SummaryBackgroundResults of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects.MethodsFOCUS was a pragmatic, multicentre, parallel group, double-blind, randomised, placebo-controlled trial done at 103 hospitals in the UK. Patients were eligible if they were aged 18 years or older, had a clinical stroke diagnosis, were enrolled and randomly assigned between 2 days and 15 days after onset, and had focal neurological deficits. Patients were randomly allocated fluoxetine 20 mg or matching placebo orally once daily for 6 months via a web-based system by use of a minimisation algorithm. The primary outcome was functional status, measured with the modified Rankin Scale (mRS), at 6 months. Patients, carers, health-care staff, and the trial team were masked to treatment allocation. Functional status was assessed at 6 months and 12 months after randomisation. Patients were analysed according to their treatment allocation. This trial is registered with the ISRCTN registry, number ISRCTN83290762.FindingsBetween Sept 10, 2012, and March 31, 2017, 3127 patients were recruited. 1564 patients were allocated fluoxetine and 1563 allocated placebo. mRS data at 6 months were available for 1553 (99·3%) patients in each treatment group. The distribution across mRS categories at 6 months was similar in the fluoxetine and placebo groups (common odds ratio adjusted for minimisation variables 0·951 [95% CI 0·839–1·079]; p=0·439). Patients allocated fluoxetine were less likely than those allocated placebo to develop new depression by 6 months (210 [13·43%] patients vs 269 [17·21%]; difference 3·78% [95% CI 1·26–6·30]; p=0·0033), but they had more bone fractures (45 [2·88%] vs 23 [1·47%]; difference 1·41% [95% CI 0·38–2·43]; p=0·0070). There were no significant differences in any other event at 6 or 12 months.InterpretationFluoxetine 20 mg given daily for 6 months after acute stroke does not seem to improve functional outcomes. Although the treatment reduced the occurrence of depression, it increased the frequency of bone fractures. These results do not support the routine use of fluoxetine either for the prevention of post-stroke depression or to promote recovery of function.FundingUK Stroke Association and NIHR Health Technology Assessment Programme.
ObjectiveAnticoagulation reversal, intensive blood pressure lowering, neurosurgery, and access to critical care might all be beneficial in acute intracerebral hemorrhage (ICH). We combined and implemented these as the “ABC” hyperacute care bundle and sought to determine whether the implementation was associated with lower case fatality.MethodsThe ABC bundle was implemented from June 1, 2015 to May 31, 2016. Key process targets were set, and a registry captured consecutive patients. We compared 30‐day case fatality before, during, and after bundle implementation with multivariate logistic regression and used mediation analysis to determine which care process measures mediated any association. Difference‐in‐difference analysis compared 30‐day case fatality with 32,295 patients with ICH from 214 other hospitals in England and Wales using Sentinel Stroke National Audit Programme data.ResultsA total of 973 ICH patients were admitted in the study period. Compared to before implementation, the adjusted odds of death by 30 days were lower in the implementation period (odds ratio [OR] = 0.62, 95% confidence interval [CI] = 0.38–0.97, p = 0.03), and this was sustained after implementation (OR = 0.40, 95% CI = 0.24–0.61, p < 0.0001). Implementation of the bundle was associated with a 10.8 percentage point (95% CI = −17.9 to −3.7, p = 0.003) reduction in 30‐day case fatality in difference‐in‐difference analysis. The total effect of the care bundle was mediated by a reduction in do‐not‐resuscitate orders within 24 hours (52.8%) and increased admission to critical care (11.1%).InterpretationImplementation of the ABC care bundle was significantly associated with lower 30‐day case fatality after ICH. ANN NEUROL 2019;86:495–503
The actualization of affordable housing remains a challenge. This challenge is exacerbated by the increasing societal demand for the incorporation of sustainability principles into such housing types to improve levels of occupant health and well-being whilst avouching the desired levels of affordability. Innovative technologies and practices have been described as beneficial to the effectuation of sustainable affordable housing. However, knowledge concerning the deployment of innovative technologies and practices in sustainable affordable housing (sustainable, innovative, affordable housing—SIAH) delivery remains nascent. Consequently, there is a lack of a common ontology among stakeholders concerning how to realize SIAH. This study aims to contribute toward the development of this body of knowledge through the establishment of the critical success factors (CSFs) for effective SIAH implementation. To achieve this objective, a systematic review and bibliometric analysis focusing on a juxtaposition of sustainable, innovative and affordable housing concepts was carried out based on the relevant literature. This led to the identification and clustering of CSFs for these housing concepts at individual levels and as a collective (SIAH). The findings of the study consisted of the establishment of four distinct yet interrelated facets through which SIAH can be achieved holistically, namely, housing design, house element, housing production method and housing technology. A total of 127 CSFs were found to be aligned to these facets, subsequently clustered, and conclusively used for the development of a SIAH CSF framework. The most frequently occurring CSFs with predominant interconnections were the utilization of energy-efficient systems/fittings, tenure security, a comfortable and healthy indoor environment, affordable housing price in relation to income and using water-efficient systems/fittings CSFs, and establishing the emergent SIAH CSF framework. The framework in this study is useful in the documentation of SIAH features for construction projects and further studies into SIAH CSFs.
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