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Inken Padberg,1 Benjamin Hotter,1,2 Andrea Liebenau,1 Petra Knispel,1,3 Sophie Lehnerer,1,2 Sabine Heel,4 Ian Wellwood,5 Andreas Meisel1–3 1Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany; 2Neurocure Clinical Research Center, Department of Neurology, Charité Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany; 3Berliner Schlaganfall-Allianz e.V., Berlin, Germany; 4Zentrum für Ambulante Neuropsychologie und Verhaltenstherapie (ZANV), Berlin, Germany; 5Department of Public-Health and Primary Care, University of Cambridge, Cambridge, UKCorrespondence: Inken Padberg Tel +49 30 450 560142Fax +49 30 450 560952Email inken.padberg@charite.dePurpose: Details on adequate care and prevalence of depression in long-term stroke aftercare are limited. We aimed to determine long-term depression rates after stroke and to test for an association between depression and inadequate screening, socio-economic complications and lack of sub-optimal care.Patients and Methods: In this cross-sectional study, 57 patients were re-invited into the clinic 2– 3 years after stroke. Patients were interviewed about recalled screening concerning depression and unmet needs. Depression, the patient’s social situation, and confounders were assessed by standardized scores.Results: In our study, 20% (n = 11) of patients were classified as depressed by the HDRS-17 score result. However, only 36% of all patients recalled to have been previously screened for depression and only 43% of those patients also recalled out-patient screening. Patients classified as depressed reported significantly lower recalled screening rates (9% vs 43%; p = 0.036) and higher rates of self-reported unmet need with emotional problems (72% vs 18%; p

Frances Early,1 Ian Wellwood,2 Isla Kuhn,3 Christi Deaton,2 Jonathan Fuld1 1Centre for Self-Management Support, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; 2Clinical Nursing Research Group, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Cambridge, UK; 3Medical Library, University of Cambridge School of Clinical Medicine, Cambridge, UK Abstract: Pulmonary rehabilitation (PR) reduces the number and duration of hospital admissions and readmissions, and improves health-related quality of life in patients with COPD. Despite clinical guideline recommendations, under-referral and limited uptake to PR contribute to poor treatment access. We reviewed published literature on the effectiveness of interventions to improve referral to and uptake of PR in patients with COPD when compared to standard care, alternative interventions, or no intervention. The review followed recognized methods. Search terms included “pulmonary rehabilitation” AND “referral” OR “uptake” applied to MEDLINE, EMBASE, CINAHL, PsycINFO, ASSIA, BNI, Web of Science, and Cochrane Library up to January 2018. Titles, abstracts, and full papers were reviewed independently and quality appraised. The protocol was registered (PROSPERO # 2016:CRD42016043762). We screened 5,328 references. Fourteen papers met the inclusion criteria. Ten assessed referral and five assessed uptake (46,146 patients, 409 clinicians, 82 hospital departments, 122 general practices). One was a systematic review which assessed uptake. Designs, interventions, and scope of studies were diverse, often part of multifaceted evidence-based management of COPD. Examples included computer-based prompts at practice nurse review, patient information, clinician education, and financial incentives. Four studies reported statistically significant improvements in referral (range 3.5%–36%). Two studies reported statistically significant increases in uptake (range 18%–21.5%). Most studies had methodological and reporting limitations. Meta-analysis was not conducted due to heterogeneity of study designs. This review demonstrates the range of approaches aimed at increasing referral and uptake to PR but identifies limited evidence of effectiveness due to the heterogeneity and limitations of study designs. Research using robust methods with clear descriptions of intervention, setting, and target population is required to optimize access to PR across a range of settings. Keywords: health services research, service improvement, access to healthcare, evidence-based practice, long-term condition, supervised exercise

Introduction The World Health Organization's Impairment, Disability and Handicap (IDH) model [1] defines disability as 'any restriction or lack (resulting from an impairment) of ability to perform an activity within [...]

As part of a survey to collect data which would be useful in planning a district stroke service we set out to discover what the service users' (patients' and carers') perceptions and knowledge of their illness were. We prospectively identified 164 consecutive patients with acute stroke admitted to hospital. Of the 110 (67%) survivors 65 (59%) patients and 80 (73%) carers completed a semi-structured interview. Most (46, 71%) patients and (68, 85%) carers thought they understood what a stroke was but 14 (22%) patients and 12 (15%) carers did not differentiate between a 'stroke' and a 'heart attack'. Carers were significantly more likely than patients to want know all the details about the patients' condition and treatment, to discuss the risk of recurrence, to receive written information and to join information groups. They were more likely than patients to feel that they had to ask for information, yet they were better able to identify general risk factors for stroke. Many patients and carers want more information and discussion about their illness and treatment during their hospital stay, however, some do not. Therefore information giving must be considered on an individual basis. Information could be delivered by: increasing available literature, voluntary group meetings, Stroke Family Care Officers and audio-visual information packages. The most efficient way of achieving an increased understanding amongst patients and carers needs to be found. [ABSTRACT FROM AUTHOR]

Introduction: Hospital associated deconditioning is a well-established phenomenon. Whilst mechanisms are not well understood, one is thought to be skeletal muscle wasting and/or loss of muscle strength. The primary aim of this study was to investigate changes in knee-extension muscle strength in older patients during and after an acute-hospital admission. We also aimed to explore the potential contributions of frailty, acute-illness severity and sedentary activity, with changes in knee-extension strength. Methods: This was a prospective repeated-measures cohort study. Measurements of muscle strength and functional mobility were taken at recruitment, on day 7 of admission (or at discharge if earlier) and again 4-6 weeks post-hospitalisation. During the first 7 days of admission, daily measurements of muscle strength were taken. Results: We recruited 70 participants, of which 65 had at least one repeated measure in hospital. Median age was 84 years, and participants participated in the study for a median of 6 days whilst in hospital, on average participants were ‘active’ for less than 4% of the day. Knee-extension strength significantly reduced by approximately 11% during hospitalisation, but no significant changes occurred post-hospitalisation. A repeated measures mixed model included 292 observations from 62 participants and showed a significant decrease in the reduction in muscle strength as patients’ sedentary time decreased on days 2 to 7 of the study. Additionally, the model showed that a higher frailty score, higher baseline knee-extension strength, lower baseline c-reactive protein levels were associated with greater loss in knee-extension strength during hospitalisation. Association between change in functional mobility after hospitalisation and change in knee-extension strength during hospitalisation was non-significant. Conclusion: Our findings provide an important link in understanding themechanisms and relative contributions of risk factors to hospital associated deconditioning. Further research is needed to confirm these findings and examine the impact of reducing sedentary time on muscle strength during and post-hospitalisation. [ABSTRACT FROM AUTHOR]

Background: Several published systematic reviews have drawn conflicting conclusions on the effect of abnormal body weight (i.e. being underweight, overweight or obese) on outcomes following stroke. The 'obesity paradox' seen in several diseases (wherein obesity, often associated with mortality and morbidity, appears to be protective and improve outcomes) may be evident after stroke, but inconsistent results of existing reviews, and the issue of being underweight, are worth investigating further., Aims: To better understand the impact of body weight on prognosis after stroke, we aimed to answer the following research question: What is the effect of abnormal body weight (underweight, overweight, or obesity) on mortality and functional recovery in adults after stroke?, Summary of Review: We conducted an umbrella review to synthesize existing evidence on the effects of abnormal body weight on stroke outcomes. We searched Cumulated Index to Nursing and Allied Health Literature (CINAHL) Complete, COCHRANE Database of Systematic Reviews, PubMed, Medline, PEDro, and EMBASE Classic + EMBASE, from inception until 28 February 2023. Seven systematic reviews (1,136,929 participants) from 184 primary studies (counting duplicates) were included. While the risk of mortality increases with being underweight (body mass index (BMI) < 18.5 kg/m 2 ), excess body weight (being overweight (BMI = 25-29.9 kg/m 2 ) or obese (BMI > 30 kg/m 2 )) is associated with reduced mortality. The impact of abnormal body weight on functional recovery is less clear; data from studies of being underweight are associated with poor functional outcomes while those from studies of excess body weight are inconclusive., Conclusion: Abnormal body weight effects post-stroke outcomes and should be considered in clinical decision-making, prognostic research, and clinical trials of rehabilitation interventions. The "obesity paradox" is evident after stroke, and excess body weight is associated with reduced mortality compared to normal body weight. It is recommended that body weight is routinely recorded for stroke patients, and further research, including well-designed cohort studies with reliable weight data, is needed to further investigate the impact of body weight and distribution on post-stroke outcomes., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To systematically review and critically evaluate literature on spatiotemporal gait deviations in individuals with premanifest and manifest Huntington's Disease (HD) in comparison with healthy cohorts., Methods: We conducted a systematic review, guided by the Joanna Briggs Institute's Manual for Evidence Synthesis and pre-registered with the International Prospective Register of Systematic Reviews. Eight electronic databases were searched. Studies comparing spatiotemporal footstep parameters in adults with premanifest and manifest HD to healthy controls were screened, included and critically appraised by independent reviewers. Data on spatiotemporal gait changes and variability were extracted and synthesised. Meta-analysis was performed on gait speed, cadence, stride length and stride length variability measures., Results: We screened 2,721 studies, identified 1,245 studies and included 25 studies (total 1,088 participants). Sample sizes ranged from 14 to 96. Overall, the quality of the studies was assessed as good, but reporting of confounding factors was often unclear. Meta-analysis found spatiotemporal gait deviations in participants with HD compared to healthy controls, commencing in the premanifest stage. Individuals with premanifest HD walk significantly slower (-0.17 m/s; 95% confidence interval [CI] [-0.22, -0.13]), with reduced cadence (-6.63 steps/min; 95% CI [-10.62, -2.65]) and stride length (-0.09 m; 95% CI [-0.13, -0.05]). Stride length variability was also increased in premanifest cohorts by 2.18% (95% CI [0.69, 3.68]), with these changes exacerbated in participants with manifest disease., Conclusion: Findings suggest individuals with premanifest and manifest HD display significant spatiotemporal footstep deviations. Clinicians could monitor individuals in the premanifest stage of disease for gait changes to identify the onset of Huntington's symptoms.

Objectives: To explore the perspectives of general practitioners (GPs) on the identification and management of people, including those from ethnic minority groups, with Heart Failure with Preserved Ejection Fraction (HFpEF)., Methods: Qualitative study. Semi-structured, face-to-face or telephone interviews and focus groups were conducted with 35 GPs in England, which were audio-recorded and transcribed verbatim. Framework analysis was used to manage and interpret data., Results: Themes presented reflect four inter-related challenges: GPs' 1) lack of understanding HFpEF, impacting on 2) difficulties in communicating the diagnosis, leading to 3) uncertainty in managing people with HFpEF, further hindered by (4) discontinuity across the primary/secondary interface. All were considered more challenging by GPs when managing people from different cultures and languages., Discussion: HFpEF is not well understood by GPs, leading to diagnostic difficulty, management uncertainty and potential inequity in care offered. People with HFpEF are seen as complex, with multiple long-term conditions and requiring personalised care. Challenges in their management occur across the healthcare system. This study has identified learning needs for GPs around identification and on-going support for people with HFpEF in primary care. It will contribute to the development of more flexible and patient-centred pathways across the primary/secondary care interface.

Background: The COVID-19 pandemic has required widespread and rapid adoption of information and communications technology (ICT) platforms by health professionals. Transitioning health programs from face-to-face to remote delivery using ICT platforms has introduced new challenges., Objective: The objective of this review is to scope for ICT-delivered health programs implemented within the community health setting in high-income countries and rapidly disseminate findings to health professionals., Methods: The Joanna Briggs Institute's scoping review methodology guided the review of the literature., Results: The search retrieved 7110 unique citations. Each title and abstract was screened by at least two reviewers, resulting in 399 citations for full-text review. Of these 399 citations, 72 (18%) were included. An additional 27 citations were identified through reviewing the reference lists of the included studies, resulting in 99 citations. Citations examined 83 ICT-delivered programs from 19 high-income countries. Variations in program design, ICT platforms, research design, and outcomes were evident., Conclusions: Included programs and research were heterogeneous, addressing prevalent chronic diseases. Evidence was retrieved for the effectiveness of nurse and allied health ICT-delivered programs. Findings indicated that outcomes for participants receiving ICT-delivered programs, when compared with participants receiving in-person programs, were either equivalent or better. Gaps included a paucity of co-designed programs, qualitative research around group programs, programs for patients and carers, and evaluation of cost-effectiveness. During COVID-19 and beyond, health professionals in the community health setting are encouraged to build on existing knowledge and address evidence gaps by developing and evaluating innovative ICT-delivered programs in collaboration with consumers and carers., (©Hannah Beks, Olivia King, Renee Clapham, Laura Alston, Kristen Glenister, Carol McKinstry, Claire Quilliam, Ian Wellwood, Catherine Williams, Anna Wong Shee. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 09.03.2022.)

Background: Community-based and home-based palliative and end-of-life care (PEoLC) services, often underpinned by primary care provision, are becoming increasingly popular. One of the key challenges associated with them is their timely initiation. The latter requires an accurate enough prediction of how close to death a patient is., Methods: Using 'realist synthesis' tools, this review sought to develop explanations of how primary care and community PEoLC programmes generate their outcomes, with the explanations presented as context-mechanism-outcome configurations. Medline, Embase, CINAHL, PsycINFO, Web of Science, ASSIA, Sociological Abstracts and SCIE Social Care Online were originally searched. A multistage process of focusing the review was employed, with timely identification of the EoL stage and timely initiation of associated services representing the final review focus. Synthesised sources included 21 full-text documents and 324 coded abstracts, with 253 'core contents' abstracts generating >800 codes., Results: Numerous PEoLC policies and programmes are embedded in a framework of Preparation and Planning for Death and Dying, with identification of the dying stage setting in motion key systems and services. This is challenged by: (1) accumulated evidence demonstrating low accuracy of prognostic judgements; (2) many individuals' orientation towards Living and Hope; (3) expanding grey zones between palliative and curative care; (4) the complexity of referral decisions; (5) the loss of pertinent information in hierarchical relationships and (6) the ambiguous value of having 'more time'., Conclusion: Prioritising temporal criteria in initiating PEoLC services is not sufficiently supported by current evidence and can have significant unintended consequences., Prospero Registration Number: CRD42018097218., Competing Interests: Competing interests: GW is a deputy chair of the UK’s National Institute of Health Research Health Technology Assessment Primary Care Panel., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Aim: to investigate changes in knee-extension strength and physical function in older adults during and after acute hospital admission, and the contributions of illness severity, frailty and sedentary activity to changes in knee-extension strength., Methods: prospective repeated-measures cohort study on a sample of participants aged ≥75 recruited within 24 hours of acute hospital admission. Knee-extension, grip strength and functional mobility (de Morton Mobility Index, DEMMI) were measured at recruitment, day 7 (or discharge if earlier), and at follow-up 4-6 weeks later. During the first 7 days, continuous measurement of physical activity and daily measurements of muscle strength were taken. Participants recalled the functional ability they had 2-weeks before admission and self-reported it at follow-up (Barthel Index, BI)., Results: sixty-five of 70 participants (median age 84 years) had at least one repeated measure of muscle strength in hospital. Knee-extension strength declined during hospitalisation by 11% (P < 0.001), but did not change post-hospitalisation (P = 0.458). Grip strength did not change during hospitalisation (P = 0.665) or from discharge to follow-up (P = 0.508). General functional ability (BI) deteriorated between 2 weeks before admission and follow-up (P < 0.001). Functional mobility (DEMMI) improved during hospitalisation (P < 0.001), but did not change post-hospitalisation (P = 0.508). A repeated-measures mixed model showed that greater loss in knee-extension strength during hospitalisation was associated with increased sedentary time, frailty and baseline strength and lower baseline inflammatory levels., Conclusions: our observations add to a growing body of evidence on potential risk factors for hospital-associated deconditioning., (© The Author(s) 2020. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: About half of all people with heart failure have heart failure with preserved ejection fraction (HFpEF), in which the heart is stiff. This type of heart failure is more common in older people with a history of hypertension, obesity, and diabetes mellitus. Patients with HFpEF are often managed in primary care, sometimes in collaboration with specialists. Knowledge about how best to manage this growing population is limited, and there is a pressing need to improve care for these patients., Aim: To explore clinicians' and patients'/carers' perspectives and experiences about the management of HFpEF to inform the development of an improved model of care., Design and Setting: A multiperspective qualitative study involving primary and secondary care settings across the east of England, Greater Manchester, and the West Midlands., Method: Semi-structured interviews and focus groups were conducted. Transcribed data were analysed using framework analysis and informed by the normalisation process theory (NPT)., Results: In total, 50 patients, nine carers/relatives, and 73 clinicians were recruited. Difficulties with diagnosis, unclear illness perceptions, and management disparity were identified as important factors that may influence management of HFpEF. The NPT construct of coherence reflected what participants expressed about the need to improve the identification, understanding, and awareness of this condition in order to improve care., Conclusion: There is a pressing need to raise the public and clinical profile of HFpEF, develop a clear set of accepted practices concerning its management, and ensure that systems of care are accessible and attuned to the needs of patients with this condition., (© British Journal of General Practice 2020.)

Objectives: To identify unanswered questions for physiotherapy research and help set and prioritise the top 10 generic research priorities for the UK physiotherapy profession; updating previous clinical condition- specific priorities to include patient and carer perspectives, and reflect changes in physiotherapy practice, service provision and new technologies., Design: The James Lind Alliance (JLA) Priority Setting Partnership (PSP) methodology was adopted, utilising evidence review, survey and consensus methods., Participants: Anyone with experience and/or an interest in UK physiotherapy: patients, carers, members of the public, physiotherapists, student physiotherapists, other healthcare professionals, researchers, educators, service providers, commissioners and policy makers., Results: Five hundred and ten respondents (50% patients, carers or members of the public) identified 2152 questions (termed "uncertainties"). Sixty-five indicative questions were developed from the uncertainties using peer reviewed thematic analysis. These were ranked in a second national survey (1,020 responses (62% were complete)). The top 25 questions were reviewed in a final prioritisation workshop using an adapted nominal group technique. The top 10 research priorities focused on optimisation (top priority); access; effectiveness; patient and carer knowledge, experiences, needs and expectations; supporting patient engagement and self-management; diagnosis and prediction., Conclusions: This study is currently the UK's most inclusive consultation exercise to identify patients'and healthcare professionals'priorities for physiotherapy research. The exercise deliberately sought to capture generic issues relevant to all specialisms within physiotherapy. The research priorities identified a range of gaps in existing evidence to inform physiotherapy policy and practice. The results will assist research commissioning bodies and inform funding decisions and strategy., (Crown Copyright © 2019. Published by Elsevier Ltd. All rights reserved.)

Healthcare service and patient barriers contribute to low referral to and uptake of pulmonary rehabilitation (PR). Solutions should support skilled clinician-patient conversations and span primary care-PR boundaries to prevent disjointed working. http://bit.ly/2PVKHZf., Competing Interests: Conflict of interest: F. Early reports grants from the National Institute for Health Research during the conduct of the study. Conflict of interest: P.M. Wilson has nothing to disclose. Conflict of interest: C. Deaton reports grants from the National Institute for Health Research during the conduct of the study. Conflict of interest: I. Wellwood reports Research for Patient Benefit grant PB-PG-1215-20034 from the National Institute of Health Research (NIHR) UK during the conduct of the study. Conflict of interest: H.W. Haque has nothing to disclose. Conflict of interest: S.E. Fox has nothing to disclose. Conflict of interest: A. Yousaf has nothing to disclose. Conflict of interest: O.D. Meysner has nothing to disclose. Conflict of interest: J.R. Ward reports grants from the National Institute for Health Research during the conduct of the study; and grants from the National Institute for Health Research and the University of Cambridge outside the submitted work. Conflict of interest: S.J. Singh has nothing to disclose. Conflict of interest: J.P. Fuld reports an NIHR Research for Patient Benefit grant during the conduct of the study., (Copyright ©ERS 2020.)