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IntroductionThe ongoing ageing population is associated with an increase in the number of patients suffering a stroke, transient ischaemic attack (TIA) or myocardial infarction (MI). In these patients, implementing secondary prevention is a critical challenge and new strategies need to be developed to close the gap between clinical practice and evidence-based recommendations. We describe the protocol of a randomised clinical trial that aims to evaluate the efficiency and effectiveness of an intensive multidisciplinary follow-up of patients compared with standard care.Methods and analysisThe DiVa study is a randomised, prospective, controlled, multicentre trial including patients >18 years old with a first or recurrent stroke (ischaemic or haemorrhagic) or TIA, or a type I or II MI, managed in one of the participating hospitals of the study area, with a survival expectancy >12 months. Patients will be randomised with an allocation ratio of 1:1 in two parallel groups: one group assigned to a multidisciplinary, nurse-based and pharmacist-based 2-year follow-up in association with general practitioners, neurologists and cardiologists versus one group with usual follow-up. In each group for each disease (stroke/TIA or MI), 430 patients will be enrolled (total of 1720 patients) over 3 years. The primary outcome will be the incremental cost–utility ratio at 24 months between intensive and standard follow-up in a society perspective. Secondary outcomes will include the incremental cost–utility ratio at 6 and 12 months, the incremental cost-effectiveness ratio at 24 months, reduction at 6, 12 and 24 months of the rates of death, unscheduled rehospitalisation and iatrogenic complications, changes in quality of life, net budgetary impact at 5 years of the intensive follow-up on the national health insurance perspective and analysis of factors having positive or negative effects on the implementation of the project in the study area.Ethics and disseminationEthical approval was obtained and all patients receive information about the study and give their consent to participate before randomisation. Results of the main trial and each of the secondary analyses will be submitted for publication in a peer-reviewed journal.Trial registration numberClinicalTrials.gov Identifier:NCT04188457. Registered on 6 December 2019.

Background Giant cell arteritis (GCA) is the most common vasculitis in people ≥50 years and can be associated with stroke. We aimed to evaluate the epidemiology and characteristics of stroke in patients with GCA. Methods All patients with a biopsy-proven diagnosis of GCA were identified among residents of the city of Dijon, France (152 000 inhabitants), between 2001 and 2012 using a prospective database. Among these, patients who suffered from stroke were retrieved by crossing data from the population-based Dijon Stroke Registry. Demographics and clinical features were recorded. We considered that the stroke was GCA-related if the stroke revealed GCA or occurred between the onset of symptoms and 4 weeks after the start of treatment. Results Among the 57 biopsy-proven patients with GCA (incidence rate 10.9/100 000/year in individuals ≥50 years), 4 (7.0%) experienced a GCA-related stroke. Three were men and all had ≥2 vascular risk factors and were ≥80 years. The stroke was vertebrobasilar for 3/4 patients and undetermined for the remaining one. The incidence rate of GCA-related stroke in patients ≥50 years was 0.76/100 000/year (95% CI 0 to 2.47), 1.36/100 000/year in men (95% CI 0 to 3.63) and 0.33/100 000/year (95% CI 0 to 1.45) in women. Conclusions This population-based study demonstrated that GCA-related stroke essentially affects the vertebrobasilar territory and mainly occurs in old men with associated vascular risk factors. Although rare, GCA symptoms must be searched for in elderly patients with stroke, and optimal vascular prevention must be conducted carefully in patients with GCA with a high vascular risk before initiating GCA treatment.

Recent data have suggested that stroke incidence in young people may be rising. In this population-based study, we aimed to determine whether the incidence of stroke in people aged55 years old had changed over the last three decades.All cases of first-ever stroke (ischaemic stroke, spontaneous intracerebral haemorrhage, and undetermined stroke) occurring in Dijon, France, from 1985 to 2011 were prospectively collected from a population-based registry. Incidence rates were calculated and temporal trends were analysed by age groups and stroke subtypes using a Poisson regression to estimate incidence rate ratios (IRR). Risk factors and premorbid treatments were analysed.Over the 27-year study period, 4506 patients were recorded (53% women, mean age 74.6±14.4, 10.1% aged55 years). An increase in overall stroke incidence was noted, as was a rise in ischaemic stroke in individuals aged55 years (IRR 1.308; 95% CI 0.982 to 1.741, p=0.066 for period 1994-2002 vs period 1985-1993, and IRR 1.697; 95% CI 1.340 to 2.150, p0.001 for period 2003-2011 vs period 1994-2002), which was consistent for men and women. In these young patients, smoking was the most frequent risk factor (43%).Multiple factors may account for the increased incidence of ischaemic stroke in people aged55 years including changes in vascular risk factors, better awareness of the disease and treatment options in the population and among practitioners leading to more frequent referrals for specialised care, and improvements in stroke diagnosis. Stroke prevention must be encouraged even in young adults.

Background The need for stroke care is escalating with an ageing population, yet methods to estimate the delivery of effective care across countries are not standardised or robust. Associations between quality and intensity of care and stroke outcomes are often assumed but have not been clearly demonstrated. Objective To examine variations in acute care processes across six European populations and investigate associations between the delivery of care and survival. Methods Data were obtained from population-based stroke registers of six centres in France, Lithuania, UK, Spain, Poland and Italy between 2004 and 2006 with follow-up for 1 year. Variations in the delivery of care (stroke unit, multidisciplinary team and acute drug treatments) were analysed adjusting for case mix and sociodemographic factors using logistic regression methods. Unadjusted and adjusted survival probabilities were estimated and stratified by levels of Organised Care Index. Results Of 1918 patients with a first-ever stroke registered, 30.7% spent more than 50% of their hospital stay in a stroke unit (13.9–65.4%) among centres with a stroke unit available. The percentage of patients assessed by a stroke physician varied between 7.1% and 96.6%. There were significant variations after adjustment for confounders, in the organisation of care across populations. Significantly higher probabilities of survival (p

Objectives To confirm the effects of short-term exposure to ozone (O 3 ) on ischaemic heart and cerebrovascular disease. Methods Daily levels of urban O 3 pollution, the incidence of first-ever, recurrent, fatal and non-fatal ischaemic cerebrovascular events (ICVE) and myocardial infarction (MI) were correlated using a case-crossover design. The authors analysed 1574 ICVE and 913 MI that occurred in Dijon, France (150 000 inhabitants) from 2001 to 2007. Sulfur dioxide (SO 2 ), nitrogen dioxide (NO 2 ), carbon monoxide (CO) and particulate matter with an aerodiameter of ≤10 μg/m 3 (PM 10 ) were used to create bi-pollutant models. Using the adjusted OR, the effects of O 3 exposure were calculated for every 10 μg/m 3 increase in pollutants in multivariate logistic models adjusted for temperature, humidity, flu outbreaks and holidays. Results The authors found a significant association between exposure to O 3 and recurrent ICVE with a 3-day lag (OR=1.115; 95% CI 1.027 to 1.209). The direction and magnitude of the association between exposure to O 3 and recurrent MI were similar but not statistically significant. For incident events, the authors detected only a non-significant association for ICVE with a 2-day lag (OR=1.041; 95% CI 0.996 to 1.089). In the subgroup analysis for ICVE, the authors observed an increased association with cardiovascular risk factors (OR=1.523; 95% CI 1.149 to 2.018). For MI, the authors found an association with O 3 when hypercholesterolaemia was present (OR=1.111; 95% CI 1.020 to 1.211), and the association became stronger with the number of cardiovascular risk factors. The authors found a marked dose–response relationship. Conclusion Recurrent ICVE and MI could be triggered by short-term exposure to even low levels of O 3 , especially among subjects with severe vascular risk factors.

There is little reliable population based information about the distribution of risk factors among the various ischaemic stroke subtypes, even though determining risk factor profiles is of major importance to develop targeted preventive strategies.The distribution of first ever ischaemic stroke subtypes was established in a prospective population based study conducted in Dijon, France (152,606 inhabitants). Cases were collected between January 2005 and December 2006, and were classified using TOAST classification. Vascular risk factors were recorded to determine a risk factor profile for each subtype.332 patients with first ever ischaemic stroke (150 men and 182 women) were recorded. Adjusted incidence to world population was 54/100,000/year. The distribution of ischaemic stroke subtypes was as follows: 119 (35.8%) cases of large artery atherosclerosis, 89 (26.8%) small artery occlusions, 81 (24.4%) cardioembolisms and 43 (13%) other and undetermined causes. The most frequent vascular risk factor was hypertension, irrespective of the ischaemic stroke subtype, with a total prevalence of 62%. Using multivariate regression, a positive association between cardioembolism and age (OR 1.051; 95% CI 1.026 to 1.076; p0.001) was demonstrated and between small artery occlusion and either high blood pressure (OR 1.86; 95% CI 1.06 to 3.27; p = 0.03) or hypercholesterolaemia (OR 2.23; 95% CI 1.33 to 3.76; p = 0.02).This comprehensive prospective population based study has demonstrated that vascular risk factors exhibit a particular distribution according to the ischaemic stroke subtypes. These findings, as well as the great frequency of hypertension among stroke patients, have implications for prevention strategies, the design of clinical trials and the organisation of health care services.

Context The management of acute stroke has become a structuring model in hospital organisation with the aim to improve the acute care of stroke. Stroke has become a medical emergency since the arrival of new active treatments in cerebral infarction. Fibrinolysis, for example, needs to be administered within the first 3 hours following admission to a stroke unit. The fact that stroke is a race against time is a new reality for carers. In contrast, the consequences of a poorly organised network may be severe. If fibrinolysis were used in all of the eligible cases of cerebral infarction, we could avoid 7500 deaths or severe handicap in France every year. Objectives What triggered our interest in setting up the Professional Practice Evaluation (PPE) was the realisation in 2006 that in Dijon University Hospital only a small number of interventions involved fibrinolysis (a mean of 12 per year). The principal aim of the PPE was to identify the intrahospital factors that led to delay in admission to the Stroke Unit at Dijon CHU, while the secondary objective was to increase the use of fibrinolysis every year. Methods All of those involved in the stroke network were trained according to a standardised protocol from 01 January 2006 to 30 September 2006: Staff working in the emergency room, imaging services, biology laboratory, ambulance and transportation services and stroke unit. The indicators, which were compared before and after the PPE, were the following: the delay to imaging, to biological results, to arrival at the stroke unit and the number of fibrinolysis. This prospective work was performed from 01 January 2006 to 30 September 2006, and was evaluated in 2007, and the data were compared to prior data collected since 1985 by the Dijon Stroke Registry. Results We observed the following results: the proportion of imaging performed within the first 3 hours rose from 46% to 83 %; the mean delay to imaging decreased from156 min to 115 min, the time from arrival to imaging dropped from 87 to 37 min; the time between arrival and biological results decreased from 70 to 32 min; the mean annual number of fibrinolyses performed, around 12 per year between 2003 to 2006, tripled in 2007 and by 6 in 2008. Discussion The training of the different professionals dramatically improved all the parameters evaluated, leading to a huge increase in the number of fibrinolyses, and inestimable benefits for stroke patients. Moreover, all the services that were considered unsatisfactory, such as imaging, biological analyses and ambulance, reacted positively, which made it possible to improve the parameters. We found that carers were willing to revise their usual practices without a feeling of guilt, and thus generated a huge improvement in the whole care process. Perspectives We are evaluating the benefits in terms of the decrease in mortality and handicap since the implementation of PPE. Conclusion We have demonstrated that at no extra cost it is possible to improve a stroke network due to awareness teaching and training of the different carers, the recognition of their role and work, their responsibilities, leading to measurable progress in treatment and increased job satisfaction for carers. Contexte La prise en charge des AVC est devenue un modele structurant dans l9organisation des hopitaux pour optimiser la prise en charge de cette maladie. L9AVC est devenu une urgence medicale du fait de l9arrivee de therapeutiques actives dans l9infarctus cerebral avec la fibrinolyse intraveineuse par rt-Pa, a condition d’etre appliquees dans les 3 premieres heures dans une Unite Neuro-Vasculaire (UNV). La notion d9une course contre la montre est une realite dont chaque acteur de la prise en charge des AVC doit avoir conscience. A l9oppose, les consequences d9une prise en charge non organisee peuvent etre graves. Si tous les infarctus cerebraux eligibles a une fibrinolyse beneficiaient de cette therapeutique, 7 500 deces ou handicap severe pourraient etre evites en France chaque annee. Objectifs L’element declencheur qui a suscite en 2006 notre demarche d9une Evaluation des Pratiques Professionnelles (EPP) repose sur le constat du faible nombre de fibrinolyses effectuees au CHU de Dijon avec une moyenne de 12 fibrinolyses par an. L9objectif principal de notre EPP a ete d9identifier les determinants intra-hospitaliers a l9origine du retard d9admission a l9UNV du CHU de DIJON tandis que l9objectif secondaire a ete l9augmentation du nombre de fibrinolyses chaque annee. Methodes L9ensemble des intervenants de la filiere a ete sensibilise et forme entre le 01/01/2006 et le 30/03/2006: le personnel soignant du Service Regional d9Accueil des Urgences, du Scanner, du Service de Biochimie, du Service des Ambulanciers et de Brancardage et de l9UNV. Les indicateurs retenus pour l’evaluation de la filiere avant et apres formation, ont ete: le delai d9obtention du scanner, le delai d9obtention des examens biologiques, le delai d9arrivee a l9UNV et le nombre de fibrinolyses effectue. Ce travail prospectif, effectue du 01/01/2006 au 30/09/2006 et evalue en 2007, a permis de comparer les donnees anterieures a la formation, recueillies par le Registre Dijonnais des AVC qui fonctionne depuis 1985. Resultats Les resultats sur les indicateurs ont ete les suivants: le taux de scanners effectue dans les 3 premieres heures est passe de 46 % a 83 %; le delai moyen d9imagerie est passe de 109 a 54 minutes; le delai entre l9appel et l9imagerie a diminue de 156 a 115 minutes; le delai entre l9arrivee et l9imagerie a chute de 87 a 37 minutes; le delai entre l9arrivee et l9obtention des resultats biologiques est passe de 70 a 32 minutes; le nombre moyen de fibrinolyse annuelle effectue entre 2003 et 2006 compris entre 10 et 12, a ete multiplie par 3 en 2007, par 6 en 2008. Discussion Les 6 mois de formation des differents maillons de la filiere AVC ont permis indiscutablement d9ameliorer tous les parametres mesures, aboutissant a une augmentation remarquable du nombre des fibrinolyses, c9est-a-dire un service medical rendu aux patients inestimable. D9autre part, les indicateurs qui avaient ete analyses comme insuffisants, comme l9acces au scanner, l9acces a l9USINV, l9acces a la biologie, aux ambulanciers et au brancardage, ont suscite des reponses positives qui ont permis d9ameliorer tous les indicateurs. Nous avons observe une remise en cause non culpabilisante des differents intervenants aboutissant a une amelioration active de l9ensemble de la filiere. Perspectives Nous sommes en train d’evaluer la gain en terme de baisse de la mortalite et du handicap depuis cette EPP. Conclusion A moyens constants, nous avons demontre qu9il etait possible d9ameliorer l9efficience d9une filiere intra-hospitaliere pour les AVC par la sensibilisation et la formation ciblee des differents acteurs concernes, la reconnaissance de leur role et de leur travail et leur responsabilisation aboutissant a une amelioration des soins et valorisante pour les professionnels de sante.

Over recent decades, the emergence of evidence-based medicine has largely contributed to our knowledge of vascular risk factors for stroke. Hence, there has been considerable progress in secondary prevention of stroke thanks to randomised clinical trials, which have highlighted the efficacy of several therapies in reducing the risk of stroke recurrence and mortality. This has led to the publication of guidelines for stroke management worldwide.1 2 However, the extent to which these guidelines have been applied and their impact on the outcome in patients with stroke still need to be explored on a larger scale. A recent systematic review of population-based studies demonstrated a decline in …