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Introduction: Secondary stroke prevention depends on proper identification of the underlying etiology and initiation of optimal treatment after the index event. The aim of the NOR-FIB study was to detect and quantify underlying atrial fibrillation (AF) in patients with cryptogenic stroke (CS) or transient ischaemic attack (TIA) using insertable cardiac monitor (ICM), to optimise secondary prevention, and to test the feasibility of ICM usage for stroke physicians. Patients and methods: Prospective observational international multicenter real-life study of CS and TIA patients monitored for 12 months with ICM (Reveal LINQ) for AF detection. Results: ICM insertion was performed in 91.5% by stroke physicians, within median 9 days after index event. Paroxysmal AF was diagnosed in 74 out of 259 patients (28.6%), detected early after ICM insertion (mean 48 ± 52 days) in 86.5% of patients. AF patients were older (72.6 vs 62.2; p Discussion and conclusions: ICM was an effective tool for diagnosing underlying AF, capturing AF in 29% of the CS and TIA patients. AF was asymptomatic in most cases and would mainly have gone undiagnosed without ICM. The insertion and use of ICM was feasible for stroke physicians in stroke units.

Purpose: The purpose of this study was to explore the perceptions of health professionals regarding the ideal design of a remotely delivered diabetes-related foot disease (DFD) secondary prevention program. Methods: A qualitative study involving 33 semistructured phone interviews was conducted with health professionals with experience managing DFD. Interviews discussed the role of health professionals in managing DFD, their experience in using telehealth, perceived management priorities, preferences for a secondary prevention management program, and perceived barriers and facilitators for such a program. Interviews were audio-recorded and transcribed, and inductive thematic analysis was used to derive key themes. Results: Three themes were derived: (1) barriers in current model of DFD care, (2) facilitators and ideas for a remotely delivered secondary prevention program, and (3) potential challenges in implementation. DFD care remains acute-care focused, with variability in access to care and a lack of “clinical ownership.” Patients were perceived as often having poor knowledge and competing priorities, meaning engagement in self-care remains poor. Participants felt a remote secondary prevention program should be simple to follow and individualized to patients’ context, with embedded support from a case manager and local multidisciplinary service providers. Challenges to implementation included limited DFD awareness, poor patient motivation, patient-related issues with accessing and using technology, and the inability to accurately assess and treat the foot over telehealth. Conclusions: Health professionals felt that an ideal remotely delivered secondary prevention program should be tailored to patients’ needs with embedded support from a case manager and complemented with multidisciplinary collaboration with local service providers.

Peer support for people living with HIV has gained increasing traction and is considered a way to take an active role in self-management. The existing research examining peer support interventions has reported promising evidence of the benefits of peer support. The purpose of our scoping review was to describe research on peer support for people living with HIV. We included 53 studies and sorted them into analytic categories and conducted descriptive analyses. The studies that were published between November/December 2000 and May 2021, had a range of study designs and heterogeneous priority groups, and included 20,657 participants from 16 countries. We identified 43 evaluations of the effect of peer support and 10 evaluations of implementation, process, feasibility, cost of peer support. We also categorized peer support by key functions, finding that the most common key functions were linkage to clinical care and community resources and assistance in daily management, with only one study directly related to chronic care. There is growing research interest in peer support for people living with HIV, particularly in high-income countries and related to the evaluation of effects. The revealed gaps of prioritized functions of peer support have implications for further research. Further focus on interventions addressing secondary prevention related to noncommunicable diseases as part of a care package is recommended to meet people’s needs and preferences and increase self-management related to a chronic lifelong condition.

Background Secondary prevention medication after stroke reduces risk of recurrence, but adherence is often poor. Stroke survivors’, carers’ and nurses’ perspectives of early post-stroke medication adherence are unexplored. Aim The aim of this study was to explore stroke survivors’, carers’ and nurses’ views and experiences about adhering to medication early after post-stroke hospital discharge. Methods Qualitative individual and group interviews, utilising the Perceptions and Practicalities Framework, were employed. Nine people Results There were four main themes with two sub-themes. (1) Perceptions of medication taking after stroke. Factors affecting adherence included depression, imperceptible benefits and concerns about adverse effects. (2) Perceptions about those at higher risk of poor medication adherence. Nurses suggested that poor adherence might be more likely in those living alone or with previous non-adherence. (3) Practicalities of taking medication early after stroke; these included post-stroke disabilities, cognition, polypharmacy and lack of information. (4a) Practicalities of addressing poor medication adherence during the hospital stay. Solutions included multidisciplinary co-ordination, but nurses and stroke survivors described suboptimal use of opportunities to promote adherence. (4b) Practicalities of addressing poor medication adherence post-discharge. Solutions included modifications and support from carers, but stroke survivors reported difficulties in evolving systems for taking medications. Conclusions Stroke survivors and informal carers lack knowledge and support needed to manage medication early after discharge. Nurses’ opportunities to promote medication adherence are under-exploited. Medication adherence strategies to support stroke survivors early after discharge are needed.

One-fifth of strokes occur in the territory of the posterior circulation, but their management, particularly acute reperfusion therapy and neurointervention procedures for secondary prevention, has received much less attention than similar interventions for the anterior circulation. In this review, we overview the treatment of posterior circulation stroke, including both interventions in the acute setting and secondary prevention. We focus on areas in which the management of posterior circulation stroke differs from that of stroke in general and highlight recent advances. Effectiveness of acute revascularization of posterior circulation strokes remains in large parts unproven. Thrombolysis seems to have similar benefits and lower hemorrhage risks than in the anterior circulation. The recent ATTENTION and BAOCHE trials have demonstrated that thrombectomy benefits strokes with basilar artery occlusion, but its effect on other posterior occlusion sites remains uncertain. Ischemic and hemorrhagic space-occupying cerebellar strokes can benefit from decompressive craniectomy. Secondary prevention of posterior circulation strokes includes aggressive treatment of cerebrovascular risk factors with both drugs and lifestyle interventions and short-term dual anti-platelet therapy. Randomized controlled trial (RCT) data suggest basilar artery stenosis is better treated with medical therapy than stenting, which has a high peri-procedural risk. Limited data from RCTs in stenting for vertebral stenosis suggest that intracranial stenosis is currently best treated with medical therapy alone; the situation for extracranial stenosis is less clear where stenting for symptomatic stenosis is an option, particularly for recurrent symptoms; larger RCTs are required in this area.

Comprehensive lifestyle medicine programs have begun to show efficacy in patients with cerebrovascular disease. The Veterans Affairs (VA) health care system has a large poststroke population and VA rehabilitation departments have significant expertise and resources for promoting healthy lifestyles. A 12-week clinical lifestyle medicine program was therefore implemented for poststroke patients, along with an optional observational study evaluating cardiovascular fitness, function, body composition, vitals, and quality of life before and after the program. Seventeen of 18 clinical patients elected to participate in the study, and 3 later withdrew. The 14 participants improved VO2 max by 1.94 mL O2/min/kg ( P = .001, 95% CI 0.96-2.90). Significant improvements were seen in estimated metabolic equivalents, exercise duration, 6-minute walk test, 30-second sit to stand, grip strength, and balance. Among patients who were hypertensive at baseline, mean decrease in supine systolic blood pressure (SBP) was −9.70 mm Hg (n = 10, P = .005, 95% CI −15.7 to −3.7) and standing SBP was −11.09 mm Hg (n = 11, P = .009, 95% CI −18.7 to −3.48). There were no significant improvements in laboratory measures or body composition. Participant satisfaction was high. These findings corroborate recent literature suggesting that lifestyle programs improve stroke recovery and reduce recurrence risk.

Introduction Recent trials report positive results for preventing vascular events with dual antiplatelet therapy (DAPT) in patients with high-risk TIA or minor ischemic stroke. We aimed to investigate this population regarding influence of age on vascular risk factors, hospital stay and mortality. Patients and methods Data on patients aged 40–100 years with TIA or ischemic stroke in the Swedish Stroke Register during 2012–13 were linked with national registers. To identify patients with high-risk TIA (ABCD2 ≥6) or minor ischemic stroke (NIHSS ≤5) eligible for DAPT, we excluded patients with atrial fibrillation, anticoagulant use, prior major bleeding, or unknown stroke severity. Findings We identified 10,053 potential DAPT-candidates (mean age 72.6 years, 45.2% female, 16.4% with TIA). With advancing age, most vascular risk factors increased. Antiplatelet treatment increased from 31.9% before the event to 95.5% after discharge. Within 1 year following index event, the proportion of patients with ≥1 re-admission increased with age (29.2% in 40–64 year-olds; 47.2% in 85–100 year-olds). All-cause death per 100 person-years was 6.9 (95% CI 6.4–7.4) within 1 year, and highest in the first 30 days (15.2; 95% CI 12.8–18.2). For each year of increased age, the risk of death increased with 3.5% (p = 0.128) in patients 40–64 years and with 11.8% (p Conclusions While in theory representing a subset of patients with mild injury, our observational study highlights substantial use of health-care resources and high mortality rates among patients with high-risk TIA or minor ischemic stroke assumed eligible for DAPT.

Background Intracranial atherosclerotic stenosis is a highly prevalent cause of stroke worldwide with important ethnic disparities. Widely considered to be a common cause of stroke in Asian and Afro-Caribbean populations, relatively less is known about the burden and significance of intracranial atherosclerotic stenosis in Caucasians. Aims We aim to highlight recent insights and advances into the prevalence, prognosis, and treatment of symptomatic and asymptomatic atherosclerotic intracranial atherosclerotic stenosis in Caucasian patients. Summary of review We identified 48 articles studying intracranial atherosclerotic stenosis in Caucasian patients with ischemic stroke or transient ischemic attack. Most studies were on hospital-based cohorts of consecutive patients and half were graded as “fair” quality. There was significant variation between studies in the definition of intracranial atherosclerotic stenosis and in the imaging modalities used to detect intracranial atherosclerotic stenosis. Overall, 12.1% of Caucasian patients were found to have any intracranial atherosclerotic stenosis, 6.4% symptomatic intracranial atherosclerotic stenosis and 11.1% asymptomatic intracranial atherosclerotic stenosis, with higher rates at older ages. In studies reporting prognosis, there were 61 and 10 same-territory ischemic strokes in 1000 person-years in patients with symptomatic and asymptomatic intracranial atherosclerotic stenosis, respectively. Percutaneous stenting and angioplasty have not proven superior to intensive medical management in patients with symptomatic intracranial atherosclerotic stenosis. Conclusions Intracranial atherosclerotic stenosis has previously been neglected as a cause of stroke in Caucasians but is highly prevalent at older ages and frequently discovered with the growing use of noninvasive angiography. Intensive medical therapy is the treatment of choice, but there is a need to develop novel treatments or therapeutic approaches to lower the risk of stroke in higher risk patients.

Objective: To summarize the literature assessing the safety and efficacy of direct oral anticoagulants (DOACs) for the acute treatment and secondary prevention of venous thromboembolism (VTE) in select patients with hypercoagulable disorders. Data Sources: An electronic PubMed literature search was conducted from January 2010 to July 2020 using the following keywords: DOAC, rivaroxaban, apixaban, dabigatran, edoxaban, thrombophilia, cancer, antiphospholipid syndrome, protein C deficiency, protein S deficiency, antithrombin deficiency, factor V Leiden, prothrombin G20210A gene mutation, congenital thrombophilia, hypercoagulable, hereditary thrombophilia, acquired thrombophilia. Study Selection and Data Extraction: Articles were included if they reported clinical outcomes associated with cancer-associated VTE, antiphospholipid syndrome (APS), and other hereditary thrombophilias. Data Synthesis: The safety and efficacy of using a DOAC is highly dependent on the type of hypercoagulable disease state. Current trials support the use of edoxaban, rivaroxaban, and apixaban for the treatment of cancer-associated thrombosis (CAT), with apixaban being preferred because of lower bleeding rates compared with standard of care. The use of DOACs, especially rivaroxaban, have been associated with worse outcomes in patients with APS, whereas data on DOAC use in hereditary thrombophilia remains scarce and limited to low-risk patients. Relevance to Patient Care and Clinical Practice: This review evaluates the literature assessing the safety and efficacy of DOACs in patients with various hypercoagulable disorders. Conclusions: The current body of evidence supports the use of select DOACs for the treatment of CAT. In contrast, DOAC use in patients with APS and hereditary thrombophilia should be avoided at this time.

Background: There is an incomplete understanding of the prevalence and predictors of attainment of low-density lipoprotein cholesterol (LDL-C) goal after myocardial infarction (MI). Aim: To evaluate the prevalence of achievement of LDL-C goal of 70 mg/dL, to identify the baseline features associated with suboptimal lipid control, and to assess the use of LDL-C-lowering drug therapies (LLT) beyond the first year after MI. Methods: The EYESHOT Post-MI was a prospective, cross-sectional, Italian registry, which enrolled patients presenting to cardiologist 1 to 3 years after MI. In this retrospective post-hoc analysis, patients were categorized in 2 groups according to the achievement or not of the LDL-C goal of 70 mg/dL. Univariable and multivariable logistic regression analyses were performed to identify the baseline features associate with LDL-C≥70 mg/dL. Results: The study population included 903 patients (mean age 65.5 ± 11.5 years). Among them, LDL-C was ≥70 mg/dL in 474 (52.5%). Male sex ( P = 0.031), hypertension ( P = 0.024), prior percutaneous coronary intervention ( P = 0.016) and high education level ( P = 0.008) were higher in the LDL-C Conclusions: In patients presenting to cardiologists 1 to 3 years from the last MI event, LDL-C is not under control in a large proportion of patients, particularly in those with a low education level or without hypertension. LLT is underused in this very-high-risk setting.

Introduction While acute treatment and secondary prevention in stroke have undergone major improvements, hospital readmission after index stroke remains high. However, there are few reports on long-term readmission patterns. Patients and methods For this prospective observational study, data on demographics, functional status and living conditions were obtained from the Swedish Stroke Register (Riksstroke). Data on comorbidity and hospital readmissions up to five years post-index stroke were obtained from the Swedish National Patient Register. Patients were grouped based on number of readmissions: low (0–1) intermediate (2–4), high (5–9) or very high (≥10). Results Of the 10,092 patients included, 43.7% had been readmitted within 12 months and 74.0% within 5 years. There was an average of three readmissions per individual during the five-year interval. A small group of patients with a high-comorbidity burden accounted for the majority of readmissions: approximately 20% of patients accounted for 60% of readmissions, and 5% of patients accounted for 25%. Circulatory conditions were the most common cause followed by infectious disease, stroke, trauma and diseases of the nervous system other than stroke. The proportion of readmissions due to stroke decreased sharply in the first six months. Conclusion A small number of patients with a high degree of comorbidity accounted for the majority of hospital readmissions after index stroke. Our results highlight the need for further development of strategies to support high-risk comorbid stroke patients in the community setting. Further research describing characteristics and healthcare utilisation patterns in this group is warranted.

Human papillomavirus (HPV) is the most prevalent sexually transmitted infection worldwide and ano-genital warts (AGWs) are highly infectious. This virus is transmitted through sexual, anal, or oral contact as well as skin-to-skin contacts. Treatment for this condition has significant morbidity and it can be frustrating in certain cases. The HPV vaccination has been demonstrated as a promising strategy of secondary prevention in HPV-related diseases such as head and neck cancers, cervical diseases, and recurrent respiratory papillomatosis. Regarding AGWs, it is unclear whether vaccination can provide analogous clinical benefit. The aim of this work is to systematically review the literature regarding HPV vaccination for secondary disease prevention after treatment of AGWs. From October to December 2018, a systematic search for clinical trials was conducted in five databases: PubMed, MEDLINE, EMBASE, Cochrane, and clinicaltrials.gov using a combination of the following descriptors: ‘gardasil’ OR ‘cervarix’ OR ‘nine-valent’ OR ‘9-valent’ OR ‘vaccine’ AND ‘recurrence’ OR ‘relapse’ AND ‘hpv’ OR ‘papillomavirus’ AND ‘warts’ OR ‘condyloma.’ Data were synthetized and entered in the Review Manager software (RevMan 5.3.5) to perform the meta-analysis. The search yielded 824 potentially relevant studies. Two studies fulfilled the eligibility criteria involving 656 participants. The meta-analysis estimated the rate of recurrence of AGWs was similar between the vaccine group and the control group. The overall effect estimate was 1.02 (0.75–1.38). This is the first meta-analysis exploring the effect of HPV vaccine in preventing the relapse of AGWs. These results suggest that HPV vaccination does not provide secondary benefit in patients with previous AGWs. However, these results cannot be generalized due to the scarce number of RCTs currently available in the literature. The outcomes from future randomized controlled trials (RCTs) are warranted to further clarify the precise effect of the vaccine.

Introduction Previous studies showed insufficient control of cardiovascular risk factors (CVRF) and high stroke recurrence rates among ischemic stroke patients in Germany. Currently, no structured secondary prevention program exists in clinical routine. We present the trial design and pilot phase results of a complex intervention to improve stroke care after hospital discharge in Germany. Patients and methods SANO is a cluster-randomized trial with 30 participating regions across Germany aiming to enrol 2,790 patients (drks.de, DRKS00015322). Study intervention combines both structural and patient-centred elements. Study development was based on the Medical Research Council framework for complex interventions. In 15 intervention regions, a cross-sectoral multidisciplinary network is established to enhance CVRF control as well as detection and treatment of post-stroke complications. Recommendations on CVRF are based on high-quality secondary prevention guidelines. Study physicians use motivational interviewing and agree with patients on therapeutic targets. While hospitalised, patients also receive dietary counselling and a health-passport to track their progress. During regular visits, CVRF management and potential complications are monitored. The intervention is compared to 15 regions providing usual care. The primary endpoint is the combination of recurrent stroke, myocardial infarction and death assessed 12 months after enrolment and adjudicated in a blinded manner. Results Eighteen patients were enrolled in a pilot phase that demonstrated feasibility of patient recruitment and study procedures. Conclusion SANO is investigating a program to reduce outcome events after ischemic stroke by implementing a complex intervention. If successful, the program may be implemented in routine care on national level in Germany.

Objective: In a secondary prevention of coronary artery disease (CAD), nutritional management is an integral part of lifestyle optimisation. However, few studies have investigated the potential of remote nutritional follow-up using digital solutions. This study investigates the effectiveness of a smartphone application for nutrition education and feedback with pictures of meals by a dietitian for patients with CAD. Methods: Sixty participants with CAD were randomised to either a TeleDiet group or a control group. Participants in the TeleDiet group participated in dietary education using a messaging application. The primary outcome was the change of the Mediterranean diet score (MedDietScore). The Nutrition-Score, a modification of the MedDietScore, blood tests (blood lipids, blood glucose and kidney function), body mass index, self-efficacy, medication adherence and health-related quality of life during the observation period were analysed as secondary outcomes. Results: Sixty participants participated in the study. The difference in the MedDietScore in the TeleDiet group was greater than in the control group, but not significant (2.0 [-1.0, 4.0] vs. 0.0 [-3.0, 1.5], p = 0.066). The difference in the Nutrition-Score in the TeleDiet group was significantly greater than in the control group (3.0 [1.0, 3.5] vs. 0.0 [-3.0, 2.0], p = 0.029). Nutrition knowledge of the TeleDiet group improved significantly compared to the control group (1.9 +/- 1.7 vs. 0.8 +/- 2.1, p = 0.048). Conclusions: A feedback system using a simple messaging application that allows patients with CAD to simply send a picture of their food has a positive effect on nutrition knowledge. It could be a hint for the implementation of the Mediterranean diet. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study received funding by Daiichi-Sankyo, Inc. PD received funding through the Horizons 2020 CoroPrevention project, project number 848056. MF received funding through the Flanders Research Foundation FWO, file number 1SE1222N

Rationale Recurrent stroke, cardiovascular morbidity, and mortality are important causes of poor outcome in patients with index stroke. Despite the availability of best medical management recurrent stroke occur in up to 15–20% of patients with stroke in India. Education for stroke prevention could be a strategy to prevent recurrent strokes. Hypothesis We hypothesize that a structured semi-interactive stroke prevention package can reduce the risk of recurrent strokes, acute coronary artery syndrome, and death in patients with sub-acute stroke at the end of one year. Design Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in INDIA (SPRINT INDIA) is a multi-center stroke trial involving 25 centers under the Indian Stroke Clinical Trial Network. Patients with first ever sub-acute stroke within two days to three months of onset, age 18–85 years, mRS Summary Structured semi-interactive stroke prevention package may reduce the risk of recurrent strokes, acute coronary artery syndrome, and death in patients with sub-acute stroke. Trial registration This trial is registered with clinicaltrials.gov (NCT03228979) and CTRI (Clinical Trial Registry India; CTRI/2017/09/009600).

Background and aims The role of single pill combination therapy for stroke prevention remains to be established. We explored the perspectives of stroke survivors and healthcare professionals on single pill combination therapy for stroke prevention. Methods We conducted focus groups involving stroke survivors and healthcare professionals. Results We recruited six stroke survivors: four (67%) were female and mean age was 70 ± 12 years; and eight healthcare professionals (three Stroke Consultants, two Nurse Specialists, three General Practitioners). Improved adherence is the main perceived benefit of single pill combination therapy, although concerns exist surrounding less individualised care, unsuitability for use in the acute setting, reduced ability to titrate doses and difficulty identifying the cause of side effects. The clinical stability of patients, alongside single pill combination therapy efficacy, cost, side effect profile and evidence base for impact on risk factors and clinical outcomes are key factors influencing acceptability. Stroke survivors and healthcare professionals feel single pill combination therapy is most suitable for stable patients, although there is no evidence base for its use in this context. Conclusion Stroke healthcare professionals and stroke survivors are most amenable to using single pill combination therapy for stable patients, although its role in this context should be evaluated in studies with risk factor targets and clinical outcomes as endpoints.

Objectives:We reviewed the literature for preventive programs against illicit drug use that specifically target adults aged 18–25 (i.e. emerging adults).Methods:Narrative review of preventive programs that have a high strength of recommendation according to the US Preventive Services Task Force (USPSTF) grading system.Results:Prevention programs that met the criteria are school and college based, family-based, community based, peer-led, workplace-based, and technology-based interventions. They target the known modifiable risk factors associated with illicit drug use among adolescents and young adults.Conclusion:The preventive programs we reviewed are utilizing evidence-based strategies for the prevention of illicit drug use. Further research is needed to formulate new and effective preventive strategies for the reduction of illicit drug use by emerging adults.

High recurrence and high costs of treatment are the main problems with venous ulcer management. Therefore, it is of utmost importance to target the exact pathological cause. The role of cutaneous microvalves reflux in the pathogenesis of these ulcers has been confirmed. In this study, 20 chronic venous leg ulcers were prospectively subjected to foam sclerotherapy injection into periulcer veins using direct visualization by AccuVein AV400. Patients having infected ulcers, acute deep vein thrombosis, hypercoagulability, Ankle-Brachial Index

Sexual abuse prevention efforts should ideally include counseling for people who have attractions to children before they offend. Due to a variety of factors, many therapists do not wish to work with this population. The aim of this pilot project was to create, implement, and evaluate a short training workshop to help prepare clinical therapists ( n = 94) to respond ethically and effectively to individuals seeking counseling for pedophilic interests. Data were collected at four different clinical-therapy professional conferences over the course of 14 months. The pretest/posttest design asked questions about six specific areas of knowledge related to pedophilia, mandatory reporting, treatment needs, and goals for this difficult-to-reach population. In addition, six questions were asked about attitudes toward working with minor-attracted persons and capacity to build a therapeutic relationship. Some significant changes were detected in knowledge and attitudes about clients with pedophilia after receiving training about the topic, indicating increased willingness to work with this population and improved feelings of competence in providing services. Implications for prevention are discussed.

Background The system-integrated technology-enabled model of care (SINEMA) trial aimed to evaluate the effectiveness of a community-based multi-component intervention for secondary prevention of stroke in rural China. Objective To present the detailed statistical analysis plan for the trial prior to database locking and data analysis. Methods The detailed analysis plan outlines primary and secondary outcome measures, describes the over-arching data analysis principles to be adopted as well as more detailed descriptions of specific analytical approaches for effectiveness analyses, as well strategies to handle missing outcome data. Discussion Publication of the statistical analysis plan increases the transparency of the data analysis procedure and reduces potential bias in trial reporting. Trial registration The trial was registered with clinicaltrials.gov (NCT03185858).

Rationale An estimated 15% of all strokes are associated with untreated atrial fibrillation. Long-term secondary stroke prevention in atrial fibrillation is anticoagulation, increasingly with non-vitamin K oral anticoagulants. The optimal time to initiate anticoagulation following an atrial fibrillation-related stroke that balances hemorrhagic conversion with recurrent stroke is not yet known. Aims To determine if there is an optimal delay time to initiate anticoagulation after atrial fibrillation-related stroke that optimizes the composite outcome of hemorrhagic conversion and recurrent ischemic stroke. Sample size estimates The study will enroll 1500 total subjects split between a mild to moderate stroke cohort (1000) and a severe stroke cohort (500). Methods and design This study is a multi-center, prospective, randomized, pragmatic, adaptive trial that randomizes subjects to four arms of time to start of anticoagulation. The four arms for mild to moderate stroke are: Day 3, Day 6, Day 10, and Day 14. The time intervals for severe stroke are: Day 6, Day 10, Day 14, and Day 21. Allocation involves a response adaptive randomization via interim analyses to favor the arms that have a better risk–benefit profile. Study outcomes The primary outcome event is the composite occurrence of an ischemic or hemorrhagic event within 30 days of the index stroke. Secondary outcomes are also collected at 30 and 90 days. Discussion The optimal timing of direct oral anticoagulants post-ischemic stroke requires prospective randomized testing. A pragmatically designed trial with adaptive allocation and randomization to multiple time intervals such as the START trial is best suited to answer this question in order to directly inform current practice on this question.

INTRODUCTION: Nonadherence to medications for schizophrenia relates to frequent readmissions. Long-acting injectable (LAI) medications are shown to increase adherence and reduce admissions. AIMS: (1) Identify frequent readmissions to psychiatry. (2) Improve nursing advocacy for patients appropriate for LAIs through in-service. METHODS: Chart audits were employed for data collection. Academic detailing and dashboards were used for voluntary nursing education. The chart audit spanned 90 days pre and post in-service. All admissions to psychiatry were screened; patients with readmissions under 30 days (with the same admitting diagnosis), a schizophrenia spectrum diagnosis, and nonadherent with oral antipsychotics were included. Results: Forty-four patients met criteria and amassed 49 frequent readmissions. For inclusion criteria, the admission rate decreased by 53% and LAI prescriptions increased by 9%. Three patients from the first audit group and one from the second were initiated on LAIs. CONCLUSIONS: Attitudes toward LAIs may be improving based on RN advocacy and collaboration.

We aimed to determine whether attempts to restore and maintain sinus rhythm will reduce recurrent stroke in patients with atrial fibrillation (AF). Patients (n = 245) between March 1998 and May 2002 with AF who had an ischemic stroke including transient ischemic attack 1 to 12 months before transesophageal echocardiographic examination and had been followed for 3 years were retrospectively reviewed. Cardioversion was attempted in 130 patients; 117 (90%) patients were successfully cardioverted (rhythm control group). The 13 patients who could not be cardioverted and 115 patients who did not undergo cardioversion were assigned to the rate control group. Age, gender, ischemic heart disease, hypertension, diabetes mellitus, congestive heart failure, mitral valve disease, and left atrial diameter were similar in both groups. The rhythm control group included 56 patients (48.7%) who were still in sinus rhythm after 3 years. During follow-up, there were 2 embolic events (3.4%) and 2 deaths (3.4%) in the rhythm control group, whereas 18 embolic events (14.6%) and 18 deaths (14.6%) occurred in the rate control group ( P = .049 and P = .049, respectively). Restoration and maintenance of sinus rhythm seems to have a beneficial effect on secondary prevention of stroke in patients with AF.

Background Adjudication of endpoints is a standard procedure in cardiovascular clinical trials. However, several studies indicate that the benefit of adjudication in estimating treatment effect may be limited. Aims This post hoc analysis of SOCRATES (NCT01994720) compared the treatment effects and investigated the agreement of clinical event assessment by site investigators and independent adjudicators. Methods SOCRATES compared ticagrelor and aspirin in 13,199 patients with acute minor stroke or high-risk transient ischemic attack. The primary endpoint was stroke, myocardial infarction, or death. Stroke was the major component of the primary endpoint and a secondary endpoint. The endpoints were adjudicated by a blinded independent committee. We compared the treatment effect on the primary endpoint and stroke alone based on the investigators' and adjudicators' assessments, and investigated the agreement rate on the stroke endpoint and major hemorrhages. Results The hazard ratios (95% confidence interval) for ticagrelor versus aspirin therapy for the primary endpoint were 0.89 (0.78–1.01) when calculated on adjudicator-assessed events and 0.88 (0.78–1.00) for investigator-assessed events. The hazard ratios (95% confidence intervals) for stroke were 0.86 (0.75–0.99) based on the adjudicators' diagnoses and 0.85 (0.75–0.97) based on the investigators' diagnoses. The overall agreement between adjudicator- and investigator-diagnosed stroke was 91%, and for major hemorrhages was 88%. Conclusions In SOCRATES, there was no clinically meaningful difference in the estimated treatment effect, on either the primary endpoint or stroke, by using investigator- or adjudicator-assessed events. Double-blind treatment outcome studies with stroke endpoints may not benefit from adjudication. Trial Registration ClinicalTrials.gov Identifier: NCT01994720.

Child sexual abuse (CSA) is associated with a range of negative consequences for victims that are compounded when it recurs. We used the National Child Abuse and Neglect Data System to study a cohort of 42,036 children in 45 U.S. states with sexual abuse reports first confirmed by child protective services (CPS) during 2010 in order to identify children with increased risk for recurrence. A small proportion (3.6%) had a second confirmed sexual abuse report through 2015. In multivariate models, female gender, family hearing and vision problems, other child maltreatment, and other family violence were associated with increased risk of recurrence, while younger children, Hispanic families, and those with substance abuse tended to have less risk. One fourth of recurrence involved the same offender, usually a parent or caretaker. One fourth of cases were referred for any CPS services, which were more likely to be provided for families with poverty, drug or alcohol problems, or other violence. Only substance abuse services significantly reduced recurrence in multivariable models. Those trying to reduce CSA recurrence should recognize that certain case characteristics are associated with greater recurrence, and most CPS services do not significantly reduce CSA recurrence.

The present research examines the integration into employment of prisoners on parole who had been under the supervision of the Prisoner Rehabilitation Authority during the period 2007-2010. The supervision program included rehabilitation in the community, with the emphasis on employment. The research compares integration in employment and rates of reincarceration for the supervised group with prisoners who had been released from prison after serving their full sentences. The findings indicate that among prisoners who had participated in the supervision program, there is better integration into employment, a higher wage level, and lower rate of reincarceration. Based on these results, it may be tentatively inferred that the supervision program possesses a high potential for reintegrating released prisoners into the community.

Objective: To compare the effects of high-intensity interval training versus moderate-intensity continuous training on risk markers of arrhythmic death in patients who recently suffered from an acute coronary syndrome. Design: Double-blind (patient and evaluator) randomized controlled trial. Setting: Cardiovascular Prevention and Rehabilitation Centre (EPIC Centre) of the Montreal Heart Institute, Montreal, Canada. Subjects: A total of 43 patients were randomized following an acute coronary syndrome. Interventions: Patients were assigned to either high-intensity interval training (n = 18) or isocaloric moderate-intensity continuous training (n = 19), three times a week for a total of 36 sessions. Main measures: Heart rate recovery for 5 minutes, heart rate variability for 24 hours, occurrence of ventricular arrhythmias, and QT dispersion were measured before and after the 36 sessions of training. Results: Among the 43 patients randomized, 6 participants in the high-intensity interval training group stopped training for reasons unrelated to exercise training and were excluded from the analyses. Heart rate recovery improved solely in the high-intensity interval training group, particularly at the end of recovery period ( p < 0.05). There were no differences in heart rate variability, occurrence of ventricular arrhythmias, or QT dispersion parameters between the groups at study end. Conclusion: Despite the lack of power to detect any large difference between the two interventions with respect to risk markers of arrhythmic death, high-intensity interval training appears safe and may be more effective at improving heart rate recovery relative to moderate-intensity continuous training in our patients following acute coronary syndrome.

The aims of this small-scale study were to explore the feasibility and outcomes of a parent-implemented intervention for two-year-olds at risk of language difficulties, and to explore the implications for the public health model of speech and language therapy (SLT). This adds to limited research into targeted SLT public health interventions. It is the first study to investigate early language intervention delivered by trained therapy assistants (TAs) rather than clinicians. Nine children aged between 26 and 31 months took part. Seven (78%) completed the six-session intervention. The outcome measure was the Words subscale of the Language Use Inventory. The gross motor subscale of the Ages and Stages Questionnaire was used as a control measure. Children’s skills were assessed twice before intervention and once afterwards. At baseline, six participants had expressive language delay and no wider speech, language and communication needs (SLCNs). Five of this subgroup showed language use skills within the typical range following intervention. At baseline, three participants had expressive language delay and previously undetected receptive language and/or social interaction difficulties. None of this sub-group showed improved age-adjusted language use skills following intervention. All nine participants had gross motor skills in the typical range at each time point. These exploratory findings suggest this targeted intervention is feasible. This study presents no evidence of short-term impact of this intervention for two-year-olds with expressive language delay and wider SLCNs. These findings suggest this targeted language intervention for two-year-olds may be associated with accelerated language development for some two-year-olds at risk of language difficulties because of expressive language delay; and may help identify two-year-olds with previously undetected wider SLCNs, and therefore facilitate early access to specialist support. We highlight limitations in the study size, design and outcome measures, and identify how these preliminary findings can inform future research.

Objective Statins are recommended as the first-line treatments for reducing the risk of major adverse cardiovascular events (MACE) in patients with acute coronary syndrome (ACS). The present study aimed to establish the baseline lipid levels associated with the greatest benefit from statin therapy in this population. Methods The study used a retrospective cohort methodology. In total, 636 patients with ACS were enrolled at Shaanxi Provincial People’s Hospital from 2011 to 2013. Participants were divided into four groups (group 1, hyperlipidemia with inconsistent statin use; group 2, no hyperlipidemia with inconsistent statin use; group 3, no hyperlipidemia with consistent statin use; and group 4, hyperlipidemia with consistent statin use). Results Patients in groups 3 (hazard ratio [HR] = 0.49, 95% confidence interval [CI] = 0.29–0.82) and 4 (HR = 0.21, 95% CI = 0.10–0.45) had lower risks of MACE than those in group 1. In subgroup analysis, patients in group 4 had a lower risk of MACE than those in group 3 (adjusted HR = 0.43, 95% CI = 0.21–0.89). Conclusion Sustained statin therapy is associated with a lower risk of adverse outcomes in patients with ACS, especially in those with higher baseline lipid levels.