Peter Langhorne

University of Glasgow, Glasgow, Scotland, United Kingdom

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Publications (244)1562.23 Total impact

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    ABSTRACT: Lower respiratory tract infections frequently complicate stroke and adversely affect outcome. There is currently no agreed terminology or gold-standard diagnostic criteria for the spectrum of lower respiratory tract infections complicating stroke, which has implications for clinical practice and research. The aim of this consensus was to propose standardized terminology and operational diagnostic criteria for lower respiratory tract infections complicating acute stroke. Systematic literature searches of multiple electronic databases were undertaken. An evidence review and 2 rounds of consensus consultation were completed before a final consensus meeting in September 2014, held in Manchester, United Kingdom. Consensus was defined a priori as ≥75% agreement between the consensus group members. Consensus was reached for the following: (1) stroke-associated pneumonia (SAP) is the recommended terminology for the spectrum of lower respiratory tract infections within the first 7 days after stroke onset; (2) modified Centers for Disease Control and Prevention (CDC) criteria are proposed for SAP as follows-probable SAP: CDC criteria met, but typical chest x-ray changes absent even after repeat or serial chest x-ray; definite SAP: CDC criteria met, including typical chest x-ray changes; (3) there is limited evidence for a diagnostic role of white blood cell count or C-reactive protein in SAP; and (4) there is insufficient evidence for the use of other biomarkers (eg, procalcitonin). Consensus operational criteria for the terminology and diagnosis of SAP are proposed based on the CDC criteria. These require prospective evaluation in patients with stroke to determine their reliability, validity, impact on clinician behaviors (including antibiotic prescribing), and clinical outcomes. © 2015 American Heart Association, Inc.
    Stroke 06/2015; DOI:10.1161/STROKEAHA.115.009617 · 6.02 Impact Factor
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    ABSTRACT: The proportion of the world's population aged over 60 years is increasing. Therefore, there is a need to examine different methods of healthcare provision for this population. Medical day hospitals provide multidisciplinary health services to older people in one location. To examine the effectiveness of medical day hospitals for older people in preventing death, disability, institutionalisation and improving subjective health status. Our search included the Cochrane Effective Practice and Organisation of Care (EPOC) Group Register of Studies, CENTRAL (2013, Issue 7), MEDLINE via Ovid (1950-2013 ), EMBASE via Ovid (1947-2013) and CINAHL via EbscoHost (1980-2013). We also conducted cited reference searches, searched conference proceedings and trial registries, hand searched select journals, and contacted relevant authors and researchers to inquire about additional data. Randomised and quasi-randomised trials comparing medical day hospitals with alternative care for older people (mean/median > 60 years of age). Two authors independently assessed trial eligibility and risk of bias and extracted data from included trials. We used standard methodological procedures expected by the Cochrane Collaboration. Trials were sub-categorised as comprehensive care, domiciliary care or no comprehensive care. Sixteen trials (3689 participants) compared day hospitals with comprehensive care (five trials), domiciliary care (seven trials) or no comprehensive care (four trials). Overall there was low quality evidence from these trials for the following results.For the outcome of death, there was no strong evidence for or against day hospitals compared to other treatments overall (odds ratio (OR) 1.05; 95% CI 0.85 to 1.28; P = 0.66), or to comprehensive care (OR 1.26; 95% CI 0.87 to 1.82; P = 0.22), domiciliary care (OR 0.97; 95% CI 0.61 to 1.55; P = 0.89), or no comprehensive care (OR 0.88; 95% CI 0.63 to 1.22; P = 0.43).For the outcome of death or deterioration in activities of daily living (ADL), there was no strong evidence for day hospital attendance compared to other treatments (OR 1.07; 95% CI 0.76 to 1.49; P = 0.70), or to comprehensive care (OR 1.18; 95% CI 0.63 to 2.18; P = 0.61), domiciliary care (OR 1.41; 95% CI 0.82 to 2.42; P = 0.21) or no comprehensive care (OR 0.76; 95% CI 0.56 to 1.05; P = 0.09).For the outcome of death or poor outcome (institutional care, dependency, deterioration in physical function), there was no strong evidence for day hospitals compared to other treatments (OR 0.92; 95% CI 0.74 to 1.15; P = 0.49), or compared to comprehensive care (OR 1.05; 95% CI 0.79 to 1.40; P = 0.74) or domiciliary care (OR 1.08; 95% CI 0.67 to 1.74; P = 0.75). However, compared with no comprehensive care there was a difference in favour of day hospitals (OR 0.72; 95% CI 0.53 to 0.99; P = 0.04).For the outcome of death or institutional care, there was no strong evidence for day hospitals compared to other treatments overall (OR 0.85; 95% CI 0.63 to 1.14; P = 0.28), or to comprehensive care (OR 1.00; 95% CI 0.69 to 1.44; P = 0.99), domiciliary care (OR 1.05; 95% CI 0.57 to1.92; P = 0. 88) or no comprehensive care (OR 0.63; 95% CI 0.40 to 1.00; P = 0.05).For the outcome of deterioration in ADL, there was no strong evidence that day hospital attendance had a different effect than other treatments overall (OR 1.11; 95% CI 0.68 to 1.80; P = 0.67) or compared with comprehensive care (OR 1.21; 0.58 to 2.52; P = 0.61), or domiciliary care (OR 1.59; 95% CI 0.87 to 2.90; P = 0.13). However, day hospital patients showed a reduced odds of deterioration compared with those receiving no comprehensive care (OR 0.61; 95% CI 0.38 to 0.97; P = 0.04) and significant subgroup differences (P = 0.04).For the outcome of requiring institutional care, there was no strong evidence for day hospitals compared to other treatments (OR 0.84; 95% CI 0.58 to 1.21; P = 0.35), or to comprehensive care (OR 0.91; 95% CI 0.70 to 1.19; P = 0.49), domiciliary care (OR 1.49; 95% CI 0.53 to 4.25; P = 0.45), or no comprehensive care (OR 0.58; 95% CI 0.28 to 1.20; P = 0.14). There is low quality evidence that medical day hospitals appear effective compared to no comprehensive care for the combined outcome of death or poor outcome, and for deterioration in ADL. There is no clear evidence for other outcomes, or an advantage over other medical care provision.
    Cochrane database of systematic reviews (Online) 06/2015; 6:CD001730. DOI:10.1002/14651858.CD001730.pub3 · 5.94 Impact Factor
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    ABSTRACT: Stroke-associated pneumonia, a leading cause of hospital-acquired infection after stroke, affects a fifth of stroke survivors annually. Associated with increased risk of death and poorer rehabilitation outcomes, research suggests a possible relationship between stroke-associated pneumonia and patients' oral health. The aim of this study is to evaluate the feasibility of a randomized controlled trial of the clinical and cost effectiveness of enhanced oral healthcare vs. usual oral healthcare for people in stroke care settings. Our pilot, multicentered, pragmatic, stepped wedge, cluster randomized controlled trial oral healthcare [Stroke Oral healthCare pLan Evaluation (SOCLE II)] will compare enhanced oral healthcare intervention and usual oral healthcare. Over 13 months, across 4 wards, we seek to recruit 400 patients (estimating an average of 23 beds per site and a 50% recruitment rate) and 60 nursing staff (estimating an average of 20 members of staff per site and a 75% recruitment rate). Initially, control data (usual oral healthcare) will be collected from all sites. In a randomized, stepped manner, wards will convert to deliver the enhanced oral healthcare intervention. Outcomes will be captured across dimensions of care (as recommended for evaluations of complex interventions) at baseline and weekly thereafter. Primary outcomes are pneumonia (patients), knowledge and attitudes (staff), and specialist dental referrals (service). Secondary outcomes include oral health quality of life, plaque, antibiotics, length of stay, death (patients), use of oral healthcare equipment and products, completed assessments, and documented oral healthcare plans (staff). As one of the first stepped wedge, cluster randomized, controlled trials in stroke care mapping of the complex intervention, our choice of primary and secondary outcomes and choice of trial design are described. © 2015 World Stroke Organization.
    International Journal of Stroke 06/2015; DOI:10.1111/ijs.12530 · 4.03 Impact Factor
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    ABSTRACT: Investigate the perspectives of patients and nursing staff on the implementation of an augmented continence care intervention after stroke. Qualitative data were elicited during semi-structured interviews with patients (n = 15) and staff (14 nurses; nine nursing assistants) and analysed using thematic analysis. Mixed acute and rehabilitation stroke ward. Stroke patients and nursing staff that experienced an enhanced continence care intervention. Four themes emerged from patients' interviews describing: (a) challenges communicating about continence (initiating conversations and information exchange); (b) mixed perceptions of continence care; (c) ambiguity of focus between mobility and continence issues; and (d) inconsistent involvement in continence care decision making. Patients' perceptions reflected the severity of their urinary incontinence. Staff described changes in: (i) knowledge as a consequence of specialist training; (ii) continence interventions (including the development of nurse-led initiatives to reduce the incidence of unnecessary catheterisation among patients admitted to their ward); (iii) changes in attitude towards continence from containment approaches to continence rehabilitation; and (iv) the challenges of providing continence care within a stroke care context including limitations in access to continence care equipment or products, and institutional attitudes towards continence. Patients (particularly those with severe urinary incontinence) described challenges communicating about and involvement in continence care decisions. In contrast, nurses described improved continence knowledge, attitudes and confidence alongside a shift from containment to rehabilitative approaches. Contextual components including care from point of hospital admission, equipment accessibility and interdisciplinary approaches were perceived as important factors to enhancing continence care. © The Author(s) 2015.
    Clinical Rehabilitation 06/2015; DOI:10.1177/0269215515589331 · 2.18 Impact Factor
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    ABSTRACT: Diagnosis of pneumonia complicating stroke is challenging, and there are currently no consensus diagnostic criteria. As a first step in developing such consensus-based diagnostic criteria, we undertook a systematic review to identify the existing diagnostic approaches to pneumonia in recent clinical stroke research to establish the variation in diagnosis and terminology. Studies of ischemic stroke, intracerebral hemorrhage, or both, which reported occurrence of pneumonia from January 2009 to March 2014, were considered and independently screened for inclusion by 2 reviewers after multiple searches using electronic databases. The primary analysis was to identify existing diagnostic approaches for pneumonia. Secondary analyses explored potential reasons for any heterogeneity where standard criteria for pneumonia had been applied. Sixty-four studies (56% ischemic stroke, 6% intracerebral hemorrhage, 38% both) of 639 953 patients were included. Six studies (9%) reported no information on the diagnostic approach, whereas 12 (19%) used unspecified clinician-reported diagnosis or initiation of antibiotics. The majority used objective diagnostic criteria: 20 studies (31%) used respiratory or other published standard criteria; 26 studies (41%) used previously unpublished ad hoc criteria. The overall occurrence of pneumonia was 14.3% (95% confidence interval 13.2%-15.4%; I(2)=98.9%). Occurrence was highest in studies applying standard criteria (19.1%; 95% confidence interval 15.1%-23.4%; I(2)=98.5%). The substantial heterogeneity observed was not explained by stratifying for other potential confounders. We found considerable variation in terminology and the diagnostic approach to pneumonia. Our review supports the need for consensus development of operational diagnostic criteria for pneumonia complicating stroke. © 2015 American Heart Association, Inc.
    Stroke 04/2015; 46(5). DOI:10.1161/STROKEAHA.114.007843 · 6.02 Impact Factor
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    ABSTRACT: The aim of this pilot study was to determine the feasibility of a multicenter, randomized, controlled trial in India of a family-led, trained caregiver-delivered, home-based rehabilitation intervention vs. routine care. A prospective, randomized (within seven-days of hospital admission), blinded outcome assessor, controlled trial of structured home-based rehabilitation delivered by trained and protocol-guided family caregivers (intervention) vs. routine care alone (control) was conducted in patients with residual disability. Key feasibility measures were recruitment, acceptance and adherence to assessment procedures, and follow-up of participants over six-months. CTRI/2014/10/005133. A total of 104 patients from the stroke unit at Christian Medical College, Ludhiana were recruited over nine-months. Recruitment was feasible and accepted by patients and their carers. Important observations were made regarding potential unblinding of the participants, contamination of therapy between the randomized groups, organization of home visits, and resources required for a multicenter study. The pilot study established the feasibility of conducting a large-scale study of family-led, trained caregiver-delivered, home-based stroke rehabilitation in a low resource setting. The main phase of the trial 'ATTEND' is currently underway in over 10 centers in India. © 2015 World Stroke Organization.
    International Journal of Stroke 03/2015; 10(4). DOI:10.1111/ijs.12475 · 4.03 Impact Factor
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    Stroke 02/2015; 46(3). DOI:10.1161/STROKEAHA.114.008295 · 6.02 Impact Factor
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    ABSTRACT: Further research is needed to better identify the methods of evaluating processes and outcomes of stroke care. We investigated whether achieving 4 evidence-based components of a care bundle in a Scotland-wide population with ischemic stroke is associated with 30-day and 6-month outcomes. Using national datasets, we looked at the effect of 4 standards (stroke unit entry on calendar day of admission [day 0] or day following [day 1], aspirin on day 0 or day 1, scan on day 0, and swallow screen recorded on day 0) on mortality and discharge to usual residence, at 30 days and 6 months. Data were corrected for the validated 6 simple variables, admission year, and hospital-level random effects. A total of 36 055 patients were included. Achieving stroke unit admission, swallow screen, and aspirin standards were associated with reduced 30-day mortality (adjusted odds ratio [95% confidence interval]: 0.82 [0.75-0.90], 0.88 [0.77-0.99], and 0.39 [0.35-0.43], respectively). Thirty-day all-cause mortality was higher when fewer standards were achieved, from 0 versus 4 (adjusted odds ratio [95% confidence interval], 2.95 [1.91-4.55]) to 3 versus 4 (adjusted odds ratio [95% confidence interval], 1.21 [1.09-1.34]). This effect persisted at 6 months. When less than the full care bundle was achieved, discharge to usual residence was less likely at 6 months (3 versus 4 standards; adjusted odds ratio [95% confidence interval], 0.91 [0.85-0.98]). Achieving a care bundle for ischemic stroke is associated with reduced mortality at 30 days and 6 months and increased likelihood of discharge to usual residence at 6 months. © 2015 American Heart Association, Inc.
    Stroke 02/2015; 46(4). DOI:10.1161/STROKEAHA.114.007608 · 6.02 Impact Factor
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    ABSTRACT: Background Improvements in stroke management have led to increases in the numbers of stroke survivors over the last decade and there has been a corresponding increase of hospital readmissions after an initial stroke hospitalisation. The aim of this study was to examine the one year risk of having a readmission due to infective, gastrointestinal or immobility (IGI) complications and to identify temporal trends and any risk factors.Methods Using a cohort of first hospitalised for stroke patients who were discharged alive, time to first event (readmission for IGI complications or death) within 1 year was analysed in a competing risks framework using cumulative incidence methods. Regression on the cumulative incidence function was used to model the risks of having an outcome using the covariates age, sex, socioeconomic status, comorbidity, discharge destination and length of hospital stay.ResultsThere were a total of 51,182 patients discharged alive after an incident stroke hospitalisation in Scotland between 1997¿2005, and 7,747 (15.1%) were readmitted for IGI complications within a year of the discharge. Comparing incident stroke hospitalisations in 2005 with 1997, the adjusted risk of IGI readmission did not increase (HR¿=¿1.00 95% CI (0.90, 1.11). However, there was a higher risk of IGI readmission with increasing levels of deprivation (most deprived fifth vs. least deprived fifth HR¿=¿1.16 (1.08, 1.26).Conclusions Approximately 15 in 100 patients discharged alive after an incident hospitalisation for stroke in Scotland between 1997 and 2005 went on to have an IGI readmission within one year. The proportion of readmissions did not change over the study period but those living in deprived areas had an increased risk.
    BMC Neurology 01/2015; 15(1):3. DOI:10.1186/s12883-014-0257-1 · 2.49 Impact Factor
  • International Journal of Stroke 01/2015; 10(1). DOI:10.1111/ijs.12423 · 4.03 Impact Factor
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    ABSTRACT: There are many randomized controlled trials relating to stroke rehabilitation being carried out in China, which are often published in Chinese-language journals. A recent update to our Cochrane systematic review of physical rehabilitation to improve function and mobility after stroke included 96 trials; over half (51) were conducted in China; 37 of these included studies were published in Chinese. Analyses within this Cochrane review support the conclusion that physical rehabilitation, using a mix of components from different approaches, is effective for the recovery of function and mobility after stroke. The inclusion of the Chinese studies had a substantial impact on the volume of evidence and, consequently, the conclusions. In this paper, we explore whether it is appropriate to draw implications for clinical practice throughout the world from evidence relating to a complex rehabilitation intervention delivered within one particular geographical healthcare setting. We explore the unique challenges associated with incorporating the body of evidence from China, particularly the Chinese-language publications, and identify the ongoing debate about the quality of Chinese research publications. We conclude that the growing body of evidence from China has important implications for future systematic reviews and evidence-based stroke care, but analysis and interpretation raise challenges, and improved reporting is critical.
    International Journal of Stroke 12/2014; 9(8). DOI:10.1111/ijs.12339 · 4.03 Impact Factor
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  • Peter Langhorne
    Stroke 11/2014; 45(12). DOI:10.1161/STROKEAHA.114.005805 · 6.02 Impact Factor
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    ABSTRACT: Background The prevalence of multimorbidity (the presence of two or more long-term conditions) is rising internationally. Multimorbidity affects patients by increasing their burden of symptoms, but is also likely to increase the self-care demands, or treatment burden, that they experience. Treatment burden refers to the effort expended in operationalising treatments, navigating healthcare systems and managing relations with healthcare providers. This is an important problem for people with chronic illness such as stroke. Polypharmacy is an important marker of both multimorbidity and burden of treatment. In this study, we examined the prevalence of multimorbidity and polypharmacy in a large, nationally representative population of primary care patients with and without stroke, adjusting for age, sex and deprivation.MethodsA cross-sectional study of 1,424,378 participants aged 18 years and over, from 314 primary care practices in Scotland that were known to be demographically representative of the Scottish adult population. Data included information on the presence of stroke and another 39 long-term conditions, plus prescriptions for regular medications.ResultsIn total, 35,690 people (2.5%) had a diagnosis of stroke. Of the 39 comorbidities examined, 35 were significantly more common in people with stroke. Of the people with a stroke, the proportion that had one or more additional morbidities present (94.2%) was almost twice that in the control group (48%) (odds ratio (OR) adjusted for age, sex and socioeconomic deprivation 5.18; 95% confidence interval (CI) 4.95 to 5.43). In the stroke group, 12.6% had a record of 11 or more repeat prescriptions compared with only 1.5% of the control group (OR adjusted for age, sex, deprivation and morbidity count 15.84; 95% CI 14.86 to 16.88). Limitations include the use of data collected for clinical rather than research purposes, a lack of consensus in the literature on the definition of certain long-term conditions, and the absence of statistical weighting in the measurement of multimorbidity, although the latter was deemed suitable for descriptive analyses.Conclusions Multimorbidity and polypharmacy were strikingly more common in those with a diagnosis of stroke compared with those without. This has important implications for clinical guidelines and the design of health services.
    BMC Medicine 10/2014; 12(1):151. DOI:10.1186/PREACCEPT-1272432928127782 · 7.28 Impact Factor
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    ABSTRACT: Background and Purpose—Guidelines recommend screening stroke-survivors for cognitive impairments. We sought to collate published data on test accuracy of cognitive screening tools. Methods—Index test was any direct, cognitive screening assessment compared against reference standard diagnosis of (undifferentiated) multidomain cognitive impairment/dementia. We used a sensitive search statement to search multiple, cross-disciplinary databases from inception to January 2014. Titles, abstracts, and articles were screened by independent researchers. We described risk of bias using Quality Assessment of Diagnostic Accuracy Studies tool and reporting quality using Standards for Reporting of Diagnostic Accuracy guidance. Where data allowed, we pooled test accuracy using bivariate methods. Results—From 19 182 titles, we reviewed 241 articles, 35 suitable for inclusion. There was substantial heterogeneity: 25 differing screening tests; differing stroke settings (acute stroke, n=11 articles), and reference standards used (neuropsychological battery, n=21 articles). One article was graded low risk of bias; common issues were case–control methodology (n=7 articles) and missing data (n=22). We pooled data for 4 tests at various screen positive thresholds: Addenbrooke’s Cognitive Examination-Revised (<88/100): sensitivity 0.96, specificity 0.70 (2 studies); Mini Mental State Examination (<27/30): sensitivity 0.71, specificity 0.85 (12 studies); Montreal Cognitive Assessment (<26/30): sensitivity 0.95, specificity 0.45 (4 studies); MoCA (<22/30): sensitivity 0.84, specificity 0.78 (6 studies); Rotterdam-CAMCOG (<33/49): sensitivity 0.57, specificity 0.92 (2 studies). Conclusions—Commonly used cognitive screening tools have similar accuracy for detection of dementia/multidomain impairment with no clearly superior test and no evidence that screening tools with longer administration times perform better. MoCA at usual threshold offers short assessment time with high sensitivity but at cost of specificity; adapted cutoffs have improved specificity without sacrificing sensitivity. Our results must be interpreted in the context of modest study numbers: heterogeneity and potential bias.
    Stroke 09/2014; [epub ahead of print](10). DOI:10.1161/STROKEAHA.114.005842 · 6.02 Impact Factor
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    ABSTRACT: Request Permissions in the middle column of the Web page under Services. Further information about this Once the online version of the published article for which permission is being requested is located, click can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Stroke in Requests for permissions to reproduce figures, tables, or portions of articles originally published Permissions: by guest on September 23, 2014 Downloaded from by guest on September 23, 2014 Downloaded from e202 V arious physical rehabilitation approaches may be used to promote recovery of function and mobility after stroke. Controversy and debate about the relative effectiveness of approaches persist. Objectives We aimed to determine whether physical rehabilitation approaches are effective in recovery of function and mobility in people with stroke, and to assess whether any one physical reha-bilitation approach is more effective than any other approach. Methods A stakeholder group, comprising stroke survivors, caregivers, and physiotherapists, made decisions using consensus-making techniques relating to the scope and focus of this updated review. 1 We performed a comprehensive search (to December 2012), 1 in-cluding randomized controlled trials of physical rehabilitation ap-proaches in adult stroke survivors. Interventions comprised a range of philosophically different approaches to promote recovery of function or mobility. Randomized controlled trials of single specific treatments were excluded. Outcomes analyzed were independence in activities of daily living, motor function, balance, gait, and length of stay. Two reviewers independently applied selection criteria, assessed risk of bias and extracted data. We calculated standardized mean dif-ferences (SMD) using a random effects model. Main Results Ninety-six studies (10 401 participants) were included. More than half of the studies (50/96) were performed in China. In general, the studies were heterogeneous, and many were poorly reported. Physical rehabilitation was beneficial, when compared with no treatment, on functional recovery after stroke (27 studies, 3423 participants; SMD=0.78; 95% confidence interval [CI], 0.58– 0.97, for activities of daily living scales), and this effect was noted to persist beyond the length of the intervention period (9 studies, 540 participants; SMD=0.58; 95% CI, 0.11–1.04). This evidence principally arises from studies performed in China. Physical rehabilitation was more effective than usual care or attention control in improving motor function (12 studies, 887 participants; SMD=0.37; 95% CI, 0.20–0.55), balance (5 studies, 246 participants; SMD=0.31; 95% CI, 0.05–0.56), and gait velocity (14 studies, 1126 participants; SMD=0.46; 95% CI, 0.32–0.60). No one physical rehabilitation approach was more (or less) effective than any other approach in improving independence in activities of daily living (8 studies, 491 participants; test for subgroup differences: P=0.71) or motor function (9 studies, 546 participants; test for subgroup differences: P=0.41).
    Stroke 09/2014; Pollock A, Baer G, Campbell P, Choo PL, Forster A, Morris J, Pomeroy VM, Langhorne P. Physical rehabilitation approaches for the recovery of function and mobility after stroke: Major update. Stroke. Published online first: 2nd September 2014 ISSN: 1524-4628.(10). DOI:10.1161/STROKEAHA.114.006275 · 6.02 Impact Factor
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    ABSTRACT: Background and aim Randomised trials indicate that stroke unit care reduces morbidity and mortality after stroke. Similar results have been seen in observational studies but many have not corrected for selection bias or independent predictors of outcome. We evaluated the effect of stroke unit compared with general ward care on outcomes after stroke in Scotland, adjusting for case mix by incorporating the six simple variables (SSV) model, also taking into account selection bias and stroke subtype. Methods We used routine data from National Scottish datasets for acute stroke patients admitted between 2005 and 2011. Patients who died within 3 days of admission were excluded from analysis. The main outcome measures were survival and discharge home. Multivariable logistic regression was used to estimate the OR for survival, and adjustment was made for the effect of the SSV model and for early mortality. Cox proportional hazards model was used to estimate the hazard of death within 365 days. Results There were 41 692 index stroke events; 79% were admitted to a stroke unit at some point during their hospital stay and 21% were cared for in a general ward. Using the SSV model, we obtained a receiver operated curve of 0.82 (SE 0.002) for mortality at 6 months. The adjusted OR for survival at 7 days was 3.11 (95% CI 2.71 to 3.56) and at 1 year 1.43 (95% CI 1.34 to 1.54) while the adjusted OR for being discharged home was 1.19 (95% CI 1.11 to 1.28) for stroke unit care. Conclusions In routine practice, stroke unit admission is associated with a greater likelihood of discharge home and with lower mortality up to 1 year, after correcting for known independent predictors of outcome, and excluding early non-modifiable mortality.
    Journal of neurology, neurosurgery, and psychiatry 06/2014; DOI:10.1136/jnnp-2013-307478 · 5.58 Impact Factor
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    ABSTRACT: Background and Purpose-Extended cardiac monitoring immediately after acute ischemic stroke (AIS) increases paroxysmal atrial fibrillation (PAF) detection, but its reliability for detection or exclusion of longer term paroxysmal PAF is unknown. We evaluated the positive and negative predictive value (PPV and NPV) of AF detection early after AIS, for PAF confirmation 90 days later. Methods-We investigated 49 patients within 7 days of AIS for PAF according to current guidelines; 23 patients received 7 days of additional noninvasive cardiac event monitoring with an R-test device early after their stroke (ISRCTN 97412358). Ninety days after AIS, everyone underwent 7 days of cardiac event monitoring. We calculated the PPV and NPV of immediate PAF detection through extended cardiac event monitoring and through any investigative modality, for the presence of PAF on the 90-day event monitor. Results-PAF detected by a 7-day event monitor within 2 weeks of AIS had a PPV of 100% (95% confidence interval, 72%-100%) for PAF confirmation after 90 days. NPV after 7 days of event monitoring was 64% (95% confidence interval, 35%-87%). PAF detected early through any modality had a PPV of 100% (95% confidence interval, 76%-100%). However, the NPV in the absence of R-test monitoring was only 42% (95% confidence interval, 28%-58%). Conclusions-AF detection through any means immediately after stroke holds strong PPV for confirmation after 90 days, justifying treatment decisions on early monitoring alone. However, failure to identify AF through early monitoring has only modest NPV even after 7 days of monitoring; repeated investigation is desirable.
    Stroke 06/2014; 45(7). DOI:10.1161/STROKEAHA.114.005405 · 6.02 Impact Factor
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    ABSTRACT: Standing up from a seated position is one of the most frequently performed functional tasks, is an essential pre-requisite to walking and is important for independent living and preventing falls. Following stroke, patients can experience a number of problems relating to the ability to sit-to-stand independently.
    Cochrane database of systematic reviews (Online) 05/2014; 5(5):CD007232. DOI:10.1002/14651858.CD007232.pub4 · 5.70 Impact Factor
  • Cochrane database of systematic reviews (Online) 04/2014; · 5.94 Impact Factor

Publication Stats

8k Citations
1,562.23 Total Impact Points


  • 1999–2015
    • University of Glasgow
      • Institute of Cardiovascular and Medical Sciences
      Glasgow, Scotland, United Kingdom
  • 2014
    • Oxford University Hospitals NHS Trust
      Oxford, England, United Kingdom
  • 2013
    • The University of Manchester
      • Centre for Vascular and Stroke Research
      Manchester, ENG, United Kingdom
  • 2012
    • Akademia Wychowania Fiycznego im. Jergo Kukuczki w Katowicach
      Catowice, Silesian Voivodeship, Poland
  • 2007
    • King's College London
      Londinium, England, United Kingdom
    • University of Florence
      • Dipartimento di Neuroscienze, Psicologia, Area del Farmaco e Salute del Bambino
      Florence, Tuscany, Italy
  • 2002–2007
    • The Bracton Centre, Oxleas NHS Trust
      Дартфорде, England, United Kingdom
    • UK Department of Health
      Londinium, England, United Kingdom
  • 2006
    • University of East Anglia
      Norwich, England, United Kingdom
  • 2004
    • The University of Northampton
      Northampton, England, United Kingdom
  • 1994–2001
    • Western General Hospital
      Edinburgh, Scotland, United Kingdom