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A polypill-type strategy for primary prevention was first published at the turn of the century and advised that a multi-ingredient pill applied to an adult population would prevent up to 80% of cardiovascular and stroke events. Such a pill should contain small doses of antihypertensives, lipid-lowering drugs, and some nutrients. The startling increase of the global stroke burden has led to a revival of this concept and the propagation of a population-based prevention strategy. Recent cardiovascular fixed-dose combination trials have shown a significant effect in reducing not only blood pressure and cholesterol levels but also in reducing cardiovascular and stroke events. In most of the studies, the study population was for secondary prevention and the total number of strokes was small. Nevertheless, it is now clear that a large proportion of primary prevention must take this path. It is especially promising when combined with community health workers interventions for modifying risk behavior. While a polypill-type approach seems most efficacious in underserved regions of high-income countries as well as in low- and middle-income countries, it seems to have a large overall effect in spite of some problems with nonadherence or potential side effects. It should be available and affordable for large target populations. Larger phase 4 studies are under way.

The optimal management of post-stroke cognitive impairment remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making around prevention, diagnosis, treatment and prognosis. These guidelines were developed according to ESO standard operating procedure and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and, where possible, meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. There was limited randomised controlled trial evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Interventions to improve lifestyle and treat vascular risk factors may have many health benefits but a beneficial effect on cognition is not proven. We found no evidence around routine cognitive screening following stroke but recognise the importance of targeted cognitive assessment. We described the accuracy of various cognitive screening tests but found no clearly superior approach to testing. There was insufficient evidence to make a recommendation for use of cholinesterase inhibitors, memantine nootropics or cognitive rehabilitation. There was limited evidence on the use of prediction tools for post-stroke cognitive syndromes (cognitive impairment, dementia and delirium). The association between post-stroke cognitive impairment and most acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on acute MRI brain may help predict cognitive outcomes. These guidelines have highlighted fundamental areas where robust evidence is lacking. Further, definitive randomised controlled trials are needed, and we suggest priority areas for future research. ispartof: European Stroke Journal vol:6 issue:3 pages:1-177 ispartof: location:England status: Published online

Background Regularly updated data on stroke and its pathological types, including data on their incidence, prevalence, mortality, disability, risk factors, and epidemiological trends, are important for evidence-based stroke care planning and resource allocation. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) aims to provide a standardised and comprehensive measurement of these metrics at global, regional, and national levels. Methods We applied GBD 2019 analytical tools to calculate stroke incidence, prevalence, mortality, disability-adjusted life-years (DALYs), and the population attributable fraction (PAF) of DALYs (with corresponding 95% uncertainty intervals [UIs]) associated with 19 risk factors, for 204 countries and territories from 1990 to 2019. These estimates were provided for ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage, and all strokes combined, and stratified by sex, age group, and World Bank country income level. Findings In 2019, there were 12·2 million (95% UI 11·0–13·6) incident cases of stroke, 101 million (93·2–111) prevalent cases of stroke, 143 million (133–153) DALYs due to stroke, and 6·55 million (6·00–7·02) deaths from stroke. Globally, stroke remained the second-leading cause of death (11·6% [10·8–12·2] of total deaths) and the third-leading cause of death and disability combined (5·7% [5·1–6·2] of total DALYs) in 2019. From 1990 to 2019, the absolute number of incident strokes increased by 70·0% (67·0–73·0), prevalent strokes increased by 85·0% (83·0–88·0), deaths from stroke increased by 43·0% (31·0–55·0), and DALYs due to stroke increased by 32·0% (22·0–42·0). During the same period, age-standardised rates of stroke incidence decreased by 17·0% (15·0–18·0), mortality decreased by 36·0% (31·0–42·0), prevalence decreased by 6·0% (5·0–7·0), and DALYs decreased by 36·0% (31·0–42·0). However, among people younger than 70 years, prevalence rates increased by 22·0% (21·0–24·0) and incidence rates increased by 15·0% (12·0–18·0). In 2019, the age-standardised stroke-related mortality rate was 3·6 (3·5–3·8) times higher in the World Bank low-income group than in the World Bank high-income group, and the age-standardised stroke-related DALY rate was 3·7 (3·5–3·9) times higher in the low-income group than the high-income group. Ischaemic stroke constituted 62·4% of all incident strokes in 2019 (7·63 million [6·57–8·96]), while intracerebral haemorrhage constituted 27·9% (3·41 million [2·97–3·91]) and subarachnoid haemorrhage constituted 9·7% (1·18 million [1·01–1·39]). In 2019, the five leading risk factors for stroke were high systolic blood pressure (contributing to 79·6 million [67·7–90·8] DALYs or 55·5% [48·2–62·0] of total stroke DALYs), high body-mass index (34·9 million [22·3–48·6] DALYs or 24·3% [15·7–33·2]), high fasting plasma glucose (28·9 million [19·8–41·5] DALYs or 20·2% [13·8–29·1]), ambient particulate matter pollution (28·7 million [23·4–33·4] DALYs or 20·1% [16·6–23·0]), and smoking (25·3 million [22·6–28·2] DALYs or 17·6% [16·4–19·0]). Interpretation The annual number of strokes and deaths due to stroke increased substantially from 1990 to 2019, despite substantial reductions in age-standardised rates, particularly among people older than 70 years. The highest age-standardised stroke-related mortality and DALY rates were in the World Bank low-income group. The fastest-growing risk factor for stroke between 1990 and 2019 was high body-mass index. Without urgent implementation of effective primary prevention strategies, the stroke burden will probably continue to grow across the world, particularly in low-income countries. Funding Bill & Melinda Gates Foundation.

The increasing burden of stroke and dementia emphasizes the need for new, well-tolerated and cost-effective primary prevention strategies that can reduce the risks of stroke and dementia worldwide, and specifically in low- and middle-income countries (LMICs). This paper outlines conceptual frameworks of three primary stroke prevention strategies: (a) the “polypill” strategy; (b) a “population-wide” strategy; and (c) a “motivational population-wide” strategy. (a) A polypill containing generic low-dose ingredients of blood pressure and lipid-lowering medications (e.g. candesartan 16 mg, amlodipine 2.5 mg, and rosuvastatin 10 mg) seems a safe and cost-effective approach for primary prevention of stroke and dementia. (b) A population-wide strategy reducing cardiovascular risk factors in the whole population, regardless of the level of risk is the most effective primary prevention strategy. A motivational population-wide strategy for the modification of health behaviors (e.g. smoking, diet, physical activity) should be based on the principles of cognitive behavioral therapy. Mobile technologies, such as smartphones, offer an ideal interface for behavioral interventions (e.g. Stroke Riskometer app) even in LMICs. (c) Community health workers can improve the maintenance of lifestyle changes as well as the adherence to medication, especially in resource poor areas. An adequate training of community health workers is a key point. Conclusion An effective primary stroke prevention strategy on a global scale should integrate pharmacological (polypill) and lifestyle modifications (motivational population-wide strategy) interventions. Side effects of such an integrative approach are expected to be minimal and the benefits among individuals at low-to-moderate risk of stroke could be significant. In the future, pragmatic field trials will provide more evidence.

Background Botulinum toxin A (BoNT-A) is considered a safe and effective treatment for spasticity and dystonia. Individual interinjection intervals are critical for the maintenance of the effect. In Austria, BoNT outpatient clinics were shutdown from November to December 2020 during COVID-19 control measures, leading to rescheduling of BoNT-A injections. This survey aimed at investigating the influence of injection delays on symptoms, physical functioning, and quality of life (QoL) of the affected patients. Methods Between April and July 2021, 32 outpatients (21 females, mean age: 63.4 ± 12.1 years) treated ≥ 12 months at the BoNT outpatient clinic Horn-Allentsteig (Austria) and experienced ≥ 2 week injection delays, completed a structured face-to-face questionnaire. Results Indications were dystonia (34%), spasticity (63%), and hyperhidrosis (3%). Injections were delayed by 10 weeks (median, range: 2–15). Muscle cramps increased in 95% of patients with spasticity, muscle twitches in 91% of those with dystonia, and pain in 9% and 60% for dystonia and spasticity, respectively. Overall, 75% reported functional worsening, and deterioration in QoL by 62.6% ± 16.8 (mean ± SD). The impact on QoL correlated with the subjective global improvement induced by BoNT-A (Rs: 0.625; p Conclusions COVID-19-related delays in BoNT-A injections illustrate the importance of this therapy for symptom relief, functional outcome, and QoL in patients suffering from involuntary muscle hyperactivity. BoNT-A therapy is essential and has to be guaranteed even in circumstances such as the COVID-19 pandemic.

Background Diabetes is an increasingly important risk factor for ischemic stroke and worsens stroke prognosis. Yet a large proportion of stroke patients who are eventually diabetic are undiagnosed. Therefore, it is important to have sensitive assessment of unrecognized hyperglycaemia in stroke patients. Design Secondary outcome analysis of a randomized controlled trial focussing on parameters of glucose metabolism and detection of diabetes and prediabetes in patients with acute ischemic stroke (AIS). Methods A total of 130 consecutively admitted patients with AIS without previously known type 2 diabetes mellitus (T2DM) were screened for diabetes or prediabetes as part of secondary outcome analysis of a randomized controlled trial that tested lifestyle intervention to prevent post-stroke cognitive decline. Patients had the oral glucose tolerance test (OGTT) and glycated hemoglobin (HbA1c) measurements in the second week after stroke onset and after 1 year. The detection rates of diabetes and prediabetes based on the OGTT or HbA1c values were compared. Results By any of the applied tests at the second week after stroke onset 62 of 130 patients (48%) had prediabetes or T2DM. Seventy-five patients had results from both tests available, the OGTT and HbA1c; according to the OGTT 40 (53.3%) patients had normal glucose metabolism, 33 (44%) had prediabetes, two (2.7%) T2DM. In 50 (66.7%) patients the HbA1c results were normal, 24 (32%) in the prediabetic and one (1.3%) in the diabetic range. The detection rate for disorders of glucose metabolism was 10% higher (absolute difference; relative difference 29%) with the OGTT compared with HbA1c. After 1 year the detection rate for prediabetes or T2DM was 7% higher with the OGTT (26% relative difference). The study intervention led to a more favourable evolution of glycemic status after 1 year. Conclusion The OGTT is a more sensitive screening tool than HbA1c for the detection of previously unrecognized glycemic disorders in patients with acute stroke with an at least a 25% relative difference in detection rate. Therefore, an OGTT should be performed in all patients with stroke with no history of diabetes. Trial registrationhttp://clinicaltrials.gov. Unique identifier: NCT01109836.

Background and purpose The aim of this pooled patient-level data analysis was to test if multidomain interventions, addressing several modifiable vascular risk factors simultaneously, are more effective than usual post-stroke care for the prevention of cognitive decline after stroke. Methods This pooled patient-level data analysis included two randomized controlled trials using a multidomain approach to target vascular risk factors in stroke patients and cognition as primary outcome. Changes from baseline to 12 months in the trail making test (TMT)-A, TMT-B and 10-words test were analysed using stepwise backward linear mixed models with study as random factor. Two analyses were based on the intention-to-treat (ITT) principle using different imputation approaches and one was based on complete cases. Results Data from 322 patients (157 assigned to multidomain intervention and 165 to standard care) were analysed. Differences between randomization groups for TMT-A scores were found in one ITT model (P = 0.014) and approached significance in the second ITT model (P = 0.087) and for complete cases (P = 0.091). No significant intervention effects were found for any of the other cognitive variables. Conclusion We found indications that multidomain interventions compared with standard care can improve the scores in TMT-A at 1 year after stroke but not those for TMT-B or the 10-words test. These results have to be interpreted with caution due to the small number of patients.

This review summarizes the potential for polypill therapies for stroke prevention. While a number of studies applying different approaches regarding polypill have been performed, none of them has had a focus on stroke as the main outcome. A combination pill containing drugs such as statins, diuretics, and other antihypertensives is currently available in various formats. Estimates focusing mostly on primary prevention show that using such a combination drug a reduction in the 5-year stroke incidence by 50% can be achieved – especially in low- and middle-income countries with a high prevalence of risk factors even among people at young ages. A combination of a large supporting population-wide program with a registry-based quality control is the most likely perspective and can be achieved within a reasonable time frame and potentially have significant influence in young stroke populations.

SUMMARYThe evolutionary potential of organisms depends on the presence of sufficient genetic variation for traits subject to selection, as well as on the genetic covariances among them. While genetic variation ultimately derives from mutation, theory predicts the depletion of genetic (co)variation under consistent directional or stabilizing selection in natural populations. We estimated and compared additive genetic (co)variances for several standard life history traits, including some for which this has never been assessed, before and after 24 generations of artificial selection on male size in the yellow dung flyScathophaga stercoraria(Diptera: Scathophagidae) using a series of standard half-sib breeding experiments. As predicted, genetic variances (VA), heritabilities (h2) and evolvabilities (IA) of body size, development time, first clutch size, and female age at first clutch were lower after selection. As independent selection lines were crossed prior to testing, we can rule out that this reduction is due to genetic drift. In contrast to the variances, and against expectation, the additive genetic correlations between the sexes for development time and body size remained strong and positive (rA =0.8–0.9), while the genetic correlation between these traits within the sexes tended to strengthen (but not significantly so). Our study documents that the effect of selection on genetic variance is predictable, whereas that on genetic correlations is not.

Definition of stroke In epidemiological studies, stroke is defined by clinical findings and symptoms [1]: rapidly developed signs of focal (or global) disturbance of cerebral function lasting more than 24 hours (unless interrupted by surgery or death), with no apparent cause other than a vascular origin. This approach is supplemented with neuroimaging but even with advanced imaging techniques the diagnosis is based on clinical signs. Therefore, precise definitions of clinical signs are needed. WHO definitions are [1]: Definite focal signs: unilateral or bilateral motor impairment (including dyscoordination) unilateral or bilateral sensory impairment aphasis/dysphasis (non-fluent speech) hemianopia (half-sided impairment of visual fields) diplopia forced gaze (conjugate deviation) dysphagia of acute onset apraxia of acute onset ataxia of acute onset perception deficit of acute onset. Not acceptable as sole evidence of focal dysfunction: dizziness, vertigo localized headache blurred vision of both eyes dysarthria (slurred speech) impaired cognitive function (including confusion) impaired consciousness seizures. (Although strokes can present in this way, these signs are not specific and cannot therefore be accepted as definite evidence of stroke.) Neuroimaging studies are needed for classification of stroke by subtypes: subarachnoid hemorrhage, intracerebral hemorrhage and brain infarction (necrosis). Although there may be large variations in stroke subtype distributions between populations, thrombotic and embolic strokes are responsible for about 80–85% of all strokes in the Indo-European populations, and as low as 65% in some Asian populations. Subarachnoid hemorrhage represents 5–10% of all strokes, and occurs more often in younger subjects, while both intracerebral and especially thrombotic and embolic stroke increase markedly with age.

The aim of primary prevention is to reduce the risk of first-ever stroke in asymptomatic people. Seven factors are regarded as potentially modifiable risk factors for vascular diseases: high blood pressure, high cholesterol, smoking, excessive or heavy regular alcohol consumption, physical inactivity, overweight and dietary factors. The strategy in primary prevention is to lower stroke risk attributed to these factors through education, lifestyle changes and medication. Non-modifiable risk factors arising from diseases such as atrial fibrillation or diabetes mellitus can be lowered by controlling and treating the underlying disorder. Targets of primary stroke prevention can be the entire population or high-risk – but stroke-free – individuals partly suffering from disorders such as hypertension or diabetes mellitus. Lifestyle factors Stroke prevalence has been associated with individual lifestyle factors (e.g. smoking, exercise, body mass index (BMI), alcohol consumption) in several studies. Healthy lifestyle in general was considered in one large prospective cohort study of healthy women. In this study, healthy lifestyle, consisting of abstinence from smoking, low-normal body mass index, moderate alcohol consumption, regular exercise and healthy diet, was found to be associated with a reduction in ischemic stroke (RR 0.3; 95% CI 0.1–0.6) [1]. Using the data of two large cohort studies, the Nurses' Health Study (71 243 women) and the Health Professionals Follow-up Study (43 685 men), Chiuve et al. [2] defined a low-risk lifestyle score based on the five lifestyle components non-smoking, moderate activity ≥ 30 min/day, healthy diet, body mass index 2 and modest alcohol consumption (men 5–30 g/day, women 5–15 g/day).

Background and aim Behavioral and lifestyle interventions in stroke patients need to be intense enough to result in sustainable treatment differences among groups of a randomized trial. Therefore, we report the effects of multidomain interventions on lifestyle and laboratory parameters after 12 and 24 months from a trial that examined whether intensive risk factor management can prevent cognitive decline in ischemic stroke patients. Methods This prospective randomized, open-label, blinded endpoint trial recruited patients within three months after acute stroke in five Austrian neurological clinics during June 2010 and November 2012. One hundred and one patients were randomized into multidomain intervention and 101 into standard care. Lifestyle interventions were individualized to match predefined targets of regular physical activity, healthy diet, and adequate physiological risk factor control. Results A total of 167 participants (80 intervention, 87 control) completed the 12-month visit and 155 (76 intervention, 79 control) the 24-month visit. During the first 12 months, adherence to healthy lifestyle and adequately controlled physiological parameters (measured by summary scores) improved significantly in the intervention group compared to controls (p Conclusions These results demonstrate that intensified individualized multidomain lifestyle interventions in stroke patients are effective in promoting healthy lifestyle in stroke care.

Background and Purpose— Cognitive impairment occurs in ≤30% of all stroke survivors. However, effective therapies aimed at preventing poststroke cognitive decline are lacking. We assessed the efficacy of a multidomain intervention on preventing cognitive decline after stroke. Methods— In this randomized, observer-blind trial patients were recruited within 3 months after an acute stroke in 5 Austrian neurological centers. Patients were assigned to a 24-month lifestyle-based multidomain intervention or standard stroke care. Primary outcomes were the cognitive subscale of the Alzheimer Disease Assessment Scale (ADAS-cog) and occurrence of cognitive decline in the composite scores of at least 2 of 5 cognitive domains at 24 months. Results— A total of 101 patients were randomized into multi-intervention and 101 into standard care during June 2010 and November 2012. Of them, 76 patients in the intervention group and 83 in the control group were included in the final intention-to-treat analysis. At 24 months, 8 of 76 (10.5%) patients in the intervention group and 10 of 83 (12.0%) patients in the control group showed cognitive decline corresponding to a relative risk reduction of 0.874 (95% confidence interval, 0.364–2.098). The change in ADAS-cog from baseline to 24 months was not different either (median 0 [IQR, −1 to 2] in both groups; P =0.808). Conclusions— This trial found no benefit of 24-month multidomain intervention with focus on improvement in lifestyle and vascular risk factors on the incidence of poststroke cognitive decline in comparison with standard stroke care. Studies with a larger sample size are needed. Clinical Trial Registration— URL: http://clinicaltrials.gov . Unique identifier: NCT01109836.

Background As type 2 diabetes (T2D) patients have a high risk for coronary heart disease (CHD) and all-cause mortality and smoking is a major single risk factor for total and CHD mortality, it is important to understand the impact of smoking to the outcome events in comparison to people without T2D. Studies of excess risk of CHD incidence and mortality, and all-cause mortality in T2D patients related to smoking are controversial. We aimed to assess the risk of CHD incidence and mortality, and all-cause mortality in a large Finnish population cohort consisting of people with and without T2Daccording to smoking status. Methods Prospective follow-up of 28 712 men and 30 700 women aged 25–64 years living in eastern and south-western Finland. The data on mortality were obtained from the nationwide death register using the unique national personal identification number. Follow-up information regarding CHD was based on the Finnish Hospital Discharge Register for non-fatal outcomes. The Cox proportional hazards models were used to estimate the association between diabetes and smoking subgroups and the risk for total and CHD mortality. Results T2D patients who were smoking had higher all-cause mortality in both men (HR 3.76; 95% CI 2.95-4.78) and women (HR 4.51; 95% CI 2.91-7.00) than non-smoking diabetic men (HR 2.03; 95% CI 1.51-2.74) and women (HR 2.11; 95% CI 1.71-2.59). The CHD mortality risk for smoking men with T2D was higher (HR 6.15; 95% CI 4.22-8.96) than in non-smoking diabetic men (HR 2.62; 95% CI 1.60-4.29). Similar results were found in women revealing corresponding HR for CHD mortality of 6.92 (95% CI 2.79-17.19) for smoking, T2D women and 4.06 (95% CI 2.83-5.82) for non-smoking T2D women, respectively. Even though the risk of CHD incidence in T2D patients who had stopped smoking was statistically significantly higher than in their non-smoking non-diabetic counterparts, their CHD incidence was lower than in smoking T2D patients (HR in men 3.00; HR in women 2.80). Conclusion It is important to address tobacco consumption in T2D patients, especially during primary health care contacts in order to reduce their high risk of CHD and all-cause mortality., published version, peerReviewed

Contains fulltext : 170402.pdf (Publisher’s version ) (Open Access) Post-stroke dementia (PSD) or post-stroke cognitive impairment (PSCI) may affect up to one third of stroke survivors. Various definitions of PSCI and PSD have been described. We propose PSD as a label for any dementia following stroke in temporal relation. Various tools are available to screen and assess cognition, with few PSD-specific instruments. Choice will depend on purpose of assessment, with differing instruments needed for brief screening (e.g., Montreal Cognitive Assessment) or diagnostic formulation (e.g., NINDS VCI battery). A comprehensive evaluation should include assessment of pre-stroke cognition (e.g., using Informant Questionnaire for Cognitive Decline in the Elderly), mood (e.g., using Hospital Anxiety and Depression Scale), and functional consequences of cognitive impairments (e.g., using modified Rankin Scale). A large number of biomarkers for PSD, including indicators for genetic polymorphisms, biomarkers in the cerebrospinal fluid and in the serum, inflammatory mediators, and peripheral microRNA profiles have been proposed. Currently, no specific biomarkers have been proven to robustly discriminate vulnerable patients ('at risk brains') from those with better prognosis or to discriminate Alzheimer's disease dementia from PSD. Further, neuroimaging is an important diagnostic tool in PSD. The role of computerized tomography is limited to demonstrating type and location of the underlying primary lesion and indicating atrophy and severe white matter changes. Magnetic resonance imaging is the key neuroimaging modality and has high sensitivity and specificity for detecting pathological changes, including small vessel disease. Advanced multi-modal imaging includes diffusion tensor imaging for fiber tracking, by which changes in networks can be detected. Quantitative imaging of cerebral blood flow and metabolism by positron emission tomography can differentiate between vascular dementia and degenerative dementia and show the interaction between vascular and metabolic changes. Additionally, inflammatory changes after ischemia in the brain can be detected, which may play a role together with amyloid deposition in the development of PSD. Prevention of PSD can be achieved by prevention of stroke. As treatment strategies to inhibit the development and mitigate the course of PSD, lowering of blood pressure, statins, neuroprotective drugs, and anti-inflammatory agents have all been studied without convincing evidence of efficacy. Lifestyle interventions, physical activity, and cognitive training have been recently tested, but large controlled trials are still missing.

Background:Dysphagia is a common complication after stroke. Early assessment of swallowing can prevent severe consequences such as aspiration pneumonia. The Gugging Swallowing Screen (GUSS), a valid and widely-used bedside-screen, has been criticised to overestimate the necessity of nasogastric tubes (NGT) compared to fiberoptic endoscopic evaluation of swallowing (FEES) in severe stroke patients. This cross-sectional study compares the diet recommendations of GUSS and FEES as well as the actually implemented diet in severe stroke patients and investigates if they differ because of the items u201evigilanceu201c and u201evoluntary coughu201c in the GUSS-pretest.Methods:The diet-recommendations given by FEES, GUSS and the actually implemented diet were compared for 20 patients with severe acute stroke (National Institute of Health Stroke Scale [NIHSS] u2265 15).Results:The GUSS recommended nothing per os (NPO) for all severe strokes; in 50% of these, FEES recommended equally NPO. For the other ten patients, the FEES recommended a less strict level-1 diet. This diet was implemented in five cases, all other patients received NPO. Eleven out of 15 patients with NPO showed insufficient vigilance whereas all five patients with level-1 diet were awake (p=0.008). Only 1/15 (7%) patients administered to NPO could cough voluntary compared to 2/5 (40%) with diet level-1 (p=0.140).Conclusion:GUSS is a suitable diagnostic-tool for dysphagia in severe stroke patients. In clinical practice, the decision for NPO is based on vigilance but not on the ability of voluntary coughing. The additional use of FEES may prevent NGT in severe stroke with good vigilance.

Introduction: Multiple, complex interventions are increasingly tested in randomized, clinical trials without enabling a clear view of the strength of the intervention, especially its probability to influence outcome. Such interventions have to be strong enough to create group differences, be acceptable by patients, be realistically designed and deliverable within the health system, and ethical. If found to have a positive effect, it should have a sustainable effect after the trial is drawn to a close. It is necessary to adapt the intensity of the intervention to contrast with guideline-based treated controls and to ensure sufficient means to carry through to the end of the trial. Method: Using a multiple domain life-style based intervention in a randomized trial to prevent cognitive decline following stroke (ClinicalTrials.gov Identifier: NCT01109836), our focus was on nutrition and physical exercise in addition to risk factor management. We performed single component analysis as well as the use of a life-style summary score and a laboratory supported life-style summary score. Results: 80 participants in the intervention group and 87 in the control group completed the 12 months visit. We found a significant improvement in adherence to healthy lifestyle factors and adequately controlled physiological parameters as well as significant differences for both summary scores, all p 2 and currently non-smoking. Laboratory values included blood pressure Conclusion: Complex interventions used for secondary prevention stroke trials have to be intense enough to become effective when comparing to treatment according to current guidelines.