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Introduction: Stroke induces changes in plasma microRNA (miRNA) expression in the first 24hrs post-injury, but few have characterized miRNA expression during the early recovery phase. Hypothesis: We hypothesized that plasma miRNA expression would evolve over the first month post-stroke with fewer significantly altered miRNAs over time as inflammation and edema resolve. Methods: Longitudinal samples were collected 5, 15, and 30 days post-stroke from 2 studies (BIOREC and MORSE, n=55 combined at each time point) and compared to controls matched for age, sex, race and cardiovascular comorbidities. Stroke samples collected on average around day 15 from a second study (CPASS, n=48) were also compared to matched controls and used as a validation cohort. MiRNA expression was determined with OpenArray qRT-PCR quantifying 758 miRNAs. Significant miRNAs had a corrected p-value less than 0.05 and fold-change greater than |1.5|. Results: Eight miRNAs remained significantly altered across all 3 time points in the discovery cohort and in the day 15 validation cohort (decreased expression compared to controls: miR-101-3p, miR-107, miR-16-2-3p, miR-19a-3p, miR-19b-3p, and miR-26b-5p; increased expression: miRNA-199a-3p and miR-652-3p). The number of significant miRNAs more than doubled from post-stroke day 5 to days 15 and 30 (19, 53, and 45 miRNAs respectively in BIOREC/MORSE, 49 miRNAs at day 15 in CPASS). At day 5 most significant miRNAs (14/19) showed decreased expression compared to controls whereas by day 30 most demonstrated increased expression (36/45). Many of the significant miRNAs, including miR-107 and miR-652-3p, and many others at days 15 and 30 were enriched in brain or CSF in prior studies. Conclusions: While several miRNAs show significant change in expression consistently from 5 to 30 days post-stroke, there is also an expansion of significant miRNAs at days 15 and 30. This expansion includes many miRNAs enriched in brain or CSF and could represent a shift from inflammation to neural repair processes, but this requires further study.

Stroke is the second leading cause of death and the third leading cause of disability-adjusted life years worldwide. Although numerous therapies have been developed over the past 10 years to treat acute ischemic stroke, the stark reality remains that only 5% of these patients are so treated in the United States,1 in part, because of treatment window times 7 million stroke survivors …

Background: Genetic factors may be useful to understand differences in outcomes post-stroke. We studied an imaging measure of brain atrophy in relation to two genotypes that may be associated with differences in stroke recovery, the val 66 met genotype for brain-derived neurotrophic factor (BDNF) and the ApoE e4 genotype. Each genotype has been associated with brain atrophy in non-stroke populations. The current study hypothesized that each genotype is associated with brain atrophy after stroke. Methods: The ICARE Study examined behavioral outcomes after stroke in relation to motor therapies. Of 361 ICARE enrollees, genetic and neuroimaging data were available in 127. The volume of the ventricles and the brain were measured, and brain atrophy expressed as the Ventricle-Brain Ratio (VBR). For MRI scans, VBR was first extracted from the scans using ALVIN then manually refined. For CT scans, VBR was extracted manually. All VBR measurements were verified by a neuroimaging expert. VBR was examined in relation to the two genotypes of interest, BDNF val 66 met and ApoE e4, controlling for the 3 covariates employed in ICARE: motor deficits, enrollment site, and time post-stroke at study entry. Results: There were 61 MRI and 66 CT scans. These were acquired 5±11 days post-stroke, which did not vary according to either genotype. Median ventricle volume=26.1 cc; brain volume=1,163 cc; and VBR=0.024. The BDNF val 66 met genotype was present in 23 subjects; ApoE e4, in 41; both were in HW equilibrium. Presence of the BDNF val 66 met genotype was associated with greater atrophy: median VBR increased 1.97-fold when this genotype was present vs. absent (p=0.01), controlling for above covariates; and remained significant (p=0.04) when also controlling for age. This BDNF gene-imaging correlate did not extend to gene-behavioral findings. The ApoE e4 genotype was not related to VBR (p=0.88). Conclusions: Median degree of brain atrophy is 97% greater in patients with stroke when the BDNF val 66 met genotype is present, at least for the mild-moderately impaired subjects enrolled in ICARE. Understanding the biology of inter-subject differences in brain anatomy after stroke can provide insights into patient heterogeneity and inform efforts to individualize stroke recovery therapies.

Introduction: MicroRNAs are small, non-coding RNAs that control gene expression by inhibiting protein translation. Preclinical studies in rodent stroke models suggest that changes in microRNA expression contribute to neural repair mechanisms. To our knowledge, no one has previously assessed microRNA changes during the recovery phase of human stroke. Hypothesis: Patients with significant upper limb recovery following stroke will have alteration of neural repair-related microRNA expression when compared to those with poor recovery. Methods: Plasma was collected at 19 days post-stroke from 27 participants with mild-moderate upper extremity impairment enrolled in the Critical Periods After Stroke Study (CPASS). MicroRNA expression was assessed using TaqMan microRNA assays (Thermo Fisher Scientific). Good recovery was defined as ≥ 6 point change in the Action Research Arm Test (ARAT) score from baseline to 6 months. Bioinformatics analysis compared the plasma microRNA expression profiles of participants with good vs. poor recovery. Candidate biomarkers were identified after correcting for multiple comparisons using a false discovery rate < 0.05. Results: Eleven microRNAs had significantly altered expression in the good (n=22) vs. poor (n=5) recovery groups, with two showing increased expression - miR-371-3p and miR-520g, and nine showing decreased expression - miR-449b, miR-519b, miR-581, miR-616, miR-892b, miR-941, miR-1179, miR-1292 and miR1296. Three of these could be implicated in neural repair mechanisms. Elevated miR-371-3p levels increase the likelihood that pluripotent stem cells will differentiate into neural progenitors. MiR-892b decreases levels of amyloid precursor protein, which has been implicated as a regulator of synapse formation. Finally miR-941, the only known human-specific microRNA, downregulates the CSPα protein which is involved in neurotransmitter release. Conclusions: This preliminary study suggests that circulating microRNAs in the plasma may help serve as biomarkers of neural repair and aid in understanding human neural repair mechanisms. If validated in larger studies with appropriate controls, these markers could aid in timing rehabilitation therapy or designing recovery-based therapeutics.

Introduction: Lasagna’s Law, that the prevalence of a disease falls to 10% of your estimate the day you start recruitment , is relevant for stroke rehab trials. Data describing the problem are limited for very early trials (within 30 days) since most trials focus on more chronic survivors and moderate upper-extremity (UE) impairment (NIHSS motor arm > 0). Very early trials are important for rehab because animal data suggest very early intervention may improve recovery. We thus provide estimates on barriers to recruitment for very early rehabilitation trials in the US. Methods: We used screening data for the Phase II Critical Periods After Stroke Study RCT, designed to identify when after stroke patients are most responsive to motor training. Starting Aug 2014, 893 patients eventually admitted to inpatient rehab were screened (5 ±2 days post stroke). Results: We enrolled 4.3% of those screened, at 15.5 ±4.9 days post stroke. Participants had ischemic/hemorrhagic stroke within 28d, and moderate UE impairment (NIHSS motor arm > 0 and manual muscle test score >2- on shoulder flexion/abduction). The largest % were excluded for being “too mild” (35.7%, NIHSS motor arm = 0), or “too late” (18%, unable to receive first study-related treatment < 30 days of stroke). A smaller percentage were “too severe” (3.6%, UE motor assessment scale Conclusion: Frequent barriers to recruitment for inpatient rehab trials include persistent but too mild UE motor impairment and delayed admission to inpatient rehab. For early intervention studies, screening and treatment must begin in the acute hospital setting. Further, there is a patient subset whose motor impairment persists, but is too mild for most trials. These mildly affected individuals warrant more investigation.

The purpose of this review is to provide an update on the latest neurorehabilitation literature for motor recovery in stroke and traumatic brain injury to assist clinical decision making and assessing future research directions.The emerging approach to motor restoration is now multimodal. It engages the traditional multidisciplinary rehabilitation team, but incorporates highly structured activity-based therapies, pharmacology, brain stimulation and robotics. Clinical trial data support selective serotonin reuptake inhibitors and amantadine to assist motor recovery poststroke and traumatic brain injury, respectively. Similarly, there is continued support for intensity as a key factor in activity-based therapies, across skilled and nonskilled interventions. Aerobic training appears to have multiple benefits; increasing the capacity to meet the demands of hemiparetic gait improves endurance for activities of daily living while promoting cognition and mood. At this time, the primary benefit of robotic therapy lies in the delivery of highly intense and repetitive motor practice. Both transcranial direct current and magnetic stimulation therapies are in early stages, but have promise in motor and language restoration.Advancements in neurorehabilitation have shifted treatment away from nonspecific activity regimens and amphetamines. As the body of knowledge grows, evidence-based practice using interventions targeted at specific subgroups becomes progressively more feasible.

Background and Purpose— The National Institute of Neurological Disorders and Stroke initiated development of stroke-specific Common Data Elements (CDEs) as part of a project to develop data standards for funded clinical research in all fields of neuroscience. Standardizing data elements in translational, clinical, and population research in cerebrovascular disease could decrease study start-up time, facilitate data sharing, and promote well-informed clinical practice guidelines. Methods— A working group of diverse experts in cerebrovascular clinical trials, epidemiology, and biostatistics met regularly to develop a set of stroke CDEs, selecting among, refining, and adding to existing, field-tested data elements from national registries and funded trials and studies. Candidate elements were revised on the basis of comments from leading national and international neurovascular research organizations and the public. Results— The first iteration of the National Institute of Neurological Disorders and Stroke (NINDS) stroke-specific CDEs comprises 980 data elements spanning 9 content areas: (1) biospecimens and biomarkers; (2) hospital course and acute therapies; (3) imaging; (4) laboratory tests and vital signs; (5) long-term therapies; (6) medical history and prior health status; (7) outcomes and end points; (8) stroke presentation; and (9) stroke types and subtypes. A CDE website provides uniform names and structures for each element, a data dictionary, and template case report forms, using the CDEs. Conclusions— Stroke-specific CDEs are now available as standardized, scientifically vetted, variable structures to facilitate data collection and data sharing in cerebrovascular patient-oriented research. The CDEs are an evolving resource that will be iteratively improved based on investigator use, new technologies, and emerging concepts and research findings.

Constraint-induced movement therapy (CIMT) is among the most developed training approaches for motor restoration of the upper extremity (UE).Very Early Constraint-Induced Movement during Stroke Rehabilitation (VECTORS) was a single-blind phase II trial of CIMT during acute inpatient rehabilitation comparing traditional UE therapy with dose-matched and high-intensity CIMT protocols. Participants were adaptively randomized on rehabilitation admission, and received 2 weeks of study-related treatments. The primary endpoint was the total Action Research Arm Test (ARAT) score on the more affected side at 90 days after stroke onset. A mixed model analysis was performed.A total of 52 participants (mean age 63.9 +/- 14 years) were randomized 9.65 +/- 4.5 days after onset. Mean NIHSS was 5.3 +/- 1.8; mean total ARAT score was 22.5 +/- 15.6; 77% had ischemic stroke. Groups were equivalent at baseline on all randomization variables. As expected, all groups improved with time on the total ARAT score. There was a significant time x group interaction (F = 3.1, p0.01), such that the high intensity CIT group had significantly less improvement at day 90. No significant differences were found between the dose-matched CIMT and control groups at day 90. MRI of a subsample showed no evidence of activity-dependent lesion enlargement.Constraint-induced movement therapy (CIMT) was equally as effective but not superior to an equal dose of traditional therapy during inpatient stroke rehabilitation. Higher intensity CIMT resulted in less motor improvement at 90 days, indicating an inverse dose-response relationship. Motor intervention trials should control for dose, and higher doses of motor training cannot be assumed to be more beneficial, particularly early after stroke.

The purposes of this report were to: 1) determine the amount of upper extremity use in people with hemiparesis post stroke during their inpatient rehabilitation stay, and 2) to examine the relationships between upper extremity use and impairments and activity limitations at this early time point after stroke. We studied 34 subjects with mild-to-moderate acute hemiparesis (mean time since stroke = 9.3 days) and 10 healthy control subjects. Upper extremity use was measured over 24 hours using bilateral wrist accelerometers. Upper extremity impairments and activity limitations were measured using standard clinical techniques and tests. We found that healthy control subjects use their dominant and nondominant upper extremities 8-9 hours per day. Hemiparetic subjects used their affected and unaffected upper extremities substantially less than control subjects, 3.3 and 6.0 hours per day, respectively. Seven of ten impairment level measures and each of the activity level measures were related to affected upper extremity use. The impairment measures that were related to upper extremity use were those measures that assessed the ability to activate muscles (ie active range of motion and force production) and the measurement of shoulder pain. Our data show that affected upper extremity use is minimal during the inpatient rehabilitation stay, especially given that patients in this setting are required to have 3 hours of therapy per day. We speculate that accelerometer measurements of upper extremity use could be used in a variety of settings and that the objective information they provide would be of great value to clinicians as they select treatments and evaluate progress.

Background: Cognitive dysfunction has been considered a primary deficit to be addressed after mild stroke. Higher order cognitive deficits immediately after mild stroke may lead to poor longitudinal outcomes. However, existing stroke outcome studies tend to focus on physical capacity and mood rather than cognitive function. Aim: To examine contribution of acute impairment of executive function(EF) and verbal memory (VM) after mild stroke to one year outcomes on Stroke Impact Scale (SIS, health-related quality of life), Activity Card Sort (ACS, activity participation), and Reintegration to Normal Living (RNL, life satisfaction), independent of demographics, ADL and depression. Methods: Patients with ischemic stroke and initial NIHSS ≤ 5 enrolled in PROTECT-DC trial were included. Multiple linear regression analyses identified baseline variables significantly associated with each outcome of interest for all patients completing both baseline and one-year assessments. For each outcome, Model 1 included covariates: age, sex, race, education, lesion side, NIHSS, Barthel Index, Lawton IADL, and depression. In Model 2, all Model 1 variables and dichotomized cognitive variables (impaired versus not impaired) were entered into the equation. Examination of R2 change between Models 1 & 2 identified unique contributions of impaired EF or VM to each one-year outcome beyond Model 1 variables. Results: A total of 86 participants completed baseline assessment and one-year SIS were included for analyses. Our results show that EF was significantly and independently associated with the SIS total score beyond other baseline variables. Participants with acute EF deficits at baseline had poorer SIS outcome at one year: mean 7.47 lower SIS score compared to patients without EF deficits (p = .021). Similar results were found for ACS and RNL. Conclusion: Analyses suggest impact of EF deficits on activity participation, health-related quality of life, and life satisfaction one year after mild stroke. The findings highlight importance of assessment of EF deficits after mild stroke. We suggest that rehabilitation interventions aimed at improving long-term outcomes require careful consideration of assessing and treating EF deficits during the acute phase of mild stroke.

Background: A NIHSS total score ≤ 5 is a common criteria for mild stroke. Persons with scores in this range are often considered too mild for tPa treatment and not in need of rehabilitation. There may be distinct patterns of stroke symptoms, possibly not all deficits or combination of deficits produce similar levels of disability. Aim: To investigate if patient profiles created by analysis of initial NIHSS item scores predict 90 day and 1 year outcome on the Modified Rankin Scale (mRS) and Stroke Impact Scale (SIS). Methods: Patients with ischemic stroke and initial NIHSS score ≤ 5 enrolled in the PROTECT DC trial were included. Latent class analysis of NIHSS items was used to create discrete symptom profiles: patients with similar item responses were grouped within the same profile group. Logistic regression using profile groups as independent variables predicted 90 day and 1 year mRS scores. Kruskal-Wallace tests examined differences on Stroke Impact Scale (SIS) Participation scores across the groups. Results: 153 participants were included in the latent class analysis, yielding a 3-profile model. Profile A (82 patients, 54%) represented mild strokes with low probability of abnormality on all NIHSS items. Profile B (16 patients, 11%) patients had right-side motor impairment and sensory deficits. Profile C (55 patients, 36%) patients were more likely to have facial palsy and dysarthria. The median NIHSS score decreased from the most severe Profile B (mdn=3.00) to the most mild Profile A (mdn=1.00), with Profile C (mdn=2.00) between the two extremes. Profile B had significantly higher rates (p Conclusion: Patients with initial NIHSS scores ≤ 5 with right-side motor weakness and sensory deficits had more unfavorable outcomes. We suggest that mild strokes are not a homogenous group and should not be treated equally in clinical settings.

For phase III RCTs, sample heterogeneity is useful for both generalizability of findings and providing insight into treatment effects for specific subgroups. Prior studies in stroke rehabilitation have rarely explored differences in intervention effects between racial and ethnic subgroups across participating sites. We examined participant characteristics across centers, with the hypothesis that strategic use of a multi-center structure across 3 distinct urban geographical areas (Atlanta, GA, Los Angeles, CA and Washington, DC) would generate a sample diverse enough to explore differences in treatment effects by racial and ethnic subgroups Methods: The ICARE Stroke Initiative is a randomized multi-center clinical trial designed to compare the effectiveness of the Accelerated Skill Acquisition Program (ASAP) to an equivalent dose of usual and customary outpatient occupational therapy (DEUCC) and a monitoring only usual therapy group (UCC). Demographics, stroke characteristics and cognitive outcomes collected at baseline for randomized participants (N = 361) were compared across the 3 centers using ANOVA or χ2 tests for continuous and categorical outcomes, respectively. Results: We found significant differences in race and ethnicity (p Conclusions: ICARE’s strategic center selection resulted in a diverse and robust dataset, allowing for post hoc exploration of treatment effect differences by subgroup and for the intention-to-treat analysis, determination of generalizability of treatment effects across a racially and ethnically diverse population.

Background and Purpose —We sought to determine predictors of acute hospital costs in patients presenting with acute ischemic stroke to an academic center using a stroke management team to coordinate care. Methods —Demographic and clinical data were prospectively collected on 191 patients consecutively admitted with acute ischemic stroke. Patients were classified by insurance status, premorbid modified Rankin scale, stroke location, stroke severity (National Institutes of Health Stroke Scale score), and presence of comorbidities. Detailed hospital charge data were converted to cost by application of department-specific cost-to-charge ratios. Physician’s fees were not included. A stepwise multiple regression analysis was computed to determine the predictors of total hospital cost. Results —Median length of stay was 6 days (range, 1 to 63 days), and mortality was 3%. Median hospital cost per discharge was $4408 (range, $1199 to $59 799). Fifty percent of costs were for room charges, 19% for stroke evaluation, 21% for medical management, and 7% for acute rehabilitation therapies. Sixteen percent were admitted to an intensive care unit. Length of stay accounted for 43% of the variance in total cost. Other independent predictors of cost included stroke severity, heparin treatment, atrial fibrillation, male sex, ischemic cardiac disease, and premorbid functional status. Conclusions —We conclude that the major predictors of acute hospital costs of stroke in this environment are length of stay, stroke severity, cardiac disease, male sex, and use of heparin. Room charges accounted for the majority of costs, and attempts to reduce the cost of stroke evaluation would be of marginal value. Efforts to reduce acute costs should be monitored for potential cost shifting or a negative impact on quality of care.

Background: Executive functions (EF) are essential for independence and engagement in complex activities. Neuropsychological and functional evaluations of stroke outcome may be insensitive to subtle EF deficits present in mild stroke (mCVA) despite low NIHSS scores and excellent outcome based on the Barthel Index (BI>95) and Modified Rankin Scale (MRS< 1). We evaluated EF deficits in 25 individuals with first mCVA (admission NIHSS < 5) and 21 matched controls on the Multiple Errands Test-Revised (MET-R). Methods: Inclusion criteria: age > 18 years, first clinical stroke, functional independence (pre-stroke BI >95 and MRS < 1) and community residence at admission and 6 month follow-up. Demographic and clinical information were obtained at acute admission to acute neurology stroke service. Stroke was confirmed by a neurologist and acute imaging reviewed to score stroke lesions and location and white matter disease. Six month follow-up included a neuropsychological test battery, self-reported outcomes by the Stroke Impact Scale (SIS) and Reintegration to Normal Living Scale (RNLI) and the MET-R, a performance test previously used with TBI. The MET-R is a timed test which requires following standard instructions and rules while performing multiple tasks in a real-world environment. Results: Sample mean age was 60 ± 10.8 years; 65% female and 30 % Black, with no significant demographic differences between groups. The mCVA group reported SIS Global Recovery Scores of 68 ± 21.6, Participation Scores of 73.8 ±24.1 and Memory Scores of 77.2 ± 17.5. Differences between controls and the mCVA group were significant for MET-R sub-scores including: Tasks Completed (p Conclusion: Persons with Persons with mCVA lacking obvious cognitive or motor impairments may be discharged home without rehabilitation or support because currently available measures are inadequate to identify the presence of EF deficits. Subjective complaints of difficulty with cognitively demand activities at follow-up should be evaluated. Rehabilitation can effectively address these deficits.

Background: Many stroke trials fail to meet recruitment goals or need additional time to accrue sufficient subjects to support hypothesis testing. Many investigators also report difficulties recruiting diverse samples. One cause may be a lack of understanding of the complexity of the process and insufficient resources devoted to recruitment efforts. We s quantified and analyzed the number of interactions needed to present study materials and obtain a final response to an invitation to participate in a stroke intervention trial seeking a diverse sample. Methods: Patients with acute ischemic stroke or TIA admitted to five hospitals in the District of Columbia were screened for enrollment in PROTECT-DC (Prevention of Recurrent Throboembolic Events District of Columbia). All participants were approached during the acute phase of stroke treatment. No recruitment occurred in the ED. Recruitment staff were trained for cultural competency, culturally tailored recruitment materials and scripts were provided. Detailed logs of each encounter were made. Data included number of face-to-face contacts and telephone conversations with potential participants and family members. Results: from June 2009 to June 2011, 1915 patients were admitted with stroke, 619 (32%) met inclusion criteria, mean age 65, 52 % female and 66 % African American. Of, these 286 (46%) patients were discharged before being approached. Of the total eligible 333 (54%) were approached ; 130 (39%) consented, 109 (33%) refused the remaining 94 (28 %) made no decision.. The mean number of contacts before obtaining a decision was 2.81 ± 1.15 (range 1-6). There were no significant differences in consent rates by gender (p=0.44) or race (p=0.64), however blacks required significantly more contacts (p Conclusion: Approximately recruitment visits were required to successfully recruit subjects for this non ED hospital based stroke prevention trial. On average recruiters spent 5 hours in direct recruitment activities per consented subject. Substantial effort is associated with “soft refusals” in patients who do not wish to volunteer. Successful recruitment requires adequate resources and appropriate staff training and support. It is important to recognize these resource needs when planning a stroke intervention trial.

BACKGROUND: Stroke is one of the major causes of death and disability in America. The Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE) project aims to compare a theoetically-defensible, evidence-based arm therapy, Accelerated Skill Acquisition Program, with traditional therapies. Imaging of the brain provides evidence of the location and severity of the stroke lesion. Researchers can analyze selected images acquired prior to enrollment and perform knowledge discovery of correlation between the size and location of the lesion and specific rehabilitation outcomes. However, large-scale trials such as ICARE encounter challenges for integrating imaging data from multiple healthcare institutions across the country. The ICARE project has 7 clinical sites distributed across the country, with more than 160 patients randomized thus far, tens of gigabytes of imaging data are involved. Therefore, we propose to develop a web-based system with tools that can support imaging and informatics related data within such a randomized controlled trial and allow for tele-consultation and collaboration. EVALUATION: The system includes a database and file storage system, a Health Insurance Portability and Accountability Act (HIPAA)-compliant anonymizer, a web-based Graphical User Interface (GUI) and decision-support tools such as lesion quantifying tools and image analysis. The GUI allows users to upload, search and review the images, patient information and annotations. The HIPAA-compliant anonymizer will anonymize any private information according to HIPAA. The lesion quantifying tool will help clinicians to measure, quantify, and characterize the size of lesion and evaluate the rehabilitation progress. The system will be used within 7 clinical sites and evaluated by researchers in the ICARE trial. DISCUSSION: The system allows for tele-consultation and is facilitated through the development of a thin-client image viewing application. Clinicians and researchers across the country can manage the imaging data, make and store annotations, measure the lesion size, and collaborate to identify the imaging biomarkers that would ultimately enhance the existing ICARE clinical trial database. Moreover, the anonymizer tool can be used not only for imaging data in this rehabilitation trial, but also for other data from multi-site clinical trials since most studies are required to be anonymized. CONCLUSION: A comprehensive imaging informatics system for a large-scale controlled stroke rehabilitation trial is developed. Physicians and clinical researchers are able to collect, organize and analyze stroke cases efficiently and effectively across multiple sites.

We sought to assess the type, frequency, and clinical predictors of neuromedical complications occurring during inpatient rehabilitation after stroke. One hundred consecutive patient records were reviewed. All medical and neurological complications requiring a physician's order for further evaluation or treatment were recorded. Complications were urinary tract infection (44 cases), depression (33), musculoskeletal pain (31), urinary retention (25), falls (25), fungal dermatitis (24), hypotension (19), diabetes mellitus (16), hypertension (15), and other neuromedical problem (194). The mean +/- SD numbers of medical and neurological complications per patient were 3.6 +/- 2 and 0.6 +/- 0.8, respectively. Complications were independently related to both the severity of functional disability as judged by Barthel score (r = -.42, P < .001) and length of rehabilitation hospital stay (r = .54, P < .001). Cardiac complications were predicted by New York Heart Association class 3 or 4 symptomatology on admission (P < .05). The age, sex, interval from stroke to rehabilitation hospital admission, and ischemic versus hemorrhagic etiology of the stroke were unrelated to the number of complications observed. Thirteen patients required transfer back to an acute-care hospital, one of whom died within 24 hours of transfer. There were no deaths on the rehabilitation unit. We have defined the type and frequency of neuromedical complications during inpatient rehabilitation after stroke. Their frequency varies with the severity of stroke, cardiovascular comorbidity, and length of stay.

Introduction: The transtheoretical model describes how people modify a problem behavior or acquire positive behaviors. The central construct is the stages of change, where behavior change is a continuum describing readiness to change: precontemplation, contemplation, preparation, action, and maintenance. People progress through these stages at varying rates, often moving back and forth along the continuum before attaining maintenance. We investigated whether urban underserved persons newly hospitalized for stroke or TIA intend to change their stroke prevention behaviors, and their belief about their premorbid behaviors. Methods: Participants in the PROTECT DC Phase II trial of health navigation to improve adherence with secondary stroke prevention behaviors were evaluated. They met the following criteria: atherogenic ischemic stroke or TIA diagnosed within 30 days, resident of the District of Columbia, community dwelling, and able to provide informed consent. Participants were recruited at 4 hospitals, and were interviewed regarding their risk factor management intentions. Results: In 87 participants aged 60.7 ± 12 yrs, the median NIH Stroke Scale score was 2(0-16), 45% were male, 90% were African-American. Long-term (>6 mos) medication adherence was reported by 52%, 7% reported adherence 6 mos was reported by 26%, and 62% intended to start adherence. Eighty percent intended to learn more about stroke, and 94% of active smokers (30 individuals) intended to quit smoking within 6 months. Discussion: In a sample of urban underserved hospitalized for acute stroke, a large proportion reported the intent to adhere to risk management behaviors or already believed themselves adherent. Our data suggest that this population is quite motivated to engage in the recommended behaviors. Many report adherence to medication, diet and exercise recommendations prior to stroke onset; it is unclear how these perceptions relate to current stroke prevention guidelines. Urban underserved populations are receptive to behavioral changes associated with risk reduction, acute hospitalization may provide an important opportunity to initiate and refine effective stroke prevention behaviors.