Intracortical inhibition was investigated in normal human volunteers by paired-pulse transcranial magnetic stimulation, using a new, computer-assisted threshold-tracking method. Motor threshold was defined as the stimulus amplitude required to evoke a motor evoked potential of 0.2 mV (peak-to-peak) in abductor pollicis brevis, and inhibition was measured as the percentage increase in threshold, when the test stimulus was preceded by a subthreshold conditioning stimulus. This method was used to investigate the dependence of intracortical inhibition on conditioning stimulus parameters and on voluntary activity. Interstimulus interval (ISI) was first stepped from 1 to 4.5 ms, as inhibition was measured using conditioning stimuli of fixed amplitude (50-90% resting motor threshold). Maximal inhibition was produced at ISIs of 1 and 2.5 ms. The effect of conditioning stimulus intensity was then assessed at these ISIs. Inhibition occurred at significantly lower conditioning stimulus intensities with ISI=1 ms than with ISI=2.5 ms. Voluntary activity reduced inhibition at both ISIs, but had a much greater effect on inhibition at ISI=2.5 ms. Inhibition during voluntary activity was also examined for single motor units in first dorsal interosseous by generating poststimulus time histograms. Inhibition, indicated by a reduction in the later peaks of increased firing, was observed with ISI=1 ms, but not with ISI=2.5 ms. We conclude that there are two distinct phases of inhibition, occurring at ISI=1 ms and ISI=2.5 ms, differing both in thresholds and susceptibility to voluntary activity.

The most difficult clinical questions in stroke rehabilitation are "What is this patient's potential for recovery?" and "What is the best rehabilitation strategy for this person, given her/his clinical profile?" Without answers to these questions, clinicians struggle to make decisions regarding the content and focus of therapy, and researchers design studies that inadvertently mix participants who have a high likelihood of responding with those who do not. Developing and implementing biomarkers that distinguish patient subgroups will help address these issues and unravel the factors important to the recovery process. The goal of the present paper is to provide a consensus statement regarding the current state of the evidence for stroke recovery biomarkers. Biomarkers of motor, somatosensory, cognitive and language domains across the recovery timeline post-stroke are considered; with focus on brain structure and function, and exclusion of blood markers and genetics. We provide evidence for biomarkers that are considered ready to be included in clinical trials, as well as others that are promising but not ready and so represent a developmental priority. We conclude with an example that illustrates the utility of biomarkers in recovery and rehabilitation research, demonstrating how the inclusion of a biomarker may enhance future clinical trials. In this way, we propose a way forward for when and where we can include biomarkers to advance the efficacy of the practice of, and research into, rehabilitation and recovery after stroke.

2. TMS of low intensity (below threshold for a motor-evoked potential, MEP) produced a suppression of ongoing EMG activity during walking. The average latency for this suppression was 40·0 ± 1.0 ms. At slightly higher intensities of stimulation there was a facilitation of the EMG activity with an average latency of 29.5 ± 1.0 ms. As the intensity of the stimulation was increased the facilitation increased in size and eventually a MEP was clear in individual sweeps.3. In three subjects TMS was replaced by electrical stimulation over the motor cortex. Just below MEP threshold there was a clear facilitation at short latency (~28 ms). As the intensity of the electrical stimulation was reduced the size of the facilitation decreased until it eventually disappeared. We did not observe a suppression of the EMG activity similar to that produced by TMS in any of the subjects.4. The present study demonstrates that motoneuronal activity during walking can be suppressed by activation of intracortical inhibitory circuits. This illustrates for the first time that activity in the motor cortex is directly involved in the control of the muscles during human walking.

Objective: To investigate patients' and carers' experiences of Early Supported Discharge services and inform future Early Supported Discharge service development and provision. Design and subjects: Semi-structured interviews were completed with 27 stroke patients and 15 carers in the Nottinghamshire region who met evidence-based Early Supported Discharge service eligibility criteria. Participants were either receiving Early Supported Discharge or conventional services. Setting: Community stroke services in Nottinghamshire, UK. Results: A thematic analysis process was applied to identify similarities and differences across datasets. Themes specific to participants receiving Early Supported Discharge services were: the home-based form of rehabilitation; speed of response; intensity and duration of therapy; respite time for the carer; rehabilitation exercises and provision of technical equipment; disjointed transition between Early Supported Discharge and ongoing rehabilitation services. Participants receiving Early Supported Discharge or conventional community services experienced difficulties related to: limited support in dealing with carer strain; lack of education and training of carers; inadequate provision and delivery of stroke-related information; disjointed transition between Early Supported Discharge and ongoing rehabilitation services. Conclusions: Accelerated hospital discharge and home-based rehabilitation was perceived positively by service users. The study findings highlight the need for Early Supported Discharge teams to address information and support needs of patients and carers and to monitor their impact on carers in addition to patients, using robust outcome measures.

The most difficult clinical questions in stroke rehabilitation are "What is this patient's potential for recovery?" and "What is the best rehabilitation strategy for this person, given her/his clinical profile?" Without answers to these questions, clinicians struggle to make decisions regarding the content and focus of therapy, and researchers design studies that inadvertently mix participants who have a high likelihood of responding with those who do not. Developing and implementing biomarkers that distinguish patient subgroups will help address these issues and unravel the factors important to the recovery process. The goal of the present paper is to provide a consensus statement regarding the current state of the evidence for stroke recovery biomarkers. Biomarkers of motor, somatosensory, cognitive and language domains across the recovery timeline post-stroke are considered; with focus on brain structure and function, and exclusion of blood markers and genetics. We provide evidence for biomarkers that are considered ready to be included in clinical trials, as well as others that are promising but not ready and so represent a developmental priority. We conclude with an example that illustrates the utility of biomarkers in recovery and rehabilitation research, demonstrating how the inclusion of a biomarker may enhance future clinical trials. In this way, we propose a way forward for when and where we can include biomarkers to advance the efficacy of the practice of, and research into, rehabilitation and recovery after stroke.

BackgroundHospital discharge is a vulnerable stage in the patient pathway. Research highlights communication failures and the problems of co-ordination as resulting in delayed, poorly timed and unsafe discharges. The complexity of hospital discharge exemplifies the threats to patient safety found ‘between’ care processes and organisations. In developing this perspective, safe discharge is seen as relying upon enhanced knowledge sharing and collaboration between stakeholders, which can mitigate system complexity and promote safety.AimTo identify interventions and practices that support knowledge sharing and collaboration in the processes of discharge planning and care transition.SettingThe study was undertaken between 2011 and 2013 in two English health-care systems, each comprising an acute health-care provider, community and primary care providers, local authority social services and social care agencies. The study sites were selected to reflect known variations in local population demographics as well as in the size and composition of the care systems. The study compared the experiences of stroke and hip fracture patients as exemplars of acute care with complex discharge pathways.DesignThe study involved in-depth ethnographic research in the two sites. This combined (a) over 180 hours of observations of discharge processes and knowledge-sharing activities in various care settings; (b) focused ‘patient tracking’ to trace and understand discharge activities across the entire patient journey; and (c) qualitative interviews with 169 individuals working in health, social and voluntary care sectors.FindingsThe study reinforces the view of hospital discharge as a complex system involving dynamic and multidirectional patterns of knowledge sharing between multiple groups. The study shows that discharge planning and care transitions develop through a series of linked ‘situations’ or opportunities for knowledge sharing. It also shows variations in these situations, in terms of the range of actors, forms of knowledge shared, and media and resources used, and the wider culture and organisation of discharge. The study also describes the threats to patient safety associated with hospital discharge, as perceived by participants and stakeholders. These related to falls, medicines, infection, clinical procedures, equipment, timing and scheduling of discharge, and communication. Each of these identified risks are analysed and explained with reference to the observed patterns of knowledge sharing to elaborate how variations in knowledge sharing can hinder or promote safe discharge.ConclusionsThe study supports the view of hospital discharge as a complex system involving tightly coupled and interdependent patterns of interaction between multiple health and social care agencies. Knowledge sharing can help to mitigate system complexity through supporting collaboration and co-ordination. The study suggests four areas of change that might enhance knowledge sharing, reduce system complexity and promote safety. First, knowledge brokers in the form of discharge co-ordinators can facilitate knowledge sharing and co-ordination; second, colocation and functional proximity of stakeholders can support knowledge sharing and mutual appreciation and alignment of divergent practices; third, local cultures should prioritise and value collaboration; and finally, organisational resources, procedures and leadership should be aligned to fostering knowledge sharing and collaborative working. These learning points provide insight for future interventions to enhance discharge planning and care transition. Future research might consider the implementation of interviews to mediate system complexity through fostering enhanced knowledge sharing across occupational and organisational boundaries. Research might also consider in more detail the underlying complexity of both health and social care systems and how opportunities for knowledge sharing might be engendered to promote patient safety in other areas.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Objectives: To explore the perspectives of healthcare professionals and commissioners working with a stroke Early Supported Discharge service in relation to: (1) the factors that facilitate or impede the implementation of the service, and (2) the impact of the service. Design: Cross-sectional qualitative study using semi-structured interviews. Data were analysed by two researchers using a thematic analysis approach. Setting: Two Early Supported Discharge services in Nottinghamshire. Participants: Purposive sampling identified 35 key informants including practitioners, managers and commissioners. Results: The identified facilitators to the implementation of evidence-based services were: (1) the adaptability of the intervention to the healthcare context, (2) the role of rehabilitation assistants and (3) cross-service working arrangements. Perceived challenges included: (1) lack of clarity regarding the referral decision making process, (2) delays in securing social care input and (3) lack of appropriate followon services in the region. Most respondents perceived the impact of the services to be: (1) reducing inhospital stay, (2) aiding the seamless transfer of care from hospital to the community and (3) providing intensive stroke specific therapy. Commissioners called for greater evidence of service impact and clarity regarding where it fits into the stroke pathway. Conclusions: Early Supported Discharge services were perceived as successful in providing homebased, stroke specific rehabilitation. Teams would benefit from capitalising on identified facilitators and developing strategies to address the challenges. The remit and impact of the services should be clear and demonstrable, with teams strengthening links with other health and social care providers.

Purpose The purpose of this paper is to evaluate career impact of entrepreneurship education (EE) considering evidence drawn from a quantitative study of alumni within two UK higher education institutions (HEIs) from a retrospective perspective. The findings inform the value of the EE experience and its impact on both self-employability and wider employability career choices. This study will be of relevance to both enterprise support agencies and government policy makers. Design/methodology/approach This research study considers evidence drawn from an online quantitative survey of EE within two UK HEIs. The survey evaluated a range of issues including course design, programme satisfaction, impact, career outcomes and respondents demographics. Over 80 respondents completed the survey in full which was analysed using a range of bivariate techniques. Findings The evidence suggested here indicates that EE programmes provide value both in terms of helping to enable business start-ups and also in supporting other career paths, through the enterprising knowledge and skill sets graduates acquire during their specialised studies. This study contributes to the literature by recognising and measuring these contributions. For example, this study enables discernment between different EE course components and their value for different career outcomes. Research limitations/implications The study recognises the limitations of this survey data in terms of the size of the sample, number of HEIs evaluated and its point in time design. Practical implications The HEI sector must evaluate its practices and measure the effectiveness of its graduates in terms of achieving sustainable business start-up. In course design, the evidence suggested that students value both the enterprising and entrepreneurial skills and knowledge components and discern value between them in their later careers. The findings suggest that EE graduates typically experience portfolio careers with multiple occupations in different sectors and roles within both employment and self-employment. Thus it is important that EE programme design includes both enterprising and entrepreneurial components to meet the future requirements of their graduates postgraduation. Originality/value This study contributes new evidence regarding the value of EE in UK HEIs. This evidence should inform course design and policy makers regarding the value of EE in creating self-employment and creating enterprising employees.