Introduction Parkinson's disease (PD) is managed primarily by dopamine agonists and physiotherapy while virtual reality (VR) has emerged recently as a complementary method. The present study reviewed the effectiveness of VR in rehabilitation of patients with PD. Methods Literature search up to June 2019 identified ten studies (n = 343 participants) suitable for meta-analysis and 27 studies (n = 688 participants) for systematic review. Standard mean difference (SMD) and 95% confidence intervals (CI) were calculated using a random effects model. Results In meta-analysis, compared with active rehabilitation intervention, VR training led to greater improvement of stride length, SMD = 0.70 (95%CI = 0.32-1.08, p = 0.0003), and was as effective for gait speed, balance and coordination, cognitive function and mental health, quality of life and activities of daily living. Compared with passive rehabilitation intervention, VR had greater effects on balance: SMD = 1.02 (95%CI = 0.38-1.65, p = 0.002). Results from single randomised controlled trials showed that VR training was better than passive rehabilitation intervention for improving gait speed SMD = 1.43 (95%CI = 0.51-2.34, p = 0.002), stride length SMD = 1.27 (95%CI = 0.38-2.16, p = 0.005) and activities of daily living SMD = 0.96 (95%CI = 0.02-1.89). Systematic review showed that VR training significantly (p < 0.05) improved motor function, balance and coordination , cognitive function and mental health, and quality of life and activities of daily living. Conclusion VR used in rehabilitation for patients with PD improves a number of outcomes and may be considered for routine use in rehabilitation.

Therapeutic hypothermia is likely a beneficial treatment following traumatic brain injuries in adults but cannot be recommended in children.

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Objectives The National Institute of Health and Clinical Excellence and The Royal College of Physicians recommend transferring thrombolysed patients with stroke to a hyperacute stroke unit (HASU) within 4 h from hospital arrival (T Arrival-HASU ), but there is paucity of evidence to support this cut-off. We assessed if a shorter interval within this target threshold conferred a significant improvement in patient mortality. Design We conducted a retrospective analysis of prospectively collected data from the Sentinel Stroke National Audit Programme. Setting Four major UK hyperacute stroke centres between 2014 and 2016. Participants A total of 183 men (median age = 75 years, IQR = 66–83) and 169 women (median age = 81 years, IQR = 72.5–88) admitted with acute ischaemic stroke. Main outcome measures We evaluated T Arrival-HASU in relation to inpatient mortality, adjusted for age, sex, co-morbidities, stroke severity, time between procedures, time and day on arrival. Results There were 51 (14.5%) inpatient deaths. On ROC analysis, the AUC (area under the curve) was 61.1% (52.9–69.4%, p = 0.01) and the cut-off of T Arrival-HASU where sensitivity equalled specificity was 2 h/15 min (intermediate range = 30 min to 3 h/15 min) for predicting mortality. On logistic regression, compared with the fastest T Arrival-HASU group within 2 h/15 min, the slowest T Arrival-HASU group beyond upper limit of intermediate range (≥ 3 h/15 min) had an increased risk of mortality: 5.6% vs. 19.6%, adjusted OR = 5.6 (95%CI:1.5–20.6, p = 0.010). Conclusions We propose three new alarm time zones (A1, A2 and A3) to improve stroke survival: “A1 Zone” (T Arrival-HASU < 2 h/15 min) indicates that a desirable target, “A2 Zone” (T Arrival-HASU = 2 h/15 min to 3 h/15 min), indicates increasing risk and should not delay any further, and “A3 Zone” (T Arrival-HASU ≥ 3 h/15 min) indicates high risk and should be avoided.

IntroductionBecause of their high risk of stroke, anticoagulation therapy is recommended for most patients with atrial fibrillation (AF). The present study evaluated the use of anticoagulants in the community and in a hospital setting for patients with AF and its associations with stroke.MethodsPatients admitted with stroke to four major hospitals in County of Surrey, England were surveyed in the 2014–2016 Sentinel Stroke National Audit Programme. Descriptive statistics was used to summarise subject characteristics and χ² test to assess differences between categorical variables.ResultsA total of 3309 patients, 1656 men (mean age: 73.1 years±SD 13.2) and 1653 women (79.3 years±13.0) were admitted with stroke (83.3% with ischaemic, 15.7% haemorrhagic stroke and 1% unspecified). AF occurred more frequently (χ2=62.4; p<0.001) among patients admitted with recurrent (30.2%) rather than with first stroke (17.1%). There were 666 (20.1%) patients admitted with a history of AF, among whom 304 (45.3%) were anticoagulated, 279 (41.9%) were untreated and 85 (12.8%) deemed unsuitable for anticoagulation. Of the 453 patients with history of AF admitted with a first ischaemic stroke, 138 (37.2%) were on anticoagulation and 41 (49.6%) were not (χ2 = 6.3; p<0.043) and thrombolysis was given more frequently for those without prior anticoagulation treatment (16.1%) or unsuitable for anticoagulation (23.6%) compared with those already on anticoagulation treatment (8.3%; χ2=10.0; p=0.007). Of 2643 patients without a previous history of AF, 171 (6.5%) were identified with AF during hospitalisation. Of patients with AF who presented with ischaemic stroke who were not anticoagulated or deemed unsuitable for anticoagulation prior to admission, 91.8% and 75.0%, respectively, were anticoagulated on discharge.ConclusionsThe study highlights an existing burden for patients with stroke and reflects inadequate treatment of AF which results in an increased stroke burden. There is significant scope to improve the rates of anticoagulation.