Background: swallowing problems (dysphagia) are common following acute stroke and are independent predictors of short-term outcome. It is uncertain as to whether these swallowing problems are associated with outcome in the longer-term. Aim: insert to determine whether dysphagia present in the first week of acute stroke associated with long-term outcome. Methods: a population-based long-term follow-up of people with first in a life-time stroke. Dysphagia was assessed within 1 week of stroke and patients were followed up at 3 months and yearly for 5 years by face-to-face interview. Outcome was defined by survival and place of residence, using multinomial logistic regression. Barthel Scores were divided into the two groups 15-20 and 0-14, and modelled using multiple logistic regression. Results: there were 567 patients with dysphagia (mean age 74.3 years) and 621 with a safe swallow (mean age 69.6 years). Following multinomial logistic regression, residence in a nursing home was more likely to occur in those who failed the swallow test during the first week of their stroke; however, this only reached statistical significance at 3 months (relative risk ratio (RRR) = 1.73; 95% confidence interval (CI) 1.02 to 2.95), and years 4 (RRR 3.35, 1.37–8.19) and 5 (RRR 3.06, 1.06-8.83). There was also a significant association with increased mortality only during the first three months (RRR 2.03, 1.12 to 3.67). Conclusion: this study confirms that the presence of dysphagia during the acute phase of stroke is associated with poor outcome during the subsequent year, particularly at 3 months, and is associated with increased institutionalisation rate in the long term.

Background Refeeding syndrome is a potentially life-threatening condition characterised by severe intracellular electrolyte shifts, acute circulatory fluid overload and organ failure. The initial symptoms are non-specific but early clinical features are severely low-serum electrolyte concentrations of potassium, phosphate or magnesium. Risk factors for the syndrome include starvation, chronic alcoholism, anorexia nervosa and surgical interventions that require lengthy periods of fasting. The causes of the refeeding syndrome are excess or unbalanced enteral, parenteral or oral nutritional intake. Prevention of the syndrome includes identification of individuals at risk, controlled hypocaloric nutritional intake and supplementary electrolyte replacement. Objective To determine the occurrence of refeeding syndrome in adults commenced on artificial nutrition support. Design Prospective cohort study. Setting Large, single site university teaching hospital. Recruitment period 2007–2009. Participants 243 adults started on artificial nutrition support for the first time during that admission recruited from wards and intensive care. Main outcome measures Primary outcome: occurrence of the refeeding syndrome. Secondary outcome: analysis of the risk factors which predict the refeeding syndrome. Tertiary outcome: mortality due to refeeding syndrome and all-cause mortality. Results 133 participants had one or more of the following risk factors: body mass index 15% in the preceding 3–6 months, very little or no nutritional intake >10 days, history of alcohol or drug abuse and low baseline levels of serum potassium, phosphate or magnesium prior to recruitment. Poor nutritional intake for more than 10 days, weight loss >15% prior to recruitment and low-serum magnesium level at baseline predicted the refeeding syndrome with a sensitivity of 66.7%: specificity was >80% apart from weight loss of >15% which was 59.1%. Baseline low-serum magnesium was an independent predictor of the refeeding syndrome (p=0.021). Three participants (2% 3/243) developed severe electrolyte shifts, acute circulatory fluid overload and disturbance to organ function following artificial nutrition support and were diagnosed with refeeding syndrome. There were no deaths attributable to the refeeding syndrome, but (5.3% 13/243) participants died during the feeding period and (28% 68/243) died during hospital admission. Death of these participants was due to cerebrovascular accident, traumatic injury, respiratory failure, organ failure or end-of-life causes. Conclusions Refeeding syndrome was a rare, survivable phenomenon that occurred during hypocaloric nutrition support in participants identified at risk. Independent predictors for refeeding syndrome were starvation and baseline low-serum magnesium concentration. Intravenous carbohydrate infusion prior to artificial nutrition support may have precipitated the onset of the syndrome.

Background: Reciprocal relationships between researchers and patient and public involvement (PPI) contributors can enable successful PPI in research. However, research and anecdotal evidence suggest that researchers do not commonly provide feedback to PPI contributors thus preventing them from knowing whether, how or where their contributions were useful to researchers and research overall.Aims: The aim of this study was to explore the variation, types, importance of, and satisfaction with feedback given by researchers to PPI contributors in six PPI groups in England, and identify the barriers to the process of feedback.Methods: An explanatory mixed methods sequential study design with a questionnaire survey followed by semi‐structured interviews with researchers and PPI contributors in six PPI groups. PPI contributors were involved in all stages of the research process.Results: Researchers do not routinely give feedback to PPI contributors. Feedback was found to have different meanings: an acknowledgement, impact and study success and progress. PPI contributors who receive feedback are motivated for further involvement; it supports their learning and development and prompts researchers to reflect on PPI impact. The importance of the role of a PPI lead or coordinator to facilitate the process of providing feedback was also highlighted.Conclusion: This study found no generic way to give feedback indicating that mutual feedback expectations should be discussed at the outset. PPI feedback needs to become integral to the research process with appropriate time and resources allocated. PPI feedback can be seen as a key indicator of mature, embedded PPI in research.

The geographies of the current generation of young people are markedly distinct from previous generations by virtue of their access to a virtual playground. The vast majority of young people now engage in video gaming as a leisure activity. Drawing on findings from the 2009/2010 WHO Health Behaviour in School-aged Children study this paper set out to investigate the factors that might be associated with higher levels of video gaming. Information was collected from 4404 school students aged 11, 13 and 15 years, using anonymised self-completed questionnaires. Higher usage was defined as game play exceeding two hours a day. Separate analyses were conducted for boys and girls. For both genders higher levels of game playing was associated with early adolescence, opposite sex friends and minimal parental mediation. Bullying and going to bed hungry were associated with higher usage for boys only, while life satisfaction and family activities were linked to girls’ game playing only. Parents were identified as effective mediators of young people’s video game usage. The study identified gendered motivations for higher levels of game play, suggesting different interventions for boys and girls may be required in order for young people to create a balanced approach to video gaming.

Background and Purpose—: Evidence linking outdoor air pollution and incidence of stroke is limited. We examined effects of outdoor air pollution on the incidence of ischemic and hemorrhagic stroke at the population level focusing on middle-aged and older people. Methods—: We used a small-area level ecological study design and a stroke register set up to capture all incident cases of first-ever stroke occurring in a defined geographical area in south London (948 census output areas) where road traffic contributes to spatial variation in air pollution. Population-weighted averages were calculated for output areas using outdoor nitrogen dioxide and PM ₁₀ concentrations modeled at a 20-m resolution. Results—: There were 1832 ischemic and 348 hemorrhagic strokes in 1995 to 2004 occurring among a resident population of 267 839. Mean (SD) concentration was 25.1 (1.2) μg/m ³ (range, 23.3–36.4 μg/m ³ ) for PM ₁₀ and 41.4 (3.0) μg/m ³ (range, 35.4–68.0 μg/m ³ ) for nitrogen dioxide. For ischemic stroke, adjusted rate ratios per 10-μg/m ³ increase, for all ages, 40 to 64 and 65 to 79 years, respectively, were 1.22 (0.77–1.93), 1.12 (0.55–2.28), and 1.86 (1.10–3.13) for PM ₁₀ and 1.11 (0.93–1.32), 1.13 (0.86–1.50), and 1.23 (0.99–1.53) for nitrogen dioxide. For hemorrhagic stroke, the corresponding rate ratios were 0.52 (0.20–1.37), 0.78 (0.17–3.51), and 0.51 (0.12–2.22) for PM ₁₀ and 0.86 (0.60–1.24), 1.12 (0.66–1.90), and 0.78 (0.44–1.39) for nitrogen dioxide. Conclusions—: Although there was no significant association between outdoor air pollutants and ischemic stroke incidence for all ages combined, there was a suggestion of increased risk among people aged 65 to 79 years. There was no evidence of increased incidence in hemorrhagic stroke.

Objectives To identify ethnic differences in survival after stroke and examine the factors that influence survival. Design Population based stroke register with follow-up. Settings South London stroke register. Participants 2321 patients with first stroke registered between January 1995 and December 2002. Main outcome measures Sociodemographic factors, risk factors for stroke and their management, severity of stroke, and acute service provision factors. Survival analysis with Kaplan-Meier curves, log rank test, and Cox's proportional hazard model with stratification. Results In univariable analyses of survival, outcome was better for black people than white people (median 33.7 v 20.0 months). After stratification by socioeconomic status, type of stroke, and Glasgow coma score, and adjustment for other potential confounders, being black was generally associated with better survival, taking into account the interaction between ethnicity and age, and ethnicity and prior Barthel score. Of the risk factors for stroke considered, current smoking (hazard ratio 1.21, 95% confidence interval 1.01 to 1.45, P = 0.044), untreated atrial fibrillation (1.36, 1.08 to 1.72, P = 0.009), untreated diabetes (1.53, 1.05 to 2.22, P = 0.027), and treated diabetes (1.61, 1.27 to 2.03, P < 0.001) were associated with reduced survival. Conclusion In general, black patients in a south London population with first ever stroke are more likely to survive than white patients, the exceptions being in those aged < 65 and those with a prior Barthel score < 15. Some pre-stroke risk factors that have the potential to be modified, including the appropriate treatment of existing health problems, have a strong impact on survival.