A randomized double-blind controlled trial of the effect of vitamin D supplementation on the abilities of elderly hospital patients to carry out basic activities of daily life is described. Those patients included in the trial had plasma 25-hydroxyvitamin D concentrations which were low or low normal as judged by the normal range in young adults. After 2 to 9 months on the trial there was no significant difference in the performance of the control and treatment groups.
Of 1094 patients with a confirmed stroke admitted to Northwick Park, a district general hospital, 364 (33%) died while in hospital, 215 (20%) were fully recovered when discharged, and 329 (30%) were too frail or too ill from diseases other than stroke to be considered for active rehabilitation. Only 121 (11%) were suitable for intensive treatment. They and 12 patients referred direct to outpatients were allocated at random to one of three different courses of rehabilitation. Intensive was compared with conventional rehabilitation and with a third regimen which included no routine rehabilitation, but under which patients were encouraged to continue with exercises taught while in hospital and were regularly seen at home by a health visitor. Progress at three months and 12 months was measured by an index of activities of daily living. Improvement was greatest in those receiving intensive treatment, intermediate in those receiving conventional treatment, and least in those receiving no routine treatment. Decreasing intensity of treatment was associated with a significant increase in the proportions of patients who deteriorated and in the extent to which they deteriorated.Probably only a few stroke patients, mostly men, are suitable for intensive outpatient rehabilitation, but for those patients the treatment is effective and realistic.
IntroductionRemedial therapists spend much of their time' rehabilitating patients disabled by strokes, though this has not been convincingly shown to improve chances of recovery. If rehabilitation is ineffective therapists' efforts are wasted and patients inconvenienced. If, on the other hand, rehabilitation is effective more investment in it might be justified.Three randomised controlled trials2-4 on the effectiveness of rehabilitation after stroke have been inconclusive, possibly because of their small numbers. Garraway et a15 have recently shown that patients admitted to a special stroke unit fared better than those admitted to medical units, but their trial was concerned largely with the effects of inpatient management, and the advantage was not sustained on longer follow-up.6 This paper compares the effectiveness of three intensities of outpatient rehabilitation.
Patients and methodsAll 1094 patients with a recent confirmed stroke who were admitted to Northwick Park Hospital from October 1972 to September 1978 were considered for the trial. Of these, 364 (33%) died while in hospital and 215 patients (20%) made a full recovery while in hospital, in terms not only of day-to-day activities but also of limb function and speech. The remaining 515 patients were considered for the trial. The main criterion for entry was that the patient should BRITISH MEDICAL JOURNAL VOLUME 282 be able to manage the most intensive of the three regimens, even if they were eventually allocated to one of the other regimens. A further 329 patients (30%) were excluded by this criterion: most of these were elderly patients, predominantly women, who were either too old or too frail for intensive reh...
Selected activities of daily living were used to measure improvement in independence of longstay elderly patients known to have low concentrations of plasma 25-hydroxyvitamin D. This was a double-blind random controlled trial lasting between 8 and 40 weeks. No significant changes were found in either group.
Strongyloides stercoralis is an endemic parasitic infection that can remain asymptomatic for years, but it can cause death in immunosuppressed individuals. Here, we present a case of Strongyloides hyperinfection in a 75-year-old male secondary to sepsis and chronic immunosuppression due to TNF-α inhibitors. Despite aggressive treatment including broad-spectrum antibiotics and antihelminths, his respiratory failure worsened and he died after palliative extubation. S. stercoralis infection remains a diagnostic challenge. Presentation with Strongyloides is often nonspecific, and eosinophilia is absent in hyperinfection. Diagnosis can be delayed, especially in low-prevalence areas where suspicion is low. Strongyloides should be considered in the differential diagnosis in the presence of risk factors including immunosuppressive therapy, and a travel history should be carefully obtained. Patients with recurrent enterobacterial sepsis or respiratory failure with diffuse infiltrates in the setting of eosinophilia should undergo testing for Strongyloides. A multidisciplinary approach can result in earlier diagnosis and favorable outcomes.
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