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After a stroke, physical activity can be key in enhancing the rehabilitation of patients and preventing a secondary stroke. In this commentary, the authors critically appraise a systematic review that investigated how different types of physical fitness training impact on the mental and physical conditions of stroke survivors. Cardiorespiratory, resistance and mixed training (especially when including walking) can improve key outcomes, such as the balance and mobility of stroke survivors, but the most suitable type of training depends on the individual needs and aims of the rehabilitation process. More research is needed to understand how the effects of the different types of training vary by considering the time between stroke and intervention onset, stroke severity, and the dose of intervention.

Mainstream economic evaluations methods may not be appropriate to capture the range of effects triggered by interventions for people with intellectual disabilities. In this systematic review, we aimed to identify, assess and synthesise the arguments in the literature on how the effects of interventions for people with intellectual disabilities could be measured in economic evaluations.We searched for studies providing relevant arguments by running multi-database, backward, forward citation and grey literature searches. Following title/abstract and full-text screening, the arguments extracted from the included studies were summarised and qualitatively assessed in a narrative synthesis.Our final analysis included three studies, with their arguments summarised in different methodological areas.Based on the evidence, we suggest the use of techniques more attuned to the population with intellectual disabilities, such sensitive preference-based instruments to collect health states data, and mapping algorithms to obtain utility values.

Background Mass outbreaks such as pandemics are associated with mental health problems requiring effective psychological interventions. Although several forms of psychological interventions may be advocated or used, some may lack strong evidence of efficacy and some may not have been evaluated in mass infectious disease outbreaks. This paper reports a systematic review of published studies (PROSPERO CRD:42020182094. Registered: 24.04.2020) examining the types and effectiveness of psychological support interventions for the general population and healthcare workers exposed to mass infectious disease outbreaks. Methods A systematic review was conducted. Randomised Controlled Trials (RCT) were identified through searches of electronic databases: Medline (Ovid), Embase (Ovid), PsycINFO (EBSCO) and the Cochrane Library Database from inception to 06.05.2021 using an agreed search strategy. Studies were included if they assessed the effectiveness of interventions providing psychological support to the general population and / or healthcare workers exposed to mass infectious disease outbreaks. Studies were excluded if they focused on man-made or natural disasters or if they included armed forces, police, fire-fighters or coastguards. Results Twenty-two RCTs were included after screening. Various psychological interventions have been used: therapist-guided therapy (n = 1); online counselling (n = 1); ‘Emotional Freedom Techniques’ (n = 1); mobile phone apps (n = 2); brief crisis intervention (n = 1); psychological-behavioural intervention (n = 1); Cognitive Behavioural Therapy (n = 3); progressive muscle relaxation (n = 2); emotional-based directed drawing (n = 1); psycho-educational debriefing (n = 1); guided imagery (n = 1); Eye Movement Desensitization and Reprocessing (EMDR) (n = 1); expressive writing (n = 2); tailored intervention for patients with a chronic medical conditions (n = 1); community health workers (n = 1); self-guided psychological intervention (n = 1), and a digital behaviour change intervention (n = 1). Meta-analyses showed that psychological interventions had a statistically significant benefit in managing depression (Standardised Mean Difference [SMD]: -0.40; 95% Confidence Interval [CI]: − 0.76 to − 0.03), and anxiety (SMD: -0.72; 95% CI: − 1.03 to − 0.40). The effect on stress was equivocal (SMD: 0.16; 95% CI: − 0.19 to 0.51). The heterogeneity of studies, studies’ high risk of bias, and the lack of available evidence means uncertainty remains. Conclusions Further RCTs and intervention studies involving representative study populations are needed to inform the development of targeted and tailored psychological interventions for those exposed to mass infectious disease outbreaks.

Falls are associated with a substantial increase in risk of mortality and are the second leading cause of unintentional death worldwide. A single fall can affect all aspects of an older person's life. These broad impacts can lead to worse disability outcomes and a higher likelihood of long-term nursing home admission. There is a need to identify not just effective falls prevention interventions but also cost effectiveness.

Background We applied Motivational Interviewing (MI) techniques, early after stroke, to facilitate psychological adjustment to life post-stroke. In our trial, MI-plus-usual-care increased the likelihood of normal mood at 3-months post-stroke, compared to usual-care alone. Whilst appropriate training, manuals, and supervision may increase adherence to core principles of this complex intervention, unintended variability in implementation inevitably remains. We aimed to explore the impact of variability on participant outcome. Methods Using our trial data (411 participants), we explored variation in MI delivery, examining: therapist characteristics (stroke care expertise/knowledge, psychology training); MI content (fidelity to MI techniques assessed with Motivational Interviewing Treatment Integrity code, describing therapist behaviours as MI-consistent, MI-neutral or MI-inconsistent); and MI dose (number/duration of sessions). Results The four MI therapists (two nurses/two psychologists) had varying expertise and MI delivery. Across therapists, mean average session duration ranged 29.5–47.8 min. The percentage of participants completing the per-protocol four sessions ranged 47%–74%. These variations were not related to participant outcome. There were uniformly high frequencies (>99%) of MI-consistent and MI-neutral interactions, and low frequencies (

The incidence of stroke in India is one of the largest worldwide. With this scoping review, we assessed the evidence on the costs of stroke, which is essential to evaluate whether stroke care interventions are cost-effective. We adopted a healthcare sector and broader societal perspective and searched electronic databases for records including stroke cost estimates (up to 2020). Following deduplication and screening of 2,510 records, we extracted the data (converted into 2020 Indian rupees [INR]) and assessed the quality of eight eligible studies. These studies, published between 2011 and 2020, covered the whole of India and specific localities and were: cost-of-illness studies (n = 3); economic evaluations (n = 2); cross-sectional costing study (n = 1); simulated costing study (n = 1); and policy/clinical review (n = 1). Among the extracted estimates, the mean total costs of stroke care per patient for the period up to six months post admission ranged from ₹19,428.86 in a government hospital in Punjab to ₹118,040.15 in a private tertiary care centre in Ludhiana. The median total out-of-pocket (OOP) payments for cardiovascular disease-related expenditures ranged from ₹18,148.88 to ₹68,464.39 across different income groups. Despite methodological limitations, the data from our scoping review will help in designing economic evaluations of stroke care interventions in India.JEL Codes: C18, C80, D61, I15, I19

Purpose Personalised information and support can be provided to cancer survivors using a structured approach. Needs assessment tools such as the Holistic Needs Assessment (HNA) in the UK and the Comprehensive Problem and Symptom Screening (COMPASS) questionnaire in Canada are recommended for use in practice; however, they are not widely embedded into practice. The study aimed to determine the extent to which nurses working in cancer care in the UK and Manitoba value NA and identify any barriers and facilitators they experience. Method Oncology nurses involved in the care of cancer patients in the UK (n = 110) and Manitoba (n = 221) were emailed a link to an online survey by lead cancer nurses in the participating institutions. A snowball technique was used to increase participation across the UK resulting in 306 oncology nurses completing the survey in the UK and 116 in Canada. Results Participants expressed concerns that these assessments were becoming bureaucratic “tick-box exercises” which did not meet patients’ needs. Barriers to completion were time, staff shortages, lack of confidence, privacy, and resources. Facilitators were privacy for confidential discussions, training, confidence in knowledge and skills, and referral to resources. Conclusion Many busy oncology nurses completed this survey demonstrating the importance they attach to HNAs and COMPASS. The challenges faced with implementing these assessments into everyday practice require training, time, support services, and an appropriate environment. It is vital that the HNA and COMPASS are conducted at optimum times for patients to fully utilise time and resources.

Background and Purpose— Identifying the etiology of acute ischemic stroke is essential for effective secondary prevention. However, in at least one third of ischemic strokes, existing investigative protocols fail to determine the underlying cause. Establishing etiology is complicated by variation in clinical practice, often reflecting preferences of treating clinicians and variable availability of investigative techniques. In this review, we systematically assess the extent to which there exists consensus, disagreement, and gaps in clinical practice recommendations on etiologic workup in acute ischemic stroke. Methods— We identified clinical practice guidelines/consensus statements through searches of 4 electronic databases and hand-searching of websites/reference lists. Two reviewers independently assessed reports for eligibility. We extracted data on report characteristics and recommendations relating to etiologic workup in acute ischemic stroke and in cases of cryptogenic stroke. Quality was assessed using the AGREE II tool (Appraisal of Guidelines for Research & Evaluation). Recommendations were synthesized according to a published algorithm for diagnostic evaluation in cryptogenic stroke. Results— We retrieved 16 clinical practice guidelines and 7 consensus statements addressing acute stroke management (n=12), atrial fibrillation (n=5), imaging (n=5), and secondary prevention (n=1). Five reports were of overall high quality. For all patients, guidelines recommended routine brain imaging, noninvasive vascular imaging, a 12-lead ECG, and routine blood tests/laboratory investigations. Additionally, ECG monitoring (>24 hours) was recommended for patients with suspected embolic stroke and echocardiography for patients with suspected cardiac source. Three reports recommended investigations for rarer causes of stroke. None of the reports provided guidance on the extent of investigation needed before classifying a stroke as cryptogenic. Conclusions— While consensus exists surrounding standard etiologic workup, there is little agreement on more advanced investigations for rarer causes of acute ischemic stroke. This gap in guidance, and in the underpinning evidence, demonstrates missed opportunities to better understand and protect against ongoing stroke risk. Registration— URL: https://www.crd.york.ac.uk/PROSPERO/ ; Unique identifier: CRD42019127822.

BackgroundDespite simpler regimens than vitamin K antagonists (VKAs) for stroke prevention in atrial fibrillation (AF), adherence (taking drugs as prescribed) and persistence (continuation of drugs) to direct oral anticoagulants are suboptimal, yet understudied in electronic health records (EHRs).ObjectiveWe investigated (1) time trends at individual and system levels, and (2) the risk factors for and associations between adherence and persistence.MethodsIn UK primary care EHR (The Health Information Network 2011–2016), we investigated adherence and persistence at 1 year for oral anticoagulants (OACs) in adults with incident AF. Baseline characteristics were analysed by OAC and adherence/persistence status. Risk factors for non-adherence and non-persistence were assessed using Cox and logistic regression. Patterns of adherence and persistence were analysed.ResultsAmong 36 652 individuals with incident AF, cardiovascular comorbidities (median CHA2DS2VASc[Congestive heart failure, Hypertension, Age≥75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category] 3) and polypharmacy (median number of drugs 6) were common. Adherence was 55.2% (95% CI 54.6 to 55.7), 51.2% (95% CI 50.6 to 51.8), 66.5% (95% CI 63.7 to 69.2), 63.1% (95% CI 61.8 to 64.4) and 64.7% (95% CI 63.2 to 66.1) for all OACs, VKA, dabigatran, rivaroxaban and apixaban. One-year persistence was 65.9% (95% CI 65.4 to 66.5), 63.4% (95% CI 62.8 to 64.0), 61.4% (95% CI 58.3 to 64.2), 72.3% (95% CI 70.9 to 73.7) and 78.7% (95% CI 77.1 to 80.1) for all OACs, VKA, dabigatran, rivaroxaban and apixaban. Risk of non-adherence and non-persistence increased over time at individual and system levels. Increasing comorbidity was associated with reduced risk of non-adherence and non-persistence across all OACs. Overall rates of ‘primary non-adherence’ (stopping after first prescription), ‘non-adherent non-persistence’ and ‘persistent adherence’ were 3.5%, 26.5% and 40.2%, differing across OACs.ConclusionsAdherence and persistence to OACs are low at 1 year with heterogeneity across drugs and over time at individual and system levels. Better understanding of contributory factors will inform interventions to improve adherence and persistence across OACs in individuals and populations.

Background: With alarming vacancy rates and dipping availability of European nurses, remedies for the shortage of nurses in the UK are urged. To accelerate the registration of new children’s nurses, a health education funder commissioned two education programmes within its region. The first is a 1-year programme designed for UK-registered nurses in adult or mental health. The second is a 2-year programme for individuals, not registered as nurses, who are child or social care graduates with experience of working with children and young people.\ud \ud Objectives: To evaluate the economic effectiveness of two accelerated children’s nursing education programmes. \ud \ud Design: Economic evaluation.\ud \ud Settings: Two accelerated children’s nursing education programmes in two sites in England. \ud \ud Participants: Nursing students enrolled in both programmes (N=20).\ud \ud Methods: We adopt a cost-consequences analysis to analyse the programmes’ costs and outcomes.\ud \ud Results: All graduates were heading for posts within the region where they studied, a favourable outcome for the funder. However, the first programme would deplete the workforce in other nursing fields, whereas the second, by quickening the graduates’ career progression, would not dent the long-term shortage in entry roles. Given our small sample size, these impacts may differ if the programmes have wider implementation. \ud \ud Conclusions: Our evaluation measures the effectiveness of two novel accelerated education programmes in tackling the nurses’ shortage. Concurrently, it contributes to developing a standardised approach for future economic evaluations in nursing education.

Background: Falls are the leading cause of fatal and non-fatal unintentional injuries in older people. In the community, 30% of adults aged 65 fall per year. The use of Exergames (active video-based exercise games) is a possible innovative, community-based approach to improve balance and function, and thus reduce falls risk. Objective: To determine the effectiveness of a tailored OTAGO based strength and balance Exergame programme for improving balance, maintaining function and reducing falls risk in older residents of assisted living facilities in the UK. Design: A two-arm cluster randomised controlled trial. Participants and setting Adults aged 55 years and older living in 18 assisted-living (sheltered housing) facilities (clusters) in the UK. Interventions: Tailored 12-week strength and balance Exergame programme, supported by physiotherapists or trained assistants plus standard care (physiotherapy advice and leaflet) versus standard care only. Main outcome measures: The primary outcome measure was balance at 12 weeks post-baseline, as assessed by the Berg Balance Scale (BBS). Secondary outcomes included: fear of falling, mobility, self-reported physical activity, falls risk, pain, mood, fatigue, cognition, healthcare utilisation and health-related quality of life; and self-reported falls over a 3-month period. Randomisation and blinding Clusters were randomised in blocks of two after participants were recruited and baseline data were collected. No blinding of those delivering or receiving the interventions, collecting or analysing data was possible. Results: Eighteen clusters were randomised (9 to each arm) with 56 participants allocated to the intervention and 50 to the control condition (78% female, mean age 78 years). Fourteen participants withdrew over the 12 weeks, mainly due to ill health, drop out rates did not differ per arm. Intention-to-treat analysis of respondents (49 Exergames; 43 control) revealed that balance was significantly improved at 12 weeks in the Exergame group; adjusted mean improvement in balance (BBS) of 6.2 (95% CI 2.4 to 10.0) and significant improvements in falls rate (p=0.001), fear of falling (p=0.007) and pain (p=0.02).The mean attendance at Exergames sessions during 12 weeks was 69% with a mean exercising time of 33 minutes/week. In the control group 12 (24%) participants fell 38 times over 3 months compared to 11 (20%) participants of the Exergame group who fell 17 times. The change in falls rates significantly favoured the intervention (incident rate ratio 0.31 (95% CI 0.16 to 0.62, p=0.001)). The point estimate of the incremental cost effectiveness ratio (ICER) was £15,209.80 per QALY. Using 10,000 bootstrap replications, at the lower bound of the NICE threshold of £20,000 per QALY, there was a 61% probability of Exergames being cost-effective. This rose to 73% at the upper bound of £30,000 per QALY. Conclusion: Exergames, as delivered in this trial, improve balance, pain and fear of falling and are an effective fall prevention strategy in assisted living facilities for older people. Health economic analysis suggests that Exergames represent a cost-effective fall prevention strategy. Clinical Trial Registration: Trial Registration ClinicalTrials.gov: NCT02634736 Funding Statement: This study was funded by Innovate UK through their SBRI programme. LM acknowledges financial support from the MRC Skills Development Fellowship (MR/N015126/1). The authors would like to acknowledge the contributions of Ms Kelly Banham, Ms Margaret Clarke, Ms Tina Duckworth, Ms Megan Lloyd, Dr Katie Thomson, Dr Calum Leask, Trafford Housing Trust, Pennine Care NHS Falls Service (Ms Debra Maloney, Dr Jay Chillala, Ms Angela Easdon), Mr Bibhas Roy, Dr Richard Deed, Prof Jackie Oldham, Dr Mark Pilling, Ms Joanne Thomas, Ms Bernadette O’Dowd. Declaration of Interests: Dawn Skelton is a Director of Later Life Training, a not for profit training company that provides training in delivery of the Otago and FaME Programmes with the UK, Europe and Singapore. No other conflicts of interest are declared. Ethics Approval Statement: Ethics approvals for this study were obtained from London - Camden & Kings Cross Research Ethics Committee, reference number 16/LO/0200.

European railways have been shaped by multiple reforms since the mid-1990s, covering industry structure, market opening and economic regulation. However, the literature has given little attention to the latter; namely the evolution and impacts of regulatory reforms amongst Europe's railways. This paper fills this gap by providing an up-to-date, bottom-up assessment of current rail regulatory practice in Europe. We develop a survey of economic regulators across Europe, thus complementing top-down studies of the impact of economic regulation by enabling a richer insight into regulatory activity and its impacts. The questionnaire is based on a review of the literature on ideal regulatory characteristics across multiple industries. Our results show that European rail regulators, in general, exhibit many of the features of ideal regulation; in particular around key features such as independence, resourcing, longevity and expertise, transparency and in turn stability and predictability. However, we find that rail regulatory bodies could take a more proactive role in shaping track access charges, given their importance in respect of efficient use of the network and maintaining non-discriminatory access. Importantly, there is also scope for regulators to play a greater role in regulating the efficiency and quality of infrastructure managers, and potentially becoming more involved in the designing stages of passenger market opening as it emerges; and these changes could deliver substantial beneficial impacts for rail users and funders across Europe.

Falls are the leading cause of fatal and non-fatal unintentional injuries in older people. The use of Exergames (active video-games) is a possible innovative, community-based approach to reduce falls risk. The objective of this study was to evaluate the effectiveness of a tailored physiotherapy-based Exergame programme for reducing falls risk in older residents of assisted living facilities in the UK. A multi-site, two-arm cluster randomised controlled trial with 3 month follow up of falls in eighteen assisted-living facilities in the UK was conducted. Tailored 12-week strength and balance Exergame programme, supported by physiotherapists or assistants plus standard care (physio advice and leaflet) against standard care only, in older adults dwelling in assisted living facilities. The primary outcome measure was balance as assessed by the Berg Balance scale (BBS). Secondary outcomes included fear of falling, mobility, pain, falls risk, fatigue, cognition and incidence of falls. Eighteen sites were recruited and randomised to each intervention (106 participants of which 56 Exergames; 50 control). Intention-to-treat analysis revealed that balance was significantly improved at 12 wks in the Exergame group with an adjusted mean increase in BBS of 6.18 (95% CI 2.38 to 9.97) and significant improvements in secondary outcomes of fear of falling and pain. Falls rate was significantly lower in the Exergames group (incidence rate ratio 0.40, (95%CI 0.22 to 0.74, p=0.001). Exergames, as delivered in this trial, improve balance, pain and fear of falling and may be considered as a fall prevention strategy in assistive living facilities for older people.

Background Cardiac arrest outside hospital is a catastrophic medical emergency experienced by an estimated 60 000 people a year in the UK. The speed and accuracy with which cardiac arrest outside hospital is recognised by 999 call handlers is fundamental to improving the chance of survival, but is extremely challenging. We aimed to identify how cardiac arrest is actually described by callers during dialogues with 999 call handlers. Methods Data was obtained from two acute NHS trusts and their two local ambulance trusts for all cases of suspected or actual out-of-hospital cardiac arrest (OHCA) or imminent medically witnessed cardiac arrest (MWCA) which led to transfer to one of the study hospitals, for a one year period (1/7/2013–30/6/2014). The 999 call recordings were listened to in full; words or phrases used by callers to describe clinical signs and symptoms were identified and clustered into key indicator symptoms using a thematic approach. Findings 429 cases of cardiac arrest were identified, of which 246 (57.3%) were dispatched using a ‘cardiac arrest’ code. 6 callers (1.4%) used the term ‘cardiac arrest’ or a synonym. Key indicator symptoms reported most frequently were unconsciousness (64.8%), ineffective breathing (61.9%), and absent breathing (48.8%). Descriptors of conscious level included diverse colloquialisms and terms relating to reduced or fluctuating level of consciousness (17.2%). Descriptors of ineffective breathing included diverse terms relating to slow, fast, irregular, agonal, dyspnoea, and shallow breathing, plus nonspecific terms (e.g. ‘breathing’s funny); and ‘don’t know’ statements. Conclusion Callers’ descriptors of key symptoms of OHCA are varied and include many colloquialisms. Call handler training should include awareness of likely descriptions, particularly of ineffective breathing, which may be more commonly reported than absent breathing.