 31, 2023. Interventions: Participants were randomly assigned to twice-weekly classes for 1 of the 3 groups: multicomponent exercise program, cognitive and social enrichment activities program, or a balance and tone program (control). Main Outcomes and Measures: The primary measures for the economic evaluation included cost-effectiveness (incremental costs per mean change in cognitive function, evaluated using the Alzheimer Disease Assessment Scale-Cognitive-Plus), cost-utility (incremental cost per quality-adjusted life-year gained), intervention costs, and health care costs. Since cognitive benefits 6 months after intervention cessation were not observed in the primary randomized clinical trial, an economic evaluation at 12 months was not performed. Results: Among 120 participants (mean [SD] age, 71 [9] years; 74 [62%] male), 34 were randomized to the multicomponent exercise program, 34 were randomized to the social and cognitive enrichment activities program, and 52 were randomized to the balance and tone control program. At the end of the 6-month intervention, the cost per mean change in Alzheimer Disease Assessment Scale-Cognitive-Plus score demonstrated that exercise was more effective and costlier compared with the control group in terms of cognitive improvement with an incremental cost-effectiveness ratio of CAD -$8823. The cost per quality-adjusted life-year gained for both interventions was negligible, with exercise less costly (mean [SD] incremental cost, CAD -$32 [$258]) and cognitive and social enrichment more costly than the control group (mean [SD] incremental cost, CAD $1018 [$378]). The balance and tone program had the lowest delivery cost (CAD $777), and the exercise group had the lowest health care resource utilization (mean [SD] $1261 [$1188]) per person. Conclusions and Relevance: The findings of this economic evaluation suggest that exercise demonstrated potential for cost-effectiveness to improve cognitive function in older adults with chronic stroke during a 6-month intervention.

Effect of Exercise Training or Complex Mental and Social Activities on Cognitive Function in Adults With Chronic Stroke: A Randomized Clinical Trial.

Importance: A stroke doubles one's risk for dementia. How to promote cognitive function among persons with chronic stroke is unclear. Objective: To evaluate the effect of exercise (EX) or cognitive and social enrichment activities (ENRICH) on cognitive function in adults with chronic stroke. Design, Setting, and Participants: This was a 3-group parallel, single-blinded, single-site, proof-of-concept randomized clinical trial at a research center in Vancouver, British Columbia, Canada. Participants included community-dwelling adults with chronic stroke, aged 55 years and older, able to walk 6 meters, and without dementia. The trial included a 6-month intervention and a 6-month follow-up. Randomization occurred from June 6, 2014, to February 26, 2019. Measurement occurred at baseline, 6 months, and 12 months. Data were analyzed from January to November 2021. Interventions: Participants were randomly allocated to twice-weekly supervised classes of: (1) EX, a multicomponent exercise program; (2) ENRICH, a program of cognitive and social enrichment activities; or (3) balance and tone (BAT), a control group that included stretches and light-intensity exercises. Main Outcomes and Measures: The primary outcome was the Alzheimer Disease Assessment Scale-Cognitive-Plus (ADAS-Cog-Plus), which included the 13-item ADAS-Cog, Trail Making Test Parts A and B, Digit Span Forward and Backward, Animal Fluency, and Vegetable Fluency. Results: One-hundred and twenty participants, with a mean (range) of 1.2 (1-4) strokes, a mean (SD) of 66.5 (53.8) months since the most recent stroke, mean (SD) baseline age of 70 (8) years, mean (SD) baseline ADAS-Cog-Plus of 0.22 (0.81), and 74 (62%) male participants, were randomized to EX (34 participants), ENRICH (34 participants), or BAT (52 participants). Seventeen withdrew during the 6-month intervention and another 7 during the 6-month follow-up. Including all 120 participants, at the end of the 6-month intervention, EX significantly improved ADAS-Cog-Plus performance compared with BAT (estimated mean difference: -0.24; 95% CI, -0.43 to -0.04; P = .02). This difference did not persist at the 6-month follow-up (estimated mean difference: -0.08; 95% CI, -0.29 to 0.12; P = .43). For the 13-item ADAS-Cog, the EX group improved by 5.65 points over the 6-month intervention (95% CI, 2.74 to 8.57 points; P < .001), exceeding the minimally clinical difference of 3.0 points. Conclusions and Relevance: These findings suggest that exercise can induce clinically important improvements in cognitive function in adults with chronic stroke. Future studies need to replicate current findings and to understand training parameters, moderators, and mediators to maximize benefits. Trial Registration: ClinicalTrials.gov identifier: NCT01916486.

A longitudinal study of stress and self-esteem in student nurses.

INTRODUCTION: It is well recognised that nurse education/training can be a stressful experience and that self-esteem is an important predictor of stress. BACKGROUND/LITERATURE: While there are a significant number of studies showing levels and contributors to stress among students. There is little evidence of how these levels change over time. The aim of the study was to investigate nursing students' experiences of stress and levels of self-esteem during three years of their undergraduate nursing programme. METHODS: Participants completed the stress in nurse education questionnaire and the culture free self-esteem inventory at various time points in the study, and a demographic questionnaire at baseline. The students who took part in the study commenced their nurse training in September 2002. DATA/RESULTS: This study has demonstrated that levels of self reported stress and "general" self-esteem are significantly different at different stages the nurse training process. Self reported stress were at the highest at the beginning of the third year and these were significantly higher when compared to stress reported at any other time point. Self-esteem levels were lowest at the end of training. CONCLUSIONS: Trying to obtain data only at single time point during nurse education/training is inadequate as this research has shown that there is indeed variation in student psychological well being across the academic year.

A comparative, longitudinal study of stress in student nurses in five countries: Albania, Brunei, the Czech Republic, Malta and Wales.

BACKGROUND AND AIMS: Stress amongst nursing students is a global issue. There is an absence of published international comparative studies which investigate this and so this paper sets out to explore the sources of stress among nursing students throughout their course of study and to determine whether they were more stressed by academic or clinical factors across five different countries (Albania, Brunei, the Czech Republic, Malta and Wales). Although each country, within this study, has a unique culture, a cross-cultural comparison can be made in an attempt to better understand stress in the student nursing population. METHODS: The study was undertaking using a descriptive quantitative design using the Stress in Nurse Education Questionnaire with 1707 nursing students across the five countries. RESULTS: The mean score for the total sample for all the items on the stress scale was 52.3 (SD 17.1). The sample from Wales had the lowest mean score and those in Brunei had the highest. Students in Brunei and Malta were more stressed by the academic elements of the course than by the clinical elements. Whereas for those students in the Czech Republic For students in Wales and in Albania - Korçe there were no differences in stress experienced between the academic and clinical elements of the course. The results indicated that there were no significant differences in total stress scores by year of study for students in Albania - Tirana, Albania-Korçe, Malta and Wales. In Brunei however, ANOVA revealed that there were significant differences in total stress scores by year of study. Further analysis revealed that students in year 3 scored higher on the overall scale than students in year 1. The individual item on the stress scale with highest mean in the Albania - Korçe and the Albania-Tirana sample was "The death of a patient" whilst the Bruneian sample, Maltese sample and Welsh sample opted for "Revising for and sitting examinations" and the Czech sample chose: "Continuous pressure to meet deadlines for assessments". CONCLUSIONS: This study has succeeded as the first of its kind to compare and contrast levels and sources of stress amongst an international sample. The findings indicate that student nurses worldwide do share much in common while still retaining individual cultural features relating to stress throughout their course of study.

The elimination of raccoon rabies from Wolfe Island, Ontario: animal density and movements.

During 1996 to 1998, an average of 52% to 55% of the raccoon (Procyon lotor) population on Wolfe Island, Ontario was vaccinated against rabies during proactive trap-vaccinate-release (TVR) operations. However, during 1999, the percent of the population vaccinated declined to 39% and an outbreak (6 cases) of raccoon rabies occurred on the island from December 1999 to January 2000. The raccoon population on Wolfe Island declined dramatically (71% reduction) from 1,067 raccoons (mean density = 8.4/km(2) [6.4-12.4, 95% CI]) during 1999 to 305 raccoons (mean density = 2.4/km(2) [0.87-4.1, 95% CI]) in the spring of 2000. Raccoon density immediately following the outbreak was significantly lower in cells with rabies cases, suggesting that rabies had a negative effect on population size. However, raccoon density had doubled by 1 yr following the outbreak. Movement of raccoons on Wolfe Island was as great as 24 km. Male raccoons moved greater distances than females. Movements to surrounding islands were also noted for raccoons ear tagged on Wolfe Island which indicates the island could serve as a focus for greater geographic rabies spread. Point infection control (PIC) during 2000, TVR during 2001-02, and the aerial distribution of Vaccinia-Rabies Glycoprotein (V-RG) baits during 2000 and 2003-05 were used to eliminate rabies from Wolfe Island. No cases have been detected since late January 2000 (to February 2007).

Effects of aquatic exercise on flexibility, strength and aerobic fitness in adults with osteoarthritis of the hip or knee.

AIM: This paper reports a study of the effects of aquatic exercise on physical fitness (flexibility, strength and aerobic fitness), self-reported physical functioning and pain in adults with osteoarthritis of the hip or knee. BACKGROUND: Osteoarthritis is a common cause of disability and a primary reason for hip and knee joint replacement. Exercise is important for preventing and/or managing the functional limitations associated with joint disease. Aquatic exercise is thought to be beneficial and is often recommended for people with osteoarthritis; however, few studies have examined the effects on people with osteoarthritis, and these have yielded inconsistent results. METHODS: A two-group randomized controlled trial with a convenience sample was used. Participants were recruited from community sources and randomly assigned to a 12-week aquatic programme or a non-exercise control condition. Data for 38 participants were collected at baseline, week 6, and week 12 during 2003 and 2004. Instruments were a standard plastic goniometer, a handheld dynamometer, the 6-minute walk test, the multidimensional Health Assessment Questionnaire, and a visual analogue scale for pain. RESULTS: Repeated measures analysis of variance showed that aquatic exercise statistically significantly improved knee and hip flexibility, strength and aerobic fitness, but had no effect on self-reported physical functioning and pain. The exercise adherence rate was 81.7%, and no exercise-related adverse effect was observed or reported. CONCLUSIONS: Beneficial short-term effects of aquatic exercise were found in adults with osteoarthritis of the hip or knee. Although the programme may not offer pain relief or self-reported improvements in physical functioning, results suggest that aquatic exercise does not worsen the joint condition or result in injury. Nurses engaging in disease management and health promotion for these patients should consider recommending or implementing aquatic classes for patients.

Behavior, movements, and demographics of rabid raccoons in Ontario, Canada: management implications.

During 1999-2003, 127 cases of raccoon variant rabies were reported in raccoons (Procyon lotor) and striped skunks (Mephitis mephitis) in Ontario, Canada. Raccoons accounted for 98% (125/127) of the reported cases with behaviors/conditions including aggression, fighting with dogs, ataxia, vocalizations, appearance of being sick, and the presence of porcupine (Erethizon dorsatum) quills. Seventy-eight percent of the rabid raccoons were adults. Juveniles were underrepresented (22%) compared with the adult/juvenile ratios found in nonrabid Ontario raccoon populations. Of the known aged raccoons, 83% were < or = 3 yr of age, and 22% of the rabid adult female raccoons had evidence of having had a litter during the year in which they were found to be rabid. The majority of rabid raccoons were reported during the fall, winter, and spring, suggesting a relationship between raccoon behavioral activities such as denning and breeding and the timing of rabies outbreaks. Multiple cases of raccoon rabies occurred at several barns, suggesting that those structures serve as focal points of rabies transmission as a result of denning activities. Movements of five rabid raccoons (range 1,564-4,143 m) were not different from movements of nonrabid raccoons in Ontario. Sixty-six percent of the rabid animals were submitted by government staff, stressing the importance of those agencies in rabies control and surveillance operations. Increased knowledge of the behaviors of rabid raccoons should assist in the development of management strategies for rabies.

Validation of a new whole blood coagulation monitoring system.

The Hemochron Response is a third generation point-of-care (POC) whole blood coagulation analyzer that retains the clinical utility of the Hemochron standard (801/8000) while providing a data management program that assists the POC coordinator with Quality Assurance (QA) compliance. Clinical and laboratory studies were performed to ensure consistency of the target anticoagulation times with the Hemochron standard and to evaluate precision and reproducibility of the Hemochron Response. Clinical tests for prothrombin time (PT) using fresh and citrated whole blood, activated clotting time (ACT), and activated partial thromboplastin time (APTT) showed excellent correlation to the Hemochron standard where r = 0.929, r = 0.969, r = 0.947, and r = 0.992, respectively. This was confirmed by a paired Student's t-test. The standard expectation for reproducibility of ACT tests has been a coefficient of variation (CV) of 10%. Laboratory studies of reproducibility and precision for the Response instrument included analysis of the CV using ACT test tubes. For normal and abnormal control plasma (CPL), the range of CVs observed was 3.3%-4.6% and 3.0%-5.0%, respectively. For heparin dose response analysis, the range for Donor 1 and 2 was 1.0%-4.2% and 1.1%-8.0%, respectively. These data suggest that the Hemochron Response is reliable and equivalent to the Hemochron standard in clinical applications.