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Aims Primary care physicians lack access to an objective cardiac function test. This study for the first time describes a novel cardiac output response to stress (CORS) test developed to improve diagnosis and monitoring of heart failure in primary care and investigates its reproducibility. Methods and results Prospective observational study recruited 32 consecutive primary care patients (age, 63 ± 9 years; female, n = 18). Cardiac output was measured continuously using the bioreactance method in supine and standing positions and during two 3 min stages of a step‐exercise protocol (10 and 15 steps per minute) using a 15 cm height bench. The CORS test was performed on two occasions, i.e. Test 1 and Test 2. There was no significant difference between repeated measures of cardiac output and stroke volume at supine standing and Stage 1 and Stage 2 step exercises (all P > 0.3). There was a significant positive relationship between Test 1 and Test 2 cardiac outputs (r = 0.92, P = 0.01 with coefficient of variation of 7.1%). The mean difference in cardiac output (with upper and lower limits of agreement) between Test 1 and Test 2 was 0.1 (−1.9 to 2.1) L/min, combining supine, standing, and step‐exercise data. Conclusions The CORS, as a novel test for objective evaluation of cardiac function, demonstrates acceptable reproducibility and can potentially be implemented in primary care.

Objective\ud Self-management of hypertension can reduce and control blood pressure (BP) compared to clinic monitoring. However, self-management relies on patients following an algorithm which may be variably adhered to. This study reports fidelity of high-risk patients to the self-management algorithm set by the TASMIN-SR trial.\ud Methods\ud Patients with hypertension, above target clinic BP and one or more of stroke, diabetes, coronary heart disease or chronic kidney disease, were invited to self-monitor following an individualised self-titration algorithm. Home BP readings and medication change details were submitted monthly for 12 months. Readings downloaded from patients’ electronic monitors were compared to written submissions and protocol fidelity was assessed.\ud Results\ud 276 patients were randomised to self-management and 225 (82%) completed the required training sessions. Of these, 166 (74%) completed self-management. 11,385/12,707 (89.6%) submitted readings were accurate compared to corresponding downloaded monitor readings. Mean error rate was 5.2% per patient, which increased with age but not co-morbidities.\ud Patients made 475/683 (69.5%) algorithm recommended medication changes, equating to nearly three medication changes per patient. Mean systolic BP for patients who completed training and made all recommended changes dropped from 141mmHg (95% CI 138.26-144.46) to 121mmHg (95% CI 118.30-124.17mmHg) compared to 129mmHg (95% CI 125.27-136.73mmHg) for patients who made none.\ud Conclusion\ud Most patients randomised to self-management completed training; however, 36% of these had dropped out by 12 months. Self-monitoring was largely undertaken properly and accurately recorded. Fidelity with self-management was associated with lower achieved systolic BP. Successful implementation of self-management into daily practice requires careful training and should be accompanied by monitoring of fidelity.

INTRODUCTION: Despite the rising prevalence of stroke, no comprehensive model of postacute stroke care exists. Research on stroke has focused on acute care and early supported discharge, with less attention dedicated to longer term support in the community. Likewise, relatively little research has focused on long-term support for informal carers. This review aims to synthesise and appraise extant qualitative evidence on: (1) long-term healthcare needs of stroke survivors and informal carers, and (2) their experiences of primary care and community health services. The review will inform the development of a primary care model for stroke survivors and informal carers. METHODS AND ANALYSIS: We will systematically search 4 databases: MEDLINE, EMBASE, PsycINFO and CINAHL for published qualitative evidence on the needs and experiences of stroke survivors and informal carers of postacute care delivered by primary care and community health services. Additional searches of reference lists and citation indices will be conducted. The quality of articles will be assessed by 2 independent reviewers using a Critical Appraisal Skills Programme (CASP) checklist. Disagreements will be resolved through discussion or third party adjudication. Meta-ethnography will be used to synthesise the literature based on first-order, second-order and third-order constructs. We will construct a theoretical model of stroke survivors' and informal carers' experiences of primary care and community health services. ETHICS AND DISSEMINATION: The results of the systematic review will be disseminated via publication in a peer-reviewed journal and presented at a relevant conference. The study does not require ethical approval as no patient identifiable data will be used.

Hypertension is the number one co-morbid condition in older people with multiple chronic conditions, and over half of those aged >80 years are prescribed two or more antihypertensive medications (equivalent to approximately 1.25 million people in the UK). Blood pressure lowering has been shown to be effective at preventing stroke and cardiovascular disease in healthy individuals aged >80 years with systolic blood pressure of >160mmHg. However, more recent evidence suggests that larger blood pressure reductions and multiple antihypertensive prescriptions may be harmful in older people. Whilst reducing the number of antihypertensive drugs prescribed to certain older patients may be beneficial, the lack of evidence to support such an approach limits the practice in routine clinical care.

The radical new US hypertension guidelines, released 3 years after the previous scientific statement, have implications far beyond their intended recipients. They include a new definition for hypertension, lower treatment targets, and extended guidance on the implementation of multidisciplinary care, including self-monitoring of blood pressure. Some recommendations are likely to generate controversy.

$\textbf{Background}$: Secondary prevention medications reduce risk of stroke recurrence, yet many people do not receive recommended treatment, nor take medications optimally. $\textbf{Objective}$: Exploring how patients report making use of practitioners' advice on secondary prevention medicines on an online forum and what feedback was received from other participants. $\textbf{Methods}$: Thematic analysis of the archive of Talkstroke (2004-2011), UK. Posts including any secondary prevention medication terms, General Practitioner (GP) and their replies were identified. $\textbf{Results}$: Fifity participants talked about practitioners' advice on secondary prevention medications in 43 discussion threads. Patients consulted practitioners for reassurance and dealing with side effects. Practitioners' advice varied from altering to maintaining current treatment. Three main themes emerged from the use of practitioners' advice: patients following advice (reassured, happy when side effects made tolerable, or still retaining anxiety about treatment); patients not following advice (admitting adherence on-off or stopping medications as side effects still not tolerable); asking other participants for feedback on advice received. Practitioners' advice was disregarded mainly when related to dealing with statin side effects, after one or two consultations. Themes for feedback involved sharing experience, directing back to practitioners, or to external evidence. $\textbf{Conclusions}$: Side effects of secondary prevention medications and statins in particular, cause anxiety and resentment in some patients, and their concerns are not always addressed by practitioners. Practitioners could consider more proactive strategies to manage such side effects. Forum feedback was appropriate and supportive of the practitioners' advice received. Our findings from peer-to-peer online conversations confirm and widen previous research.

$\textbf{Objective:}$ To identify barriers and facilitators of medication adherence in patients with stroke along with their caregivers. DESIGN: Qualitative thematic analysis of posts about secondary prevention medications, informed by Perceptions and Practicalities Approach. $\textbf{Setting:}$ Posts written by the UK stroke survivors and their family members taking part in the online forum of the Stroke Association, between 2004 and 2011. $\textbf{Participants:}$ 84 participants: 49 stroke survivors, 33 caregivers, 2 not stated, identified using the keywords 'taking medication', 'pills', 'size', 'side-effects', 'routine', 'blister' as well as secondary prevention medication terms. $\textbf{Results:}$ Perceptions reducing the motivation to adhere included dealing with medication side effects, questioning doctors' prescribing practices and negative publicity about medications, especially in regard to statins. Caregivers faced difficulties with ensuring medications were taken while respecting the patient's decisions not to take tablets. They struggled in their role as advocates of patient's needs with healthcare professionals. Not experiencing side effects, attributing importance to medications, positive personal experiences of taking tablets and obtaining modification of treatment to manage side effects were facilitators of adherence. Key practical barriers included difficulties with swallowing tablets, dealing with the burden of treatment and drug cost. Using medication storage devices, following routines and getting help with medications from caregivers were important facilitators of adherence. $\textbf{Conclusions:}$ An online stroke forum is a novel and valuable resource to investigate use of secondary prevention medications. Analysis of this forum highlighted significant barriers and facilitators of medication adherence faced by stroke survivors and their caregivers. Addressing perceptual and practical barriers highlighted here can inform the development of future interventions aimed at improving adherence to secondary prevention medication after stroke.

International audience; Approximately 10% of ischemic strokes are associated with atrial fibrillation (AF) first diagnosed at the time of stroke. Detecting asymptomatic AF would provide an opportunity to prevent these strokes by instituting appropriate anticoagulation. The AF-SCREEN international collaboration was formed in September 2015 to promote discussion and research about AF screening as a strategy to reduce stroke and death and to provide advocacy for implementation of country-specific AF screening programs. During 2016, 60 expert members of AF-SCREEN, including physicians, nurses, allied health professionals, health economists, and patient advocates, were invited to prepare sections of a draft document. In August 2016, 51 members met in Rome to discuss the draft document and consider the key points arising from it using a Delphi process. These key points emphasize that screen-detected AF found at a single timepoint or by intermittent ECG recordings over 2 weeks is not a benign condition and, with additional stroke factors, carries sufficient risk of stroke to justify consideration of anticoagulation. With regard to the methods of mass screening, handheld ECG devices have the advantage of providing a verifiable ECG trace that guidelines require for AF diagnosis and would therefore be preferred as screening tools. Certain patient groups, such as those with recent embolic stroke of uncertain source (ESUS), require more intensive monitoring for AF. Settings for screening include various venues in both the community and the clinic, but they must be linked to a pathway for appropriate diagnosis and management for screening to be effective. It is recognized that health resources vary widely between countries and health systems, so the setting for AF screening should be both country- and health system-specific. Based on current knowledge, this white paper provides a strong case for AF screening now while recognizing that large randomized outcomes studies would be helpful to strengthen the evidence base.

Background\ud Stroke is associated with the development of cognitive impairment and dementia. We assessed the effect of intensive blood pressure (BP) and/or lipid lowering on cognitive outcomes in patients with recent stroke in a pilot trial.\ud \ud Methods\ud In a multicentre, partial-factorial trial, patients with recent stroke, absence of dementia, and systolic BP (SBP) 125–170 mmHg, were assigned randomly to at least 6 months of intensive (target SBP

INTRODUCTION: Self-monitoring of blood pressure is effective in reducing blood pressure in hypertension. However previous meta-analyses have shown a considerable amount of heterogeneity between studies, only part of which can be accounted for by meta-regression. This may be due to differences in design, recruited populations, intervention components or results among patient subgroups. To further investigate these differences, an individual patient data (IPD) meta-analysis of self-monitoring of blood pressure will be performed.METHODS AND ANALYSIS: We will identify randomised trials that have compared patients with hypertension who are self-monitoring blood pressure with those who are not and invite trialists to provide IPD including clinic and/or ambulatory systolic and diastolic blood pressure at baseline and all follow-up points where both intervention and control groups were measured. Other data requested will include measurement methodology, length of follow-up, cointerventions, baseline demographic (age, gender) and psychosocial factors (deprivation, quality of life), setting, intensity of self-monitoring, self-monitored blood pressure, comorbidities, lifestyle factors (weight, smoking) and presence or not of antihypertensive treatment. Data on all available patients will be included in order to take an intention-to-treat approach. A two-stage procedure for IPD meta-analysis, stratified by trial and taking into account age, sex, diabetes and baseline systolic BP will be used. Exploratory subgroup analyses will further investigate non-linear relationships between the prespecified variables. Sensitivity analyses will assess the impact of trials which have and have not provided IPD.ETHICS AND DISSEMINATION: This study does not include identifiable data. Results will be disseminated in a peer-reviewed publication and by international conference presentations.CONCLUSIONS: IPD analysis should help the understanding of which self-monitoring interventions for which patient groups are most effective in the control of blood pressure.

Natural Flood Management (NFM) techniques aim to reduce downstream flooding by storing and slowing the flow of stormwater to river channels. These techniques include a range of measures, including setback stormwater outfalls and the physical restoration of channels and floodplains, to improve the natural functioning of catchments. An additional benefit of NFM measures is the potential reduction in sediment and pollutant delivery to the channel. Urban development releases a variety of heavy metal and nutrient pollutants that enter rivers through stormwater outfalls with adverse effects on the aquatic ecosystem. In this study, the influence of channel modification and quality of the river habitat on the sediment quality surrounding stormwater outfalls was assessed. Sediment samples were taken at several outfalls within the Johnson Creek catchment, Oregon, USA, and analysed for a variety of urban pollutants. The level of river habitat quality and modification at each site were assessed using a semi-quantitative scoring methodology. Significant increases in pollutant levels were observed at outfalls, with a greater and more variable increase at direct compared to setback outfalls. Removal efficiency of certain pollutants was found to be significantly correlated to the level of habitat quality or modification (for Fe, Ba, Sn, Mg, P, K) indicating that more natural reaches had greater potential for pollutant removal. The findings highlight the multiple benefits associated with NFM and river restoration approaches in relation to sediment quality and pollutant content.

Mercury sphygmomanometers have been commonly used in primary care to measure blood pressure but are associated with bias. Electronic blood pressure machines are being introduced in many practices and have anecdotally been associated with higher recorded blood pressure. This study examined recorded blood pressure in four practices before and after electronic blood pressure machine introduction. No consistent change in mean blood pressure was apparent following their introduction, but there was a large and significant fall in terminal digit preference suggesting improved precision of recording.

There are a large number of studies addressing the impact of continuing medical education (Davis et al. 1995) and clinical guidelines (Grimshaw & Russell 1993) on changing clinical practice, but comparatively little on the impact of purchasers of health care. There is some evidence that financial incentives and penalties can influence practice (Greco & Eisenberg 1993). It has been suggested that purchasers can play an important role in implementing research findings (Haines & Jones 1994). Indeed, the separation of purchasers and providers has been viewed as an opportunity to use knowledge about effectiveness to improve health services (Dunning et al. 1994). We report a study the aim of which was to explore the impact that a specific brief external intervention might have on a detailed aspect of clinical practice: the use of corticosteroids in preterm labour. The intervention was initiated by public health physicians on behalf of a Health Authority. It formed a part of the Getting Research Into Practice (GRIP) initiative in the old Oxford Health Region, UK. The administration of corticosteroids to mothers expected to deliver prematurely reduces neonatal mortality and morbidity (Crowley et al. 1990). The first trial which suggested that corticosteroids were effective in this role was published in 1972, and evidence from 12 trials was assembled in a systematic review published in January 1990 (Crowley et al. 1990). Despite the accumulating evidence, in 1991 many women delivering prematurely in the UK and elsewhere were not receiving corticosteroids (Anon 1992;Donaldson 1992). The apparent failure of obstetricians to make full use of this treatment has been cited as an example of the delayed implementation of research findings that can occur in clinical practice (Haines & Jones 1994; Enkin 1996).

Background Previous research suggests most UK General Practitioners (GPs) use self-monitoring of blood pressure (SMBP) to monitor control of hypertension rather than for diagnosis. This study sought to assess current practice in the use of self-monitoring and any changes in practice following more recent guideline recommendations. Aim To survey views and practice with regard to SMBP of UK GPs in 2015 and to compare to a previous survey in 2011. Design and setting Web-based survey of a regionally representative sample of 300 UK GPs. Method GPs completed an on-line questionnaire concerning the use of SMBP in the management of hypertension. Analyses comprised descriptive statistics, tests for between group differences (z test, Wilcoxon, chi square), and multivariate logistic regression. Results Results were available from 300 GPs (94% of those who started the survey). GPs reported using self-monitoring for diagnosing hypertension (169/291 (58% (95%CI 52-64))) and to monitor control (245/291 (84% (80-88))), the former significantly increased since 2011 (from 37% (33-41), pConclusion Since new UK national guidance in 2011, GPs are more likely to use SMBP in the diagnosis of hypertension but significant proportions continue to use non-standard diagnostic and monitoring thresholds. The use of out of office methods to improve the accuracy of diagnosis is unlikely to be beneficial if sub optimal thresholds are used.

Background Free blood pressure (BP) checks offered by community pharmacies offer a potentially useful opportunity to diagnose and/or manage hypertension, but the accuracy of the sphygmomanometers in use is currently unknown. Aim To assess the accuracy of validated automatic BP monitors used for BP checks in a UK retail pharmacy chain. Design and Setting 52 pharmacies from one chain were visited in a range of locations (inner city, suburban, rural) in central England. Method Monitor accuracy was compared to a calibrated reference device (Omron PA-350), at 50 mmHg intervals across the range 0-300 mmHg (static pressure test), with a difference from the reference monitor of +/-3 mmHg at any interval considered a failure. The results were analysed by usage rates and length of time in service. Results Eight (13%) monitors failed (i.e. were more than 3mmHg from reference), all underestimating BP. Monitor failure rate from the reference monitor of +/- 3 mmHg at any testing interval varied by length of time in use (2/38, 5% before 18 months vs. 4/14, 29% after 18 months; p=0.038) and to some extent but non-significantly by usage rates (4/22, 18% in monitors used more than once daily vs. 2/33, 6% in those used less frequently; p=0.204). Conclusion BP monitors within a pharmacy setting fail at similar rates to those in general practice. Annual calibration checks for blood pressure monitors are needed, even for new monitors, since these data indicate declining performance from 18 months onwards.

BACKGROUND: Thrombolysis can significantly reduce the burden of stroke but the time window for safe and effective treatment is short. In patients travelling to hospital via ambulance, the sending of a 'prealert' message can significantly improve the timeliness of treatment. OBJECTIVE: Examine the prevalence of hospital prealerting, the extent to which prealert protocols are followed and what factors influence emergency medical services (EMS) staff's decision to send a prealert. METHODS: Cohort study of patients admitted to two acute stroke units in West Midlands (UK) hospitals using linked data from hospital and EMS records. A logistic regression model examined the association between prealert eligibility and whether a prealert message was sent. In semistructured interviews, EMS staff were asked about their experiences of patients with suspected stroke. RESULTS: Of the 539 patients eligible for this study, 271 (51%) were recruited. Of these, only 79 (29%) were eligible for prealerting according to criteria set out in local protocols but 143 (53%) were prealerted. Increasing number of Face, Arm, Speech Test symptoms (1 symptom, OR 6.14, 95% CI 2.06 to 18.30, p=0.001; 2 symptoms, OR 31.36, 95% CI 9.91 to 99.24, p

BACKGROUND:\ud Thrombolysis can significantly reduce the burden of stroke but the time window for safe and effective treatment is short. In patients travelling to hospital via ambulance, the sending of a 'prealert' message can significantly improve the timeliness of treatment.\ud \ud OBJECTIVE:\ud Examine the prevalence of hospital prealerting, the extent to which prealert protocols are followed and what factors influence emergency medical services (EMS) staff's decision to send a prealert.\ud \ud METHODS:\ud Cohort study of patients admitted to two acute stroke units in West Midlands (UK) hospitals using linked data from hospital and EMS records. A logistic regression model examined the association between prealert eligibility and whether a prealert message was sent. In semistructured interviews, EMS staff were asked about their experiences of patients with suspected stroke.\ud \ud RESULTS:\ud Of the 539 patients eligible for this study, 271 (51%) were recruited. Of these, only 79 (29%) were eligible for prealerting according to criteria set out in local protocols but 143 (53%) were prealerted. Increasing number of Face, Arm, Speech Test symptoms (1 symptom, OR 6.14, 95% CI 2.06 to 18.30, p=0.001; 2 symptoms, OR 31.36, 95% CI 9.91 to 99.24, p