Recent Submissions

  • Cardiovascular disease, associated risk factors, and risk of dementia: An umbrella review of meta-analyses

    Brain, Jacob; Stephan, Blossom C. (2024)
    INTRODUCTION: Cardiovascular diseases (CVDs) have been associated with an increased risk of dementia; yet the evidence is mixed. This review critically appraises and synthesises current evidence exploring associations between dementia risk and CVD and their risk factors, including coronary heart disease, heart failure, atrial fibrillation, hypertension, hyperlipidaemia, and arterial stiffness. METHODS: MEDLINE, Embase, PsycINFO, and the Cochrane Database of Systematic Reviews were searched to identify systematic reviews with meta-analyses investigating the association between at least one of the CVDs of interest and dementia risk. The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Systematic Reviews was used to assess methodological quality. RESULTS: Twenty-five meta-analyses published between 2007 and 2021 were included. Studies largely consisted of cohorts from North America and Europe. Findings were variable, with coronary heart disease, heart failure, and atrial fibrillation consistently associated with increased risk for all-cause dementia, but results were inconsistent for Alzheimer's disease. Hypertension was more frequently associated with dementia during mid-life compared to late life. Findings concerning cholesterol were complex, and while results were inconsistent for low-density lipoprotein cholesterol and total cholesterol, there appeared to be no associations between triglycerides and high-density lipoprotein cholesterol. All meta-analyses investigating hypercholesterolaemia showed significant increases in dementia risk. There was a paucity of research on the association between arterial stiffness and dementia risk. CONCLUSION: Targeted CVD dementia prevention strategies could reduce dementia prevalence. Future research should determine the underpinning mechanisms linking heart and brain health to determine the most effective strategies for dementia risk reduction in CVD populations.
  • A scoping review of remote group-based psychological interventions for people after transient ischemic attack and stroke

    Kontou, Eirini; Lee, Abigail R.; Thorpe, Naomi (2024)
    Background Mental health and quality of life are commonly affected following a stroke or Transient Ischemic Attack (TIA) diagnosis, although many people are discharged without clear information about their psychological impact. Evidence suggests psychological interventions can be successfully delivered via remote methods (e.g. videoconferencing, telephone). However, it is unclear whether such interventions are effective for people post-stroke/TIA. This scoping review aimed to identify current evidence for remote group-based psychological interventions for people following TIA and stroke. Methods Four electronic databases (MEDLINE, Embase, PsycINFO, Scopus) were searched for articles on online group psychological interventions post-TIA and stroke. Four reviewers independently screened titles, abstracts and full texts, then two authors extracted data for included studies. A bespoke data extraction form was used to describe interventions, informed by Template for Intervention Description and Replication (TIDieR) checklists. Results The search yielded 1333 studies, from which six were included in the review. Four were feasibility studies (two randomised controlled trials, two single-group pre-/post-design). All interventions targeted stroke survivors; no studies targeted people with TIA. Delivery methods included teleconferencing, videoconferencing, an online platform (virtual multiuser world) and a hybrid approach using videoconferencing and face-to-face visits. Remote intervention components were delivered in the community or at participants’ homes. All studies included a mood measure. Improvement in mood and/or quality of life was reported across the four studies. Conclusions More research is needed to explore and confirm the potential benefits of remote delivery of group psychological interventions following stroke and TIA. Better reporting of implementation barriers/facilitators and more high-quality research are required to determine the effectiveness of remote interventions.
  • Perceptions of post- stroke fatigue among health care practitioners: A qualitative interview study

    Kontou, Eirini (2023)
    Background and Objectives: Post-Stroke Fatigue (PSF) is a complex, multidimensional, debilitating condition that affects almost half of all stroke survivors. This study explored the perceptions of physiatrists, physiotherapists, and occupational therapists about PSF and their experiences in managing patients with PSF in Saudi Arabia. Materials and Methods: Qualitative semi-structured interviews were conducted with participants from three different groups: eight physiotherapists (PTs), eight occupational therapists (OTs), and eight physiatrists (DRs). Using purposive sampling, participants with at least one year of experience in the field of PSF management were invited to take part. The data were analysed using inductive thematic analysis. Results: Twenty-four health care participants (eight PTs, eight OTs, eight DRs) were recruited. Five overarching themes encompassing various subthemes and sub-subthemes were generated: 'knowledge about post-stroke fatigue', 'diagnosing post-stroke fatigue', 'treatment approach', 'lack of awareness about post-stroke fatigue', and 'domains to improve'. The data indicated that participants used various strategies to manage PSF, including dietary changes, sleep hygiene, exercise, and energy conservation. Conclusions: Participants acknowledged that they lacked PSF-related management skills, despite possessing adequate knowledge about the management of stroke. Their openness to participating in activities that would improve their ability to diagnose and manage PSF was particularly striking.
  • Psychological support after stroke: Unmet needs and workforce requirements of clinical neuropsychological provision for optimal rehabilitation outcomes

    Kontou, Eirini (2023)
    Stroke services must detect and manage psychological and neuropsychological problems that occur after stroke, such as cognitive and language impairments, post-stroke apathy, post-stroke emotionalism, depression, anxiety, post-traumatic stress disorder, personality changes and suicidality. Stroke neuropsychology plays a key role in the assessment, understanding and management of these consequences of stroke, as well as contributing to complex case management, staff supervision and training. Where these provisions are absent from the stroke rehabilitation pathway, this significantly limits potential rehabilitation outcomes. To manage the scale of psychological and neuropsychological needs post stroke, clinical guidance recommends the use of a matched care system, in which these needs are triaged and matched with corresponding levels of support. Recent workforce guidelines provide clear professional recommendations for psychological staffing skill mix and threshold requirements for clinical oversight and clinical governance assurances.
  • Effects of dietary-based weight loss interventions on biomarkers of endothelial function: a systematic review and meta-analysis

    Stephan, Blossom C. M. (2023)
    Endothelial dysfunction is closely linked to the development of atherosclerosis. This systematic review and meta-analysis reviewed the evidence on the effect of weight loss, achieved by dietary-based interventions, on biomarkers of endothelial function (EF). Two databases (Medline, Embase) were searched from inception until November 2022 for studies that met the following criteria: 1) adult subjects (≥ 18 years) without exclusion for health status, 2) dietary interventions for weight loss, and 3) measurements of changes in EF biomarkers. Random-effect meta-analysis and meta-regression were performed. Thirty-seven articles including 1449 participants were included in the systematic review. Study duration ranged from 3-52 weeks. Overall, weight loss significantly improved biomarkers of EF [standardised mean difference (SMD):0.65; 95%CI:0.49,0.81; P < 0.001;I(2) = 91.9%]. Subgroup analyses showed weight loss significantly improved levels of E-selectin (P < 0.001), intercellular adhesion molecule-1 (ICAM-1) (P < 0.001), vascular cell adhesion molecule-1 (VCAM-1) (P < 0.001), nitrite/nitrate (NOx) (P < 0.001) and vascular endothelial growth factor (VEGF) (P < 0.001). Conversely, there was no significant improvement for von Willebrand Factor (vWF). Meta-regression analysis revealed that changes in EF biomarkers were not affected by age, BMI, quality of the studies or the amount of weight lost. A significant heterogeneity was observed for the effects of weight loss on changes in EF biomarkers. Dietary-induced weight loss may be associated with biomarkers changes indicating an improvement of EF, and it may represent a potential strategy to reduce atherosclerotic risk.
  • Exploring the association between therapist attributes, implementation fidelity and return-to work outcomes in the Return to Work after Stroke (RETAKE) trial

    Powers, Katie; das Nair, Roshan; Farrin, Amanda; Radford, Kathryn (2022)
    Background: Understanding what attributes or characteristics of those delivering interventions affect intervention fidelity and patient outcomes is important for contextualizing intervention effectiveness. It may also inform implementation of interventions in future research and clinical practice. This study aimed to explore the relationships between attributes of Occupational Therapists (OTs), their faithful delivery of an early, stroke-specialist vocational rehabilitation intervention (ESSVR) and stroke survivor return-to-work (RTW) outcomes. Method(s): Thirty-nine OTs were surveyed about their previous experience and knowledge and were trained to deliver ESSVR. ESSVR was delivered across 16 sites in England and Wales between February 2018 and November 2021. OTs received monthly mentoring to support ESSVR delivery. The amount of mentoring each OT received was recorded in OT mentoring records. Fidelity was assessed using an intervention component checklist completed using retrospective case review of one randomly selected participant per OT. Linear and logistic regression analyses explored relationships between OT attributes, fidelity, and stroke survivor RTW outcome. Result(s): Fidelity scores ranged from 30.8% to 100% (mean: 78.8%, SD: 19.2%). OT engagement in mentoring was significantly associated with fidelity (b = 0.29, 95% CI = 0.05-0.53, P < .05). High fidelity was significantly associated with positive stroke survivor RTW outcomes (OR = 1.06, 95% CI = 1.01-1.1, P = .01). Conclusion(s): Findings of this small study suggest mentoring to ensure intervention fidelity may positively influence individual participant outcomes in RTW after stroke. Upskilling OTs to deliver complex interventions, like ESSVR, in clinical trials may require mentoring support in addition to training to ensure fidelity.
  • Lasting impairments following transient ischemic attack and minor stroke: A systematic review protocol

    Kontou, Eirini (2023)
    Introduction: The focus on medical management and secondary prevention following Transient Ischemic Attack (TIA) and minor stroke is well-established. Evidence is emerging that people with TIA and minor stroke can experience lasting impairments as fatigue, depression, anxiety, cognitive impairment, and communication difficulties. These impairments are often underrecognized and inconsistently treated. Research in this area is developing rapidly and an updated systematic review is required to evaluate new evidence as it emerges. This living systematic review aims to describe the prevalence of lasting impairments and how they affect the lives of people with TIA and minor stroke. Furthermore, we will explore whether there are differences in impairments experienced by people with TIA compared to minor stroke. Method(s): Systematic searches of PubMed, EMBASE, CINAHL, PsycINFO, Cochrane Libraries will be undertaken. The protocol will follow the Cochrane living systematic review guideline with an update annually. A team of interdisciplinary reviewers will independently screen search results, identify relevant studies based on the defined criteria, conduct quality assessments, and extract data. This systematic review will include quantitative studies on people with TIA and/or minor stroke that report on outcomes in relation to fatigue, cognitive and communication impairments, depression, anxiety, quality of life, return to work/education, or social participation. Where possible, findings will be grouped for TIA and minor stroke and collated according to the time that follow-up occurred (short-term < 3 months, medium-term 3-12 months, and long-term > 12 months). Sub-group analysis on TIA and minor stroke will be performed based on results from the included studies. Data from individual studies will be pooled to perform meta-analysis where possible. Reporting will follow the Preferred Reporting Items for Systematic review and Meta-Analysis Protocol (PRISMA-P) guideline. Perspective(s): This living systematic review will collate the latest knowledge on lasting impairments and how these affect the lives of people with TIA and minor stroke. It will seek to guide and support future research on impairments emphasizing distinctions between TIA and minor stroke. Finally, this evidence will allow healthcare professionals to improve follow-up care for people with TIA and minor stroke by supporting them to identify and address lasting impairments. Copyright © 2023 Hede Ebbesen, Modrau, Kontou, Finch, Crowfoot, Crow, Heron, Hodson, Skrubbeltrang and Turner.
  • Home-based rehabilitation for survivors of stroke with severe disability (HoRSSe Study)

    Lee, Claire (2023)
    Background and aims: In the UK, over 20% of stroke survivors leave hospital with severe disability. Limited evidence-based clinical guidance is available to support their rehabilitation. Our research focusses on establish ing consensus regarding the core components of home-based rehabilitation for survivors of stroke with severe disability. The barriers to implementing these core components in a real-world setting have been explored. Methods: Stroke rehabilitation experts (n=14) including researchers, cli nicians and those with lived-experience formed two virtual nominal group technique (vNGT) panels. Findings underwent qualitative content analysis to form rich overarching consensus statements.Focus group interviews were conducted with 20 staff participants from three home-based stroke rehabilitation teams. The Context Coding Framework facilitated analysis and synthesis of findings. Results: Findings from the vNGT were distilled into 11 overarching con sensus statements. These outline core components of home-based reha bilitation for this population, including service structure, team composition, knowledge and skills required. Focus groups reported high levels of need across multiple domains with teams being insufficiently resourced to fully meet these. Strategies to overcome these barriers included upskilling a diverse range of partners and employing multi-agency collaboration. Conclusions: These consensus statements highlight the complexity of managing survivors of stroke with severe disability following discharge from hospital. Sufficient resources and collaborative working underpin the implementation of rehabilitation to manage the complex needs of this population.This study supports the provision of services for this patient group, pro viding a benchmark for commissioners and clinicians whilst setting expec tations for stroke-survivors.
  • Randomized controlled feasibility trial of swallow strength and skill training with surface electromyographic biofeedback in acute stroke patients with dysphagia

    Benfield, Jacqueline; England, Timothy J.; Everton, Lisa F.
    Background & Objectives: Swallow strength and skill training with surface electromyography (sEMG) biofeedback may improve dysphagia but little is known about the feasibility and efficacy of this intervention in acute stroke. Methods: We conducted a randomized controlled feasibility study in acute stroke patients with dysphagia. Participants were randomized to either usual care or usual care plus swallow strength and skill training with sEMG biofeedback. Primary outcomes were feasibility and acceptability. Secondary measures included swallowing and clinical outcomes, safety and swallow physiology. Results: Twenty-seven patients (13 biofeedback, 14 control) with average age of 73.3 (SD 11.0) and National Institute of Health Stroke Scale (NIHSS) of 10.7 (5.1) were recruited 22.4 (9.5) days post stroke. About 84.6% of participants completed >80% of sessions; failed sessions were mainly due to participant availability, drowsiness or refusal. Sessions lasted for an average of 36.2 (7.4) min. Although 91.7% found the intervention comfortable with satisfactory administration time, frequency and time post stroke, 41.7% found it challenging. There were no treatment-related serious adverse events. The biofeedback group had a lower Dysphagia Severity Rating Scale (DSRS) score at 2 weeks compared to control (3.2 vs. 4.3), but the difference did not reach statistical significance. Conclusions: Swallow strength and skill training with sEMG biofeedback appears feasible and acceptable to acute stroke patients with dysphagia. Preliminary data suggests it is safe and further research refining the intervention and investigating treatment dose and efficacy is warranted.
  • Implementation of IslaCare visual platform to support clinical practice in an integrated community stroke service

    Lee, Claire; Cook, Francesca (2023)
    Introduction: IslaCare is a digital platform that allows patients and clinicians to capture, store and securely share images, videos, voice notes and assessments. It facilitates decision making and is approved by NHS digital. COVID- 19 challenged services which demanded innovation in Stroke rehabilitation. Challenges included reduced in-reach access into acute services, orthotics, spasticity clinic, reduced access into care homes and patient's homes through fear of active COVID outbreaks and subsequent impacts on service delivery. IslaCare offered a solution, enabling the team to evidence clinical effectiveness and progress, inform clinical conclusions, facilitate patient in-reach processes and visually support remote assessment and monitoring. Method(s): IslaCare was initially piloted in Community Stroke Team for 12 weeks. Training was provided prior to launch. Secondary engagement with Nottingham University Hospitals NHS Trust (NUH) stroke unit commenced during the pilot period which involved the mobilisation of IslaCare at NUH. Feedback was gained from both clinicians and patients to understand the impact on clinical care and patient experience. Result(s): 63 patients have been included to date. 341 videos or photo submissions to IslaCare. 70% patient response rate. 80% staff agreed/ strongly agreed that IslaCare added value to the assessment process. 100% patients surveyed reported feeling connected with their care. Conclusion(s): IslaCare was easily rolled out across the stroke pathway and embedded into clinical practice. This enhanced effective handover of patients, improved triage and discharge planning. It has enriched patient records, measurement of progress, improved efficiency, reduced waits and chaperone input in clinic settings whilst also increasing quality of care.
  • Optimising home-based rehabilitation for survivors of stroke with severe disability

    Lee, Claire (2022)
    Background and Aims: In the UK, over 20% of stroke survivors leave hospital severely disabled. Limited evidence-based clinical guidance is available to support the rehabilitation of these individuals. Our research has focussed on establishing consensus regarding the core components of homebased rehabilitation for this population. This study explores the challenges of providing that rehabilitation and identifies strategies to overcome them. Method(s): A multiple-case study design examined three multidisciplinary rehabilitation teams providing home-based rehabilitation to this population. Data was collected from focus group transcripts with team representatives (n=20) and publicly available information such as national stroke audit data. Result(s): High levels of need were reported for these patients across multiple domains such as continence, communication and motor control. There was lack of agreement relating to who was ultimately responsible for providing rehabilitation for this group. Teams have evolved to include this population but are insufficiently commissioned to fully meet their needs. Incomplete and disjointed pathways with resultant healthcare inequalities were commonly reported. Teams have adopted multiple strategies in attempts to overcome these challenges, including upskilling a diverse range of partners. Exploiting available multi-disciplinary expertise, skills and resources across health, social care and voluntary sector boundaries enabled rehabilitation opportunities, focused interventions and optimised outcomes. Conclusion(s): Collaboration and partnership working are essential for commissioning and delivery of rehabilitation for severely disabled strokesurvivors. Multidisciplinary expertise is required, relying on coordinated multiagency rehabilitation opportunities to be realised to address existing health inequalities.
  • Using co-design in managing post-stroke fatigue: Nottingham Fatigue after Stroke Study (NotFAST2)

    Drummond, Avril; Ablewhite, Joanne; das Nair, Roshan (2022)
    Introduction: Post stroke fatigue (PSF) is an overwhelming feeling of exhaustion, which is not related to exertion, and which does not typically improve with rest. It affects approximately 50% of stroke survivors. Our aim was to provide participants with an opportunity to discuss their experiences of PSF, to talk about strategies which were thought important and to suggest how a fatigue programme could be best delivered. Method(s): We recruited - people with PSF. - family/ friends who provided support. - healthcare professionals with expertise in fatigue A maximum variation sampling strategy was used to ensure a broad range of participants and experiences. Five two-hour co-design groups were held using Microsoft Teams. Result(s): 35 participants took part over 16 weeks from across the UK. This included twelve stroke survivors, two with aphasia. Key points identified were: - Healthcare professionals often do not fully understand fatigue and often avoid talking about it. - Contact with both professionals and others with fatigue is very much valued. - Those with lived experience did not appreciate much of the language used by professions. Red flag words include normal, recovery, tired. - A 'pick and mix' option of strategies to manage fatigue was thought ideal to cater for individual needs - One participant said 'Thank goodness someone is listening' Conclusion(s): The co-design groups allowed people to exchange experiences and perceptions in a safe space. There was mutual respect for different viewpoints and the sessions facilitated insights from the different parties. The use and input of ALL experts is critical in moving this area forwards.
  • Evaluating the performance of the PRISMA-7 frailty criteria for predicting disability and death after acute ischemic stroke

    Stephan, Blossom C. M. (2022)
    OBJECTIVES: We aimed to evaluate the predictive performance of the PRISMA-7 frailty criteria regarding the composite outcome of disability or death in patients with an acute ischemic stroke, and to compare it with the Frailty Index and the National Institutes of Health Stroke Scale (NIHSS). MATERIALS AND METHODS: This prospective cohort study involved all patients aged ≥ 40 years admitted with an acute ischemic stroke between March 2019 and January 2020. We performed survival analyses, calculated risk ratios, sensitivity, specificity, and predictive values for the combined outcome of disability or death according to the presence of frailty as determined by the PRISMA-7 and the Frailty Index, and stroke severity based on the NIHSS. RESULTS: In 174 patients with acute ischemic stroke, being frail in the week before the stroke according to the PRISMA-7 was associated with a Risk Ratio of 4·50 (95%CI 1·77-11·43, P <0·001) and a Positive Predictive Value of 89% (95%CI 77-99%) for being disabled or dead 90 days after the stroke, and a Hazard Ratio of 3·33 (95%CI 1·48-7·51, P = 0·004) for the survival outcome. The predictive performance of the PRISMA-7 was not significantly different from the Frailty Index or the NIHSS. CONCLUSIONS: We provide evidence that the PRISMA-7 frailty criteria may be a useful prognostication tool in acute ischemic stroke.
  • Stroke and TIA survivors' perceptions of the COVID-19 vaccine and influences on its uptake: Cross sectional survey

    Kontou, Eirini (2022)
    Background: People who have experienced a stroke or transient ischaemic attack (TIA) have greater risks of complications from COVID-19. Therefore, vaccine uptake in this vulnerable population is important. To prevent vaccine hesitancy and maximise compliance, we need to better understand individuals' views on the vaccine. Objective(s): We aimed to explore perspectives of the COVID-19 vaccine and influences on its uptake from people who have experienced a stroke or TIA. Method(s): A cross-sectional, electronic survey comprising multiple choice and free text questions. Convenience sampling was used to recruit people who have experienced a stroke/TIA in the UK/Ireland. Result(s): The survey was completed by 377 stroke/TIA survivors. 87% (328/377) had either received the first vaccine dose or were booked to have it. The vaccine was declined by 2% (7/377) and 3% (11/377) had been offered the vaccine but not yet taken it up. 8% (30/377) had not been offered the vaccine despite being eligible. Some people expressed concerns around the safety of the vaccine (particularly risk of blood clots and stroke) and some were hesitant to have the second vaccine. Societal and personal benefits were motivations for vaccine uptake. There was uncertainty and lack of information about risk of COVID-19 related complications specifically for people who have experienced a stroke or TIA. Conclusion(s): Despite high uptake of the first vaccine, some people with stroke and TIA have legitimate concerns and information needs that should be addressed. Our findings can be used to identify targets for behaviour change to improve vaccine uptake specific to stroke/TIA patients
  • Risk factors for dementia in the context of cardiovascular disease: A protocol of an overview of reviews

    Brain, Jacob; Siervo, Mario; Stephan, Blossom C. M. (2022)
    BACKGROUND: Dementia is a major public health priority. Although there is abundant evidence of an association between dementia and poor cardiovascular health, findings have been inconsistent and uncertain in identifying which factors increase dementia risk in those with cardiovascular disease. Indeed, multiple variables including sociodemographic, economic, health, lifestyle and education may indicate who is at higher vs. lower dementia risk and could be used in prediction modelling. Therefore, the aim of this review is to synthesise evidence on the key risk factors for dementia in those with a history of cardiovascular disease. METHODS: This is an overview of reviews protocol, registered on PROSPERO (CRD42021265363). Four electronic databases including MEDLINE, EMBASE, PsycINFO, and the Cochrane Database of Systematic Reviews will be searched. Studies will be included if they are systematic reviews and/or meta-analyses that have investigated the risk of incident dementia (all-cause and subtypes including Alzheimer's disease and vascular dementia) in people with a history of coronary heart disease, heart failure, atrial fibrillation, hypertension, hyperlipidaemia, and vascular stiffness. Study selection will be completed by two independent researchers according to the eligibility criteria, and conflicts resolved by a third reviewer. References will be exported into Covidence for title and abstract sifting, full-text review, and data extraction. Methodological quality will be assessed using the AMSTAR-2 criteria and confidence of evidence will be assessed using the GRADE classification. This overview of reviews will follow PRISMA guidelines. If there is sufficient homogeneity in the data, the results will be pooled, and a meta-analysis conducted to determine the strength of association between each risk factor and incident all-cause dementia and its subtypes for each cardiovascular diagnoses separately. DISCUSSION: We will create a comprehensive summary of the key risk factors linking cardiovascular diseases to risk of incident dementia. This knowledge is essential for informing risk predictive model development as well as the development of risk reduction and prevention strategies.
  • A Biopsychosocial Intervention for Stroke Carers (BISC): development and description of the intervention

    Kontou, Eirini (2022)
    ABSTRACTObjective Family members of stroke survivors are often not supported for their caring role, with many reporting adjustment difficulties. This paper describes the development and content of a group-based intervention for informal carers of stroke survivors.Method The intervention is based on the theoretical foundation of the biopsychosocial model with the aim to understand and address the physical, psychological and social factors of caring for stroke survivors. Findings from a comprehensive literature review and a qualitative study with carers and stroke professionals were synthesized to guide the intervention development. The Template for Intervention Description and Replication (TIDieR) checklist was used as a framework to describe the intervention.Results The intervention integrates cognitive-behavioural approaches via the identification of the biopsychosocial (physical, emotional, social) factors that can have an impact on the well-being of carers. It includes education on stroke-specific topics and advice on coping strategies. It consists of six structured two-hour group sessions facilitated in a community setting. It provides information and support on adjusting to the caring role in the first year post-stroke. Intervention materials were designed for addressing carers? specific needs using psychological techniques, such as problem-solving, goal setting and relaxation exercises.Conclusion We have underlined the importance for describing and reporting the process of intervention development for complex interventions in the context of stroke rehabilitation. An intervention addressing the needs of informal stroke carers (Biopsychosocial Intervention for Stroke Carers; BISC) has been developed and described. BISC was further evaluated in a single-centre feasibility randomized controlled trial.
  • Conceptual framework for personal recovery in patients with acute myocardial infarction

    Slade, Mike (2021)
    Background Although there has been movement in cardiology to advance patient-centered approaches to postacute myocardial infarction (AMI) care, work remains to be done in aligning patient preferences with clinical care. Our objective was to characterize patients' experience of AMI and treatment to develop a new conceptual framework of patient-centered recovery in cardiology. Methods and Results We conducted in-depth interviews with people who previously experienced an AMI (2016-2019). The interview focused on participants' experiences of their recovery, which were audio-recorded, transcribed verbatim, and analyzed using a phenomenological framework. The overarching theme described by the 42 participants was feeling like a "different person" after the AMI. This shift manifested itself in both losses and gains, each of which posed new challenges to everyday life. The experience appeared to be an active process requiring people to take responsibility for their health. In terms of loss, participants describe how the AMI threatened their sense of safety and security and led to social isolation, fragility, uncertainty about the future, and difficulty expressing emotions accompanied this new fear. A conceptual framework describing the relationship between AMI, identity change, and functioning was developed. Conclusions Participants experienced the AMI as an unexpected disruption in their lives that had far-reaching effects on their daily functioning, and were resolved in numerous ways. The conceptual framework may assist in providing a theoretical basis for future interventions in cardiology that not only engage and retain patients in care but also improve long-term adherence to secondary prevention and other aspects of self-care.
  • Nitrate-rich beetroot juice reduces blood pressure in Tanzanian adults with elevated blood pressure: A double-blind randomized controlled feasibility trial

    Stephan, Blossom C. M. (2020)
    BACKGROUNDIn Sub-Saharan Africa, current strategies are struggling to control the burgeoning hypertension epidemic. Dietary interventions such as inorganic nitrate or folic acid supplementation could represent promising strategies for reducing blood pressure (BP) in this setting.OBJECTIVESThis feasibility study explores the effects of dietary inorganic nitrate supplementation, alone or in combination with folic acid, on BP in Tanzanian adults with elevated BP in Tanzania.METHODSA placebo-controlled, double-blind, randomized controlled feasibility trial was conducted. Forty-seven middle-aged and older participants (age: 50-70 y, BMI: 26.3-29.1 kg/m2) were randomly assigned to 3 conditions for a period of 60 d: 1) high-nitrate beetroot juice (∼400 mg nitrate) and folic acid (∼5 mg folic acid) (N + F), 2) high-nitrate beetroot juice and placebo (N + P), or 3) nitrate-depleted beetroot juice and placebo (P + P). Clinic and 24-h ambulatory BP and measurements of compliance in plasma (nitrate and folate concentrations) and saliva (nitrate and nitrite) were obtained at baseline, 30 d, and 60 d.RESULTSBaseline resting systolic and diastolic BP (mean ± SD) was 151.0 ± 19.4 mm Hg and 91.8 ± 11.7 mm Hg, respectively. Compliance to the interventions was high (>90%) in all groups which was confirmed by the significant increase in nitrate and folic acid concentrations in plasma and saliva samples in the treatment arms. After 60 d, 24-h systolic BP dropped by -10.8 ± 9.8 mm Hg (P < 0.001), -6.1 ± 13.2 mm Hg (P = 0.03), and -0.3 ± 9.7 mm Hg (P = 0.83) in the N + P, N + F, and P + P groups, respectively. There was a significant decrease in 24-h diastolic BP in the N + P group (-5.4 ± 5.0 mm Hg, P = 0.004), whereas changes were not significant in the N + F (-1.8 ± 8.1 mm Hg, P = 0.32) and P + P (1.6 ± 8.3 mm Hg, P = 0.43) groups.CONCLUSIONSDietary inorganic nitrate represents a potential nutritional strategy to lessen the hypertension epidemic in Sub-Saharan Africa. These findings support the rationale for future long-term investigations exploring the efficacy of dietary nitrate for lowering BP and attenuating cardiovascular disease risk in this setting.This trial was registered at isrctn.com as ISRCTN67978523.
  • Impact of memory problems post-stroke on patients and their family carers: A qualitative study

    Stephan, Blossom C. M. (2020)
    Background: Memory problems post-stroke are common and for some, these problems could then progress to a dementia illness. Once in the community, stroke-survivors are looked after by their family doctors although there is evidence that these patients may struggle to access appropriate help in the community for these problems. Although a stroke-survivor may be physically capable of performing daily tasks, they and their families may have to learn to manage and adapt to their new memory deficits. There is often less focus on cognitive recovery post-stroke from clinical services perhaps because of the lack of awareness and evidence of these adaptations. There is also good evidence that organized stroke care improves physical recovery but no equivalent evidence for the effectiveness of cognitive rehabilitation. The aim of this qualitative study was to report the impact of memory problems on the stroke-survivor and their family once they are living in the community. Methods: Semi-structured interviews were conducted with patients and family carers to gain an in-depth understanding of their experiences. Participants were invited to take part in an interview at around six and 12-months post-stroke. A topic guide was developed to explore participant's care experiences post-stroke when they have also presented with memory difficulties. Data collection and analysis were iterative; all transcripts were anonymized. The data were thematically analyzed. Results: Twenty-two interviews were conducted. Five family carers and ten stroke-survivors were interviewed at six-months post-stroke, of these eight stroke-survivors and four family carers agreed to a 12-month follow-up interview. They identified several areas of impact: (1) impact on daily life; (2) emotional impact; and (3) compensating strategies implemented in response to impact. Conclusion: Living with stroke combined with memory impairment can have negative effects on the stroke-survivor and their family once in the community. Health professionals and services in the community need to recognize the burden of managing symptoms post-stroke for these individuals and their families. Understanding the impact can enable more effective community and specialist support to be provided particularly if we were to also identify those who may then be at risk of a future dementia illness.
  • How can population-based studies best be utilized to reduce the global impact of dementia? Recommendations for researchers, funders, and policymakers

    Stephan, Blossom C. M. (2020)
    In the last two decades, there has been in-depth investigation into understanding the pathogenesis, epidemiological profiling, and clinical characterization of dementia. However, these investigations have not led to successful interventions to prevent, delay, or reverse the pathological processes underlying dementia. Recent findings of a decrease in dementia risk in high-income countries such as the UK, USA and the Netherlands highlight that dementia, at least in some cases, is preventable. This article includes a synthesis of current knowledge on dementia epidemiology, biological underpinnings, risk factors, and current prevention programs, with the aim to set the path for research, funding, and policy initiatives to address the global public health challenge of how to prevent dementia or reduce risk within the framework of population-based studies. We advocate for development of novel approaches for intelligent data synthesis that go well beyond single approaches to enable powerful risk stratification analyses. An integrated approach is needed where researchers, funders, policymakers, and stakeholders contribute to and work together to formulate effective strategies for the global monitoring and development of population-based risk reduction, treatment, and prevention programs for dementia.

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