Cuttlefish use stereopsis to strike at prey.

The camera-type eyes of vertebrates and cephalopods exhibit remarkable convergence, but it is currently unknown whether the mechanisms for visual information processing in these brains, which exhibit wildly disparate architecture, are also shared. To investigate stereopsis in a cephalopod species, we affixed "anaglyph" glasses to cuttlefish and used a three-dimensional perception paradigm. We show that (i) cuttlefish have also evolved stereopsis (i.e., the ability to extract depth information from the disparity between left and right visual fields); (ii) when stereopsis information is intact, the time and distance covered before striking at a target are shorter; (iii) stereopsis in cuttlefish works differently to vertebrates, as cuttlefish can extract stereopsis cues from anticorrelated stimuli. These findings demonstrate that although there is convergent evolution in depth computation, cuttlefish stereopsis is likely afforded by a different algorithm than in humans, and not just a different implementation.

Lipomodelling for the management of symptomatic peristomal contour abnormalities: a pilot and feasibility study.

AIM: Lipomodelling has been successfully used in reconstructive breast surgery but not yet in patients with permanent stomas. METHOD: A feasibility study of six patients with permanent stomas was undertaken. Patients underwent lipomodelling of the peristomal area. The number of leakages and quality of life were measured before and for 6 months after the procedure. RESULTS: All patients reported an improvement in their stoma-related quality of life and a reduction in the number of leakages experienced (mean: 2.25 leakages/24 h before lipomodelling and 0.5 leakages/24 h after lipomodelling). CONCLUSION: Lipomodelling appears to be an effective method to reduce stoma leakages caused by peristomal skin contour abnormalities.

Introducing structured caregiver training in stroke care: findings from the TRACS process evaluation study.

OBJECTIVE: To evaluate the process of implementation of the modified London Stroke Carers Training Course (LSCTC) in the Training Caregivers After Stroke (TRACS) cluster randomised trial and contribute to the interpretation of the TRACS trial results. The LSCTC was a structured competency-based training programme designed to help develop the knowledge and skills (eg, patient handling or transfer skills) essential for the day-to-day management of disabled survivors of stroke. The LSCTC comprised 14 components, 6 were mandatory (and delivered to all) and 8 non-mandatory, to be delivered based on individual assessment of caregiver need. DESIGN: Process evaluation using non-participant observation, documentary analysis and semistructured interviews. PARTICIPANTS: Patients with stroke (n=38), caregivers (n=38), stroke unit staff (n=53). SETTINGS: 10 of the 36 stroke units participating in the TRACS trial in four English regions (Yorkshire, North West, South East and South West, Peninsula). RESULTS: Preparatory cascade training on delivery of the LSCTC did not reach all staff and did not lead to multidisciplinary team (MDT) wide understanding of, engagement with or commitment to the LSCTC. Although senior therapists in most intervention units observed developed ownership of the LSCTC, MDT working led to separation rather than integration of delivery of LSCTC elements. Organisational features of stroke units and professionals' patient-focused practices limited the involvement of caregivers. Caregivers were often invited to observe therapy or care being provided by professionals but had few opportunities to make sense of, or to develop knowledge and stroke-specific skills provided by the LSCTC. Where provided, caregiver training came very late in the inpatient stay. Assessment and development of caregiver competence was not commonly observed. CONCLUSIONS: Contextual factors including service improvement pressures and staff perceptions of the necessity for and work required in caregiver training impacted negatively on implementation of the caregiver training intervention. Structured caregiver training programmes such as the LSCTC are unlikely to be practical in settings with short inpatient stays. Stroke units where early supported discharge is in place potentially offer a more effective vehicle for introducing competency based caregiver training. LINKED TRACS CLUSTER RANDOMISED CONTROLLED TRIAL NUMBER: ISRCTN49208824.

A cluster randomised controlled trial and economic evaluation of a structured training programme for caregivers of inpatients after stroke: the TRACS trial.

BACKGROUND: The majority of stroke patients are discharged home dependent on informal caregivers, usually family members, to provide assistance with activities of daily living (ADL), including bathing, dressing and toileting. Many caregivers feel unprepared for this role and this may have a detrimental effect on both the patient and caregiver. OBJECTIVE: To evaluate whether or not a structured, competency-based training programme for caregivers [the London Stroke Carer Training Course (LSCTC)] improved physical and psychological outcomes for patients and their caregivers after disabling stroke, and to determine if such a training programme is cost-effective. DESIGN: A pragmatic, multicentre, cluster randomised controlled trial. SETTING: Stratified randomisation of 36 stroke rehabilitation units (SRUs) to the intervention or control group by geographical region and quality of care. PARTICIPANTS: A total of 930 stroke patient and caregiver dyads were recruited. Patients were eligible if they had a confirmed diagnosis of stroke, were medically stable, were likely to return home with residual disability at the time of discharge and had a caregiver available, willing and able to provide support after discharge. The caregiver was defined as the main person--other than health, social or voluntary care provider--helping with ADL and/or advocating on behalf of the patient. INTERVENTION: The intervention (the LSCTC) comprised a number of caregiver training sessions and competency assessment delivered by SRU staff while the patient was in the SRU and one recommended follow-up session after discharge. The control group continued to provide usual care according to national guidelines. Recruitment was completed by independent researchers and participants were unaware of the SRUs' allocation. MAIN OUTCOME MEASURES: The primary outcomes were self-reported extended ADL for the patient and caregiver burden measured at 6 months after recruitment. Secondary outcomes included quality of life, mood and cost-effectiveness, with final follow-up at 12 months. RESULTS: No differences in primary outcomes were found between the groups at 6 months. Adjusted mean differences were -0.2 points [95% confidence interval (CI) -3.0 to 2.5 points; p = 0.866; intracluster correlation coefficient (ICC) = 0.027] for the patient Nottingham Extended Activities of Daily Living score and 0.5 points (95% CI -1.7 to 2.7 points; p = 0.660; ICC = 0.013) for the Caregiver Burden Scale. Furthermore, no differences were detected in any of the secondary outcomes. Intervention compliance varied across the units. Half of the participating centres had a compliance rating of > 60%. Analysis showed no evidence of higher levels of patient independence or lower levels of caregiver burden in the SRUs with better levels of intervention compliance. The economic evaluation suggests that from a patient and caregiver perspective, health and social care costs, societal costs and outcomes are similar for the intervention and control groups at 6 months, 12 months and over 1 year. CONCLUSIONS: We have conducted a robust multicentre, cluster randomised trial, demonstrating for the first time that this methodology is feasible in stroke rehabilitation research. There was no difference between the LSCTC and usual care with respect to improving stroke patients' recovery, reducing caregivers' burden, or improving other physical and psychological outcomes, nor was it cost-effective compared with usual care. Compliance with the intervention varied, but analysis indicated that a dose effect was unlikely. It is possible that the immediate post-stroke period may not be the ideal time for the delivery of structured training. The intervention approach might be more relevant if delivered after discharge by community-based teams. TRIAL REGISTRATION: Current Controlled Trials ISRCTN49208824. FUNDING: This project was funded by the MRC and is managed by the NIHR (project number 09/800/10) on behalf of the MRC-NIHR partnership, and will be published in full in Health Technology Assessment; Vol. 17, No. 46. See the NIHR Journals Library website for further project information.

Role of lipomodelling in improving aesthetic outcomes in patients undergoing immediate and delayed reconstructive breast surgery.

AIMS: The objective of this article is to report our findings regarding large-volume fat transfer in patients who have undergone autologous breast reconstruction with the latissimus dorsi (LD) flap and/or implant-based reconstruction with subsequent lipomodelling for symmetrisation. METHODS: We retrospectively collected data on all patients who have undergone lipomodelling from October 2008 to October 2011. Fat was harvested using a low-negative pressure syringe method and centrifuged at 3000 r.p.m. for 3 min. The purified fat was injected in 1 mL increments into multilayered microtunnels, starting from deeper layers and moving to superficial layers in the subcutaneous tissue. Patient satisfaction was assessed using validated Picker questions in a face-to-face consultation during follow-up visits, and the results were documented in the case notes. RESULTS: Thirty-one patients underwent lipomodelling following autologous breast reconstruction using the LD flap and implant-based reconstruction. Three patients in the study group had bilateral lipomodelling, and one patient required 3 lipomodelling sessions. Seven patients required 2 sessions, and 21 patients required a single session to achieve bilateral symmetry. The mean volume of fat that was harvested was 396 mL, and the mean injected volume of fat was 247 mL. Four patients (1 breast cancer recurrence, 2 patients with fat necrosis and 1 patient with oil cysts) developed postoperative complications. Twenty-nine patients (93%) were satisfied with the postoperative cosmetic outcome. CONCLUSION: Lipomodelling offers an additional tool to refine breast reconstructive surgery. This study demonstrates that large volumes of fat can be injected for sculpture optimisation and for reshaping reconstructed breasts with improved softness and a natural feel.

Parastomal hernia as a consequence of colorectal cancer resections can prophylactically be controlled by mesh insertion at the time of primary surgery: a literature based systematic review of published trials.

AIM: The objective of this article was to systematically analyze the randomized, controlled trials (RCTs) evaluating the role of mesh in the prevention of parastomal hernia (PSH) at the time of primary colorectal resections. METHODS: RCTs evaluating the role of mesh in the prevention of parastomal hernia (PSH) at the time of primary colorectal resections were analysed using RevMan®, and combined outcomes were expressed as odds ratio (OR) and standardized mean difference (SMD). RESULTS: Three RCTs encompassing 128 patients were retrieved for the electronic databases. There were 64 patients in the mesh group and 64 patients in the no-mesh group. In the fixed effects model, the risk of developing postoperative complications (OR, 1.0; 95% CI, 0.36, 3.20; z=0.0; =1.0) was statistically similar after using mesh for PSH prevention at the time of primary colorectal resection and stoma construction in both groups. However, the risk of developing PSH (OR, 0.11; 95% CI, 0.05, 0.27; z=4.88; P<0.00001) was significantly lower after using mesh and mesh insertion to prevent PSH development statistically did not influence (SMD, -0.42; 95% CI, -0.96, 0.12; z=1.51; P=0.13) the duration of operation. CONCLUSION: The incidence of PSH can be reduced by the insertion of mesh at stoma site at the time of primary stoma construction. A major multicentre RCT recruiting higher number of patients and longer follow up is required before recommending the routine use of mesh for PSH prevention.

A meta-analysis examining the use of tacker fixation versus no-fixation of mesh in laparoscopic inguinal hernia repair.

OBJECTIVE: The objective of this article is to systematically analyse the randomised, controlled trials comparing tacker mesh fixation (TMF) versus no-mesh fixation (NMF) in laparoscopic inguinal hernia repair (LIHR). METHODS: Randomised, controlled trials comparing TMF versus NMF in LIHR were analysed systematically using RevMan(®), and combined outcomes were expressed as risk ratio (RR) and standardised mean difference (SMD). RESULTS: Eight randomised, controlled trials encompassing 1386 patients were retrieved from the electronic databases. There were 691 patients in the TMF group and 695 patients in the NMF group. Statistically there was non-significant heterogeneity among trials. In random effects models, operating time (p = 0.15), post-operative pain (p = 0.45), post-operative complications (p = 0.55) and length of hospital stay (p = 0.11) were statistically comparable between two techniques of mesh fixation in LIHR. The risk of developing chronic groin pain (p = 0.67) and risk of hernia recurrence (p = 0.77) was also similar. CONCLUSION: NMF in LIHR does not increase the risk of hernia recurrence. It is comparable with TMF in terms of operation time, post-operative pain, post-operative complications, length of hospital stay and chronic groin pain. Therefore, based upon the results of this review NMF approach may be adopted routinely and safely in LIHR.

Acute ischaemic hemispheric stroke is associated with impairment of reflex in addition to voluntary cough.

Cough function is impaired after stroke; this may be important for protection against chest infection. Reflex cough (RC) intensity indices have not been described after stroke. RC, voluntary cough (VC) and respiratory muscle strength were studied in patients within 2 weeks of hemispheric infarct. The null hypotheses were that patients with cortical hemisphere stroke would show the same results as healthy controls on: 1) objective indices of RC and VC intensity; and 2) respiratory muscle strength tests. Peak cough flow rate (PCFR) and gastric pressure (P(ga)) were measured during maximum VC and RC. Participants also underwent volitional and nonvolitional respiratory muscle testing. Nonvolitional expiratory muscle strength was assessed by measuring P(ga) increase after magnetic stimulation over the T10 nerve roots (twitch T10 P(ga)). Stroke severity was scored using the National Institutes of Health Stroke Scale (NIHSS; maximum = 31). 18 patients (mean ± sd age 62 ± 15 yrs and NIHSS score 14 ± 8) and 20 controls (56 ± 16 yrs) participated. VC intensity was impaired in patients (PCFR 287 ± 171 versus 497 ± 122 L·min⁻¹) as was VC P(ga) (98.5 ± 61.6 versus 208.5 ± 61.3 cmH2O; p < 0.001 for both). RC PCFR was reduced in patients (204 ± 111 versus 379 ± 110 L·min⁻¹; p < 0.001), but RC P(ga) was not significantly different from that of controls (179.0 ± 78.0 versus 208.0 ± 77.4 cmH2O; p = 0.266). Patients exhibited impaired volitional respiratory muscle tests, but twitch T10 P(ga) was normal. VC and RC are both impaired in hemispheric stroke patients, despite preserved expiratory muscle strength. Cough coordination is probably cortically modulated and affected by hemispheric stroke.

Hypertension-related cognitive decline: is the time right for intervention studies?

The importance of lowering blood pressure in hypertensive subjects is well known but the relationship between hypertension and cognitive function has been a subject of considerable controversy. Cross-sectional studies investigating the relationship between blood pressure and cognition have shown conflicting relationships whilst the majority of longitudinal studies have demonstrated elevated blood pressure to be associated with cognitive decline. Randomised studies have demonstrated heterogeneous and sometimes conflicting effects of blood pressure lowering on cognitive function and suggested reasons include multiple mechanisms by which hypertension affects the brain, the variety of cognitive instruments used for assessment and differences in antihypertensive treatments. Chronic hypertension accelerates arteriosclerotic changes in the brain with a disproportionate effect on subcortical circuits associated with cerebral small vessel disease. Randomised clinical trials assessing the cognitive consequences of blood pressure reduction in people with small vessel disease are lacking and many of the existing controversies on the cognitive consequences of blood pressure lowering, especially in older people, arise from the design limitations of studies. This article describes the methodological issues in designing such a trial and the results of a pilot evaluation to see if careful selection of subjects and measurements would make undertaking intervention studies feasible. Given the predicted upswing in people with cognitive impairments, the time is right for randomised clinical trials with specific cognitive end-points to examine the relationship between cognitive function and hypertension and guide practice.

Cerebrovascular reactivity and dynamic autoregulation in ischaemic subcortical white matter disease.

BACKGROUND: It has been suggested that impaired cerebral autoregulation and vasodilatory capacity may play in role in the pathogenesis of the leukoaraiosis seen in small vessel disease. Adequate perfusion of the deep white matter of the brain depends on the relationships between blood pressure (BP), cerebral vasoreactivity and autoregulation. METHODS: 24 h ambulatory BP measurement, quantitative volumetric MRI analysis of white matter lesion (WML) volume and transcranial Doppler ultrasound assessments of CO(2) reactivity in response to hypercapnia and dynamic cerebral autoregulatory index (ARI) were undertaken in 64 patients with cerebral small vessel disease. RESULTS: Subjects had mean 24 h BP 133/76 mm Hg (SD 13/9), median WML volume 7169 (IQR 20497) mm(3), mean CO(2) reactivity 83.6 (SD 37.4)% and mean ARI 5.6 (SD 1.4) (range 0-9). In multivariate models, after adjusting for age, gender, vascular risk profile and WML volume, ARI correlated with 24 h mean BP levels (R(2) = 0.127, t = 2.440, p = 0.019) and CO(2) reactivity correlated with duration of hypertension (R(2) = 0.085, t = -2.244, p = 0.029). In individuals with hypertension for more than 10 years, ARI also correlated with nocturnal BP dipping (r = 0.806, p = 0.002). ARI and CO(2) reactivity were unaffected by WML volumes, and ARI and CO(2) reactivity were unrelated. CONCLUSION: Cerebral autoregulation and CO(2) reactivity are two distinct processes which are not related to WML volume but are related to BP levels and duration of hypertension, respectively. Greater nocturnal dipping was associated with higher ARI values, suggesting preservation of autoregulation in patients with increased vulnerability to reduced cerebral perfusion.

Cognitive function and hypertension.

The importance of lowering blood pressure (BP) in hypertensive subjects is well known but the relationship between hypertension and cognitive function is controversial. This article reviews the role of hypertension in the aetiology of cognitive impairment and the relationships between BP, cerebral perfusion and cognition. It also summarizes findings of studies addressing the effect of antihypertensive therapy and cognition. An electronic database search of MEDLINE, EMBASE and the Cochrane Library and extensive manual searching of articles were conducted to identify studies that have used objective measurements of BP and neuropsychological tests to investigate the relationship among hypertension, cognitive function and/or antihypertensive treatment. In total, 28 cross-sectional studies, 22 longitudinal studies and 8 randomized placebo-controlled trials met the inclusion criteria. Cross-sectional studies showed mixed relationships between higher BP and cognition, with many studies showing no correlation or even J- or U-shaped associations. The majority of longitudinal studies demonstrated elevated BP to be associated with cognitive decline. Randomized studies demonstrated heterogeneous and, sometimes conflicting, effects of BP lowering on cognitive function. Suggested reasons for this heterogeneity include multiple mechanisms by which hypertension affects the brain, the variety of cognitive instruments used for assessment and differences in antihypertensive treatments. Although lowering the BP is beneficial in most patients with vascular risk factors, the effects of BP reduction on cognition remain unclear. Given the predicted upswing in people with cognitive impairments, the time is right for randomized clinical trials with specific cognitive end points to examine the relationship between cognitive function and hypertension and guide practice.

Transcranial magnetic stimulation study of expiratory muscle weakness in acute ischemic stroke.

BACKGROUND: Expiratory muscle weakness due to cerebral infarction may contribute to reduced airway clearance in stroke patients. METHODS: Transcranial magnetic stimulation (TMS) at the vertex and over each hemisphere and magnetic stimulation over the T(10-11) spinal roots (Tw T(10)) and the phrenic nerves bilaterally (BAMPS) were performed in 15 acute ischemic stroke patients (age 68.9 +/- 9.8 years) and 16 matched controls. Surface electrodes recorded motor evoked potentials (MEPs) in the rectus abdominis (RA) and external oblique (EO) muscles bilaterally. Respiratory muscle function was assessed by measuring maximum static expiratory pressure (PE(max)) and changes in intragastric (P(gas)) and transdiaphragmatic (P(di)) pressure after voluntary cough, TMS, TwT(10), and BAMPS. Regression models were used to assess determinants of peak voluntary cough flow rates (PCFR). RESULTS: PCFR, cough P(gas), and vertex TMS P(gas) were decreased in stroke patients compared with controls (203.6 +/- 151.1 vs 350.8 +/- 111.7 L/min, p = 0.004; 72.7 +/- 64.5 vs 163.4 +/- 55.8 cm H(2)O, p = 0.0003 and 8.7 +/- 3.3 vs 16.7 +/- 11.5 cm H(2)O, p = 0.023, respectively). There were no differences in TwT(10) P(gas) (25.2 +/- 7.8 vs 29.4 +/- 12.4 cm H(2)O, p = 0.153) or BAMPS P(di) (21.6 +/- 7.2 vs 19.2 +/- 3.4 cm H(2)O, p = 0.163). TMS P(gas) was lower (4.1 +/- 2.8 vs 6.1 +/- 1.9 cm H(2)O, p = 0.023) following TMS of the injured compared with the uninjured hemisphere in stroke patients. Age and gender adjusted PCFR correlated with P(gas) (r = 0.51, p = 0.009) and PE(max) (r = 0.46, p = 0.024). Stroke was an independent determinant of PCFR after adjusting for P(gas) and PE(max) (p = 0.031). CONCLUSION: Ischemic cortical injury is associated with expiratory muscle weakness and may contribute to cough impairment in stroke patients.

Thrombolytic therapy for acute stroke in the United Kingdom: experience from the safe implementation of thrombolysis in stroke (SITS) register.

AIM: To describe the United Kingdom (UK) experience with thrombolytic therapy with intravenous alteplase (rt-PA) for stroke, as captured by the Implementation of Thrombolysis in Stroke (SITS) project. METHODS: The multinational Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) was an observational study to assess the safety and efficacy of thrombolytic therapy, when administered within the first 3 h after onset of ischaemic stroke. SITS-MOST was embedded within the Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register (SITS-ISTR), an internet-based, international monitoring registry for auditing the safety and efficacy of routine therapeutic use of thrombolysis in acute ischaemic stroke. We performed an analysis of data contributed to SITS-MOST and SITS-ISTR from UK centres. RESULTS: A total of 614 patients received thrombolysis for stroke between December 2002 and April 2006, 327 were registered to SITS-MOST and 287 to SITS-ISTR. Thirty-one centres treated patients in the UK, of which 23 registered patients in both SITS-MOST and SITS-ISTR and eight solely to SITS-ISTR. The median age from the UK SITS-MOST was identical to the non-UK SITS-MOST register: 68 years (IQR 59-75). The majority (96.1%) of patients from the UK were treated between 8.00 a.m. and 9.00 p.m., and only 18.4% were treated on weekend days, reflecting the difficulties of maintaining provision of a thrombolytic service out of hours. Median onset-to-treatment-time was 155 min (IQR 130-170 min) for the UK, compared to 140 min (IQR 114-165 min) for the non-UK SITS-MOST group (P < 0.001). UK SITS-MOST patients at baseline had more severe stroke in comparison with non-UK patients [median NIHSS 14.5 (IQR 9-19) vs. 12 (IQR 8-17) (P < 0.001)]. Forty-eight percent of UK patients achieved mRS of 0-2 (independence), compared to 55% of the non-UK SITS-MOST register. There was no significant difference in symptomatic intracerebral haemorrhage rate in the UK compared with the non-UK SITS-MOST patients [2.5% (95% CI 1.3-4.8) vs. 1.7% (95% CI 1.4-2.0) P = 0.28]. In the multivariate analysis, there was no statistically significant difference in any outcome between UK and non-UK SITS-MOST patients. CONCLUSION: Thrombolytic therapy for stroke has been implemented successfully at a small number of UK stroke centres, with patchy provision throughout the country. The low frequency of treatment out with office hours suggests deficient infrastructure to support delivery. UK patients tended to be more severely affected at baseline and to be treated later. Outcomes are comparable to those seen at the non-UK SITS centres.

Homocysteine, migration and early vascular impairment in people of African descent.

OBJECTIVES: A gradient of increased vascular risk with migration exists across the African diaspora. We investigated the hypothesis that differences in homocysteine/folic acid status contribute to this increased risk. DESIGN: Community cohort study of 73 Afro-Caribbeans in the United Kingdom and 151 matched Afro-Caribbeans in Jamaica with no conventional vascular risk factors. METHODS: Subjects were compared for baseline characteristics, vascular risk profile, homocysteine (tHcy), folate and B(12) concentrations. Endothelium-dependent vasodilatation was assessed by measuring the absolute change from baseline in the reflection index (RI) of the digital volume pulse during intravenous infusion of albuterol (5 microg/min, Delta RI(ALB)) and glyceryltrinitrate (GTN) (5 microg/min, Delta RI(GTN)). Carotid intima media thickness (CIMT) was measured ultrasonographically in the distal 1 cm of the common carotid artery. RESULTS: UK Afro-Caribbeans had higher tHcy (mean difference 2.3 (95% confidence interval 1.3 to 3.4) micromol/l) and lower folate (mean difference 3.2 (95% CI 1.8 to 4.7) microg/l) levels. Delta RI(ALB) was 5.1 (95% CI 2.5 to 7.6) percentage points lower and CIMT 0.124 (95% CI 0.075 to 0.173) mm greater in UK Afro-Caribbeans. Higher tHcy and lower folate concentrations correlated with impaired Delta RI(ALB) and increased CIMT. A 1 microg/l increase in folate concentration was associated with 0.3 (95% CI 0.1 to 0.5) percentage point increase in Delta RI(ALB) and 0.002 (95% CI 0.001 to 0.006) mm decrease in CIMT, independent of blood pressure, smoking and vascular risk profile. CONCLUSIONS: Lower folate concentrations in UK compared with West Indian African-Caribbeans may contribute to the higher stroke risk seen in UK African-Caribbean people.

Differences in motor activation of voluntary and reflex cough in humans.

OBJECTIVES: To study motor activation patterns of voluntary and reflex cough adjusted for cough flow rates. METHODS: Surface electromyography (EMG) and cough flow rate were measured in 10 healthy volunteers. Voluntary cough was assessed for 20 efforts in each quintile of increasing cough flow rate. Reflex cough was assessed for 25 efforts produced by nebulised l-tartaric acid. EMG was recorded over the expiratory (rectus abdominis, obliques, lower intercostals) and accessory (trapezius, pectoralis major, deltoid, latissimus dorsi) muscles. EMG activity, burst duration and onset were compared for each quintile of voluntary cough, and between voluntary and reflex cough matched for cough flow rate. RESULTS: EMG activity and burst duration of expiratory and accessory muscles during voluntary cough increased in proportion to cough flow. Expiratory muscles had longer EMG burst duration (difference 68 ms (95% CI 34 to 102), p<0.01) and earlier onset of EMG activity (difference 44 ms (95% CI 20 to 68), p<0.0001) compared with accessory muscles. EMG activity in all muscles was increased (mean 110.2% v 56.1%, p<0.001) and burst duration (mean 206 ms v 280 ms, p = 0.013) decreased in reflex cough compared with voluntary cough of equal flow rate. There were no differences in EMG onset (difference 8 ms (95% CI 25 to -9) or burst duration (difference 27 ms (95% CI 58 to -4) between expiratory and accessory muscles. CONCLUSIONS: Functional organisation of motor activity differs between voluntary and reflex cough. Voluntary cough is characterised by sequential activation whereas reflex cough is associated with early and simultaneous activation of expiratory and accessory muscles.

Is stroke unit care portable? A systematic review of the clinical trials.

BACKGROUND: It is not known if mobile stroke teams can achieve the good results seen in trials of geographically discrete stroke wards (stroke units). OBJECTIVE: To establish the effectiveness of mobile stroke teams. DESIGN: Systematic review of controlled clinical trials that compared peripatetic systems of organised stroke care (stroke team care) with alternative hospital services. METHODS: Systematic review and meta-analysis (using Cochrane Collaboration methodology and involving the primary trialists). Clinical outcomes included death, dependency, the need for institutional care and measures of the process of care such as the delivery of key investigations and treatments. RESULTS: Six clinical trials (1,085 patients) were identified; five (781 patients) compared some form of stroke team care with conventional care in general medical wards and one (304 patients) compared team care with a comprehensive stroke unit. Compared with care in general wards, stroke team care improved some aspects of the process of care, but clinical outcomes were similar. Compared with a comprehensive stroke unit, stroke team patients were significantly less likely to survive (P <0.001), return home (P < 0.001) or regain independence (P < 0.0001). Most aspects of the process of care were also poorer than in the stroke unit. CONCLUSIONS: Care from a mobile stroke team had no major impact on death, dependency or the need for institutional care.

A randomised controlled comparison of alternative strategies in stroke care.

OBJECTIVES: To compare outcomes between stroke patients managed on the stroke unit, on general wards with stroke team support or at home by specialist domiciliary team and to derive prognostic variables that will identify patients most suitable for management by each strategy. To describe organisational aspects of individual strategies of stroke care and to evaluate cost-effectiveness of each strategy and its acceptability to patients, carers and professionals. DESIGN: Prospective single-blind randomised controlled trial undertaken in patients recruited from a community-based stroke register. SETTING: Suburban district in south-east England. PARTICIPANTS: Patients with disabling stroke who could be supported at home. INTERVENTIONS: The stroke unit gave 24-hour care provided by specialist multidisciplinary team based on clear guidelines for acute care, prevention of complications, rehabilitation and secondary prevention. The stroke team provided management on general wards with specialist team support. The team undertook stroke assessments and advised ward-based nursing and therapy staff on acute care, secondary prevention and rehabilitation aspects. Domiciliary care involved management at home under the supervision of a GP and stroke specialist with support from specialist team and community services. Support was provided for a maximum of 3 months. MAIN OUTCOME MEASURES: The primary measure was death or institutionalisation at 1 year. Secondary measures were dependence, functional abilities, mood, quality of life, resource use, length of hospital stay, and patient, carer and professional satisfaction. RESULTS: Of the 457 patients randomised, 152 patients were allocated to the stroke unit; 152 patients to stroke team and 153 patients to domiciliary stroke care (average age 76 years, 48% women). The groups were well matched for baseline characteristics, stroke type and severity, level of impairment and initial disability. Fifty-one (34%) patients in the domiciliary group were admitted to hospital after randomisation. Mortality and institutionalisation at 1 year were lower on stroke unit compared with stroke team or domiciliary care. Significantly fewer patients on the stroke unit died compared with those managed by the stroke team. The proportion of patients alive without severe disability at 1 year was also significantly higher on the stroke unit compared with stroke team or domiciliary care. These differences were present at 3 and 6 months after stroke. Stroke survivors managed on the stroke unit showed greater improvement on basic activities of daily living compared with other strategies. Achievement of higher levels of function was not influenced by strategy of care. Quality of life at 3 months was significantly better in stroke unit and domiciliary care patients. There was greater dissatisfaction with care on general wards compared with stroke unit or domiciliary care. Poor outcome with domiciliary care and on general wards was associated with Barthel Index <5, incontinence and, on general wards, age over 75 years. The total costs of stroke per patient over the 12-month period were pound 11,450 for stroke unit, pound 9527 for stroke team and pound 6840 for home care. However, the mean costs per day alive for the stroke unit were significantly less than those for the specialist stroke team patients, but no different from domiciliary care patients. Costs for the domiciliary group were significantly less than for those managed by the specialist stroke team on general wards. CONCLUSIONS: Stroke units were found to be more effective than a specialist stroke team or specialist domiciliary care in reducing mortality, institutionalisation and dependence after stroke. A role for specialist domiciliary services for acute stroke is not supported by this study. Management of patients with strokes on general medical wards, even with specialist team input, is not supported by this study. The stroke unit intervention was less costly per patient day alive and more effective than the stroke team intervention. The stroke unit was more effective and of equivalent cost when compared to home care. Hence, the stroke unit is a more cost-effective intervention than either stroke team or home care. Further research is needed to understand processes contributing to the reduction in mortality on stroke units and to determine the generalisability of these results and the factors that will influence the implementation of the findings of this study in clinical practice.