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Transient ischaemic attack is an emergency medical condition that causes brief negative focal neurological symptoms such as unilateral weakness. The symptoms herald a high risk of stroke and hence require urgent assessment. The challenge lies in the brevity and compendium of associated symptoms that can ‘mimic’ a plethora of other conditions. The result is a high rate of referrals to transient ischaemic attack clinics for these stroke mimics. This article highlights the diagnostic challenges in transient ischaemic attack with relevance to unilateral weakness.

Introduction The FORWARD care bundle (Feeding via the Oral Route With Acknowledged Risk of Deterioration) is used to support patients with dysphagia eating and drinking with acknowledged risk (EDAR) at our Trust. Key aims of FORWARD include improving advanced care planning (ACP) and avoiding unnecessary readmissions. This study aimed to determine the incidence of EDAR related readmissions (RR-EDAR) after FORWARD, and the effects of ACP and discharge location. Methods Retrospective review of all patients supported by FORWARD during admissions between January 2018 and December 2019. Data were collected on number and reasons for in-Trust hospital readmissions 6 months post-discharge, preferred place of care ACPs in event of EDAR related deterioration and discharge destination. Readmission reasons were classified as RR-EDAR (e.g. chest infection, reduced oral intake) and no relation to EDAR. Means (SD) and percentages are presented with comparisons using Fishers Exact Test. Results 316 patients were included; mean (SD) age 81(12). 64% (n = 202) of patients were discharged alive, 36% (n = 114) were alive at 6 months. 38% of live discharges (n = 75) were readmitted and 52% (n = 39) of these patients were RR-EDAR. Mean (SD) RR-EDAR number was 11, and 18% (n = 7) of patients had RR-EDAR >1 (range 1–5). RR-EDAR was only 7% (n = 4) in patients wishing to remain at home vs 25% (n = 33) in those without a documented place of care (p Conclusions The majority of FORWARD patients are not readmitted. RR-EDAR comprises half of all readmitted patients and some have multiple admissions. Fewer patients with ACPs were RR-EDAR suggesting these are effective. Most patients RR-EDAR were from private homes, suggesting residential care may provide more support. Further work includes increasing ACPs, supporting patients with multiple RR-EDAR and those discharged to private homes.

There is increasing evidence to suggest that atrial fibrillation is associated with a heightened risk of dementia. The mechanism of interaction is unclear. Atrial fibrillation-induced cerebral infarcts, hypoperfusion, systemic inflammation, and anticoagulant therapy-induced cerebral microbleeds, have been proposed to explain the link between these conditions. An understanding of the pathogenesis of atrial fibrillation-associated cognitive decline may enable the development of treatment strategies targeted towards the prevention of dementia in atrial fibrillation patients. The aim of this review is to explore the impact that existing atrial fibrillation treatment strategies may have on cognition and the putative mechanisms linking the two conditions. This review examines how components of the ‘Atrial Fibrillation Better Care pathway’ (stroke risk reduction, rhythm control, rate control, and risk factor management) may influence the trajectory of atrial fibrillation-associated cognitive decline. The requirements for further prospective studies to understand the mechanistic link between atrial fibrillation and dementia and to develop treatment strategies targeted towards the prevention of atrial fibrillation-associated cognitive decline, are highlighted.

Three south-London hospital trusts undertook a feasibility study, comparing data from 93 patients who received the 14-day adhesive ambulatory electrocardiography (ECG) patch Zio XT with retrospective data from 125 patients referred for 24-hour Holter for cryptogenic stroke and transient ischaemic attack following negative 12-lead ECG. As the ECG patch was fitted the same day as the clinical decision for ambulatory ECG monitoring was made, median time to the patient having the monitor fitted was significantly reduced in all three hospital trusts compared with 24-hour Holter being ordered and fitted. Hospital visits reduced by a median of two for patients receiving Zio XT. This project supports that it is feasible to use a patch as part of routine clinical care with a positive impact on care pathways.

Patients with dysphagia may consider eating and drinking with acknowledged risk (EDAR) instead of artificial hydration/nutrition. Timely consideration of complex issues is required including dysphagia reversibility, risk/benefit discussions, patient wishes, their capacity and best interests. This study aimed to establish if EDAR protocols improve care through a systematic literature review with a secondary aim to explore important factors for the development and success of a protocol. PUBMED, MEDLINE, CINAHL and EMBASE were searched for English language articles to May 2019 with terms related to EDAR, dysphagia and end of life. Articles were agreed for inclusion by three independent reviewers. Levels of evidence were assessed using the modified Sackett scale. Study themes were identified and discussed. 8 articles met the inclusion criteria with varied methodology. The highest level of evidence was III (cohort study). Most were limited to patients with dementia, stroke, in older person’s wards or residential homes. Three articles described a systematic approach to EDAR for in-patients, reporting reductions in days nil-by-mouth until feeding plans are made and improvements in documentation of decision making, nutrition plans and capacity assessment. Five papers explored the views and knowledge of staff, patients and families/carers relating to EDAR and complex feeding decisions. Formal meta-analysis was not possible due to the level and mix of methodology. There is a paucity of evidence to determine if EDAR protocols improve care. However, support is emerging for a coordinated approach to managing EDAR. Findings suggest having a protocol is not enough; training and communication within teams is essential, together with incorporating feedback from patients and carers, and this justifies further work.

Background patients with a permanently unsafe swallow may choose to eat and drink with acknowledged risk (EDAR). Informed decision-making and advance care planning depend on prognosis, but no data have yet been published on outcomes after EDAR decisions. Methods the study was undertaken in 555 hospital inpatients’ (mean [SD] age: 83 {12}) EDAR supported by the Feeding via the Oral Route with Acknowledged Risk of Deterioration care bundle between January 2015 and November 2019. Data were collected prospectively on clinical characteristics, dates of discharge, readmissions and death (where relevant). Kaplan-Meier survival functions and readmission risks per surviving patient per month were calculated. Results mortality is 56% in the first 3 months after discharge but then mortality risk sharply decreases. The 3-month survival in EDAR patients was more likely in those Conclusion there is a high mortality and readmission risk after an EDAR decision but much of this is frontloaded into the first 3 months, with a relatively favourable prognosis thereafter. This may be an appropriate time-point to reassess the plan for eating and drinking such that it continues to reflect the most appropriate balance of risk, comfort and nutrition.

Summary Background Oral anticoagulation reduces the rate of systemic embolism for patients with atrial fibrillation by two-thirds, but its benefits for patients with previous intracranial haemorrhage are uncertain. In the Start or STop Anticoagulants Randomised Trial (SoSTART), we aimed to establish whether starting is non-inferior to avoiding oral anticoagulation for survivors of intracranial haemorrhage who have atrial fibrillation. Methods SoSTART was a prospective, randomised, open-label, assessor-masked, parallel-group, pilot phase trial done at 67 hospitals in the UK. We recruited adults (aged ≥18 years) who had survived at least 24 h after symptomatic spontaneous intracranial haemorrhage, had atrial fibrillation, and had a CHA2DS2-VASc score of at least 2. Web-based computerised randomisation incorporating a minimisation algorithm allocated participants (1:1) to start or avoid long-term (≥1 year) full treatment dose open-label oral anticoagulation. The participants assigned to start oral anticoagulation received either a direct oral anticoagulant or vitamin K antagonist, and the group assigned to avoid oral anticoagulation received standard clinical practice (antiplatelet agent or no antithrombotic agent). The primary outcome was recurrent symptomatic spontaneous intracranial haemorrhage, and was adjudicated by an individual masked to treatment allocation. All outcomes were ascertained for at least 1 year after randomisation and assessed in the intention-to-treat population of all randomly assigned participants, using Cox proportional hazards regression adjusted for minimisation covariates. We planned a sample size of 190 participants (one-sided p=0·025, power 90%, allowing for non-adherence) based on a non-inferiority margin of 12% (or adjusted hazard ratio [HR] of 3·2). This trial is registered with ClinicalTrials.gov (NCT03153150) and is complete. Findings Between March 29, 2018, and Feb 27, 2020, consent was obtained at 61 sites for 218 participants, of whom 203 were randomly assigned at a median of 115 days (IQR 49–265) after intracranial haemorrhage onset. 101 were assigned to start and 102 to avoid oral anticoagulation. Participants were followed up for median of 1·2 years (IQR 0·97–1·95; completeness 97·2%). Starting oral anticoagulation was not non-inferior to avoiding oral anticoagulation: eight (8%) of 101 in the start group versus four (4%) of 102 in the avoid group had intracranial haemorrhage recurrences (adjusted HR 2·42 [95% CI 0·72–8·09]; p=0·152). Serious adverse events occurred in 17 (17%) participants in the start group and 15 (15%) in the avoid group. 22 (22%) patients in the start group and 11 (11%) patients in the avoid group died during the study. Interpretation Whether starting oral anticoagulation was non-inferior to avoiding it for people with atrial fibrillation after intracranial haemorrhage was inconclusive, although rates of recurrent intracranial haemorrhage were lower than expected. In view of weak evidence from analyses of three composite secondary outcomes, the possibility that oral anticoagulation might be superior for preventing symptomatic major vascular events should be investigated in adequately powered randomised trials. Funding British Heart Foundation, Medical Research Council, Chest Heart & Stroke Scotland.

Introduction Patients with dysphagia may consider eating and drinking with acknowledged risk (EDAR) instead of artificial hydration/nutrition. Timely consideration of complex issues is required including dysphagia reversibility, prognosis, risk/benefit discussions, patient wishes, their capacity, best interests and advanced care planning. This study aimed to ascertain if EDAR protocols improve care through a systematic literature review. Methods PUBMED, MEDLINE, CINAHL and EMBASE were searched for English language articles to May ‘19 with terms related to EDAR, dysphagia and end of life. Articles and conference abstracts with original data were agreed for inclusion by two independent reviewers. Levels of evidence were assessed using the Sackett scale (Cook et al, Chest. 1995; 4: 227–230). Study themes were identified and discussed. Results 12 articles met the inclusion criteria with varied methodology. The highest level of evidence was III (cohort study) and most were limited to patients with dementia, stroke, in older person’s wards or residential homes. 4 articles described a systematic approach to EDAR for in-patients and reported reductions in days nil-by-mouth until feeding plans are made and improvements in documentation of decision making, nutrition plans and capacity assessment. Other major themes included the need for an EDAR protocol, staff, patient and carer/family knowledge of EDAR, development of a protocol and the language of “risk feeding”. Formal meta-analysis was not possible due to the level and mix of methodology. Conclusions There is a paucity of evidence to determine if EDAR protocols improve care. However support is emerging for a coordinated approach to managing EDAR. Findings suggest having a protocol is not enough; education, training and communication within teams and with patients and carers is essential and this justifies further work. The lack of research into the impact of EDAR protocols on patient and carer experience means they must be central to any future work.

Background: Stroke is a leading cause of death and disability in the UK with around 90,000 new stroke patients each year. The NHS England (NHSE) Long Term Plan is committed to saving 150,000 lives from cardiovascular disease over the next 10 years and improving the quality of care available for patients who have a stroke. Methods: This overview was commissioned by NHSE to summarise what we currently know and don’t know across the breadth of the care pathway. We conducted a series of evidence reviews to inform NHSE and its providers (commissioners, primary and secondary care teams, networks) of what needs to be achieved to deliver world class services equitably across England. Here, we present a concise summary of this work. Results: Our report summarised the findings of 539 research articles, which we organised into ten sections relating to different stages of the stroke care pathway, from prevention in the community, to acute pre-hospital and hospital care, and on to rehabilitation and longer-term care in the community. Priorities include better prevention (with 90% of stroke attributable to modifiable risk factors), and improving awareness to maximise the chances that people experiencing an ischaemic stroke will reach hospital in time to be eligible for acute treatments. We describe the effects of reorganising hospital care into a smaller number of 'hyperacute' centres, and early supported discharge. In the longer term after stroke, the needs of stroke survivors and their families are not being met, but we found little evidence about what works to improve the situation. Conclusions: We present in this ‘concise’ version, an overview of the evidence to support the delivery of world class stroke care in England. We conclude with an overview of gaps in the evidence base for each area, set out as research questions to be prioritised and addressed.

Feeding with acknowledged risk is appropriate for patients unsuitable for tube feeding who have an unsafe swallow that is unlikely to improve. However, without excellent multidisciplinary decision making and communication, patients may spend unnecessarily long 'nil by mouth' (NBM) and advance feeding/care plans may not be made or communicated. The FORWARD bundle (Feeding via the Oral Route With Acknowledged Risk of Deterioration) was sequentially co-designed and embedded across different services using 'plan-do-study-act' methodology to systematise best practice. Care before and after FORWARD was evaluated using a time-series analysis of 80 patients who had been risk-fed. Time NBM without tube feeding improved from 2 to 0 days (p=0.02) with significantly better documentation of capacity assessments and discussions with next of kin. There were sustained trends to improved rates of best interest discussions and communication of feeding plans to downstream care providers. The significance and applicability of these findings is discussed.

Patients with dysphagia may consider eating and drinking with acknowledged risk (EDAR) instead of artificial hydration/nutrition. Timely consideration of complex issues is required including dysphagia reversibility, risk/benefit discussions, patient wishes, their capacity and best interests.This study aimed to establish if EDAR protocols improve care through a systematic literature review with a secondary aim to explore important factors for the development and success of a protocol.PUBMED, MEDLINE, CINAHL and EMBASE were searched for English language articles to May 2019 with terms related to EDAR, dysphagia and end of life. Articles were agreed for inclusion by three independent reviewers. Levels of evidence were assessed using the modified Sackett scale. Study themes were identified and discussed.8 articles met the inclusion criteria with varied methodology. The highest level of evidence was III (cohort study). Most were limited to patients with dementia, stroke, in older person's wards or residential homes. Three articles described a systematic approach to EDAR for in-patients, reporting reductions in days nil-by-mouth until feeding plans are made and improvements in documentation of decision making, nutrition plans and capacity assessment. Five papers explored the views and knowledge of staff, patients and families/carers relating to EDAR and complex feeding decisions. Formal meta-analysis was not possible due to the level and mix of methodology.There is a paucity of evidence to determine if EDAR protocols improve care. However, support is emerging for a coordinated approach to managing EDAR. Findings suggest having a protocol is not enough; training and communication within teams is essential, together with incorporating feedback from patients and carers, and this justifies further work.

Dysphagia after stroke is common and has a significant impact on disability, institutionalisation and mortality. Patients who cannot achieve nutrition from food and fluids orally should be considered for a modified diet and/or tube feeding, taking into account their wishes and best interests. This article describes the issues in managing such patients, including feeding with acknowledged risk. The specialist stroke nurse plays a central role in the successful implementation of these strategies, particularly with regard to patient and carer education, monitoring and compliance.

BACKGROUND care of patients with a permanently unsafe swallow who are inappropriate for tube feeding is challenging. Eating and drinking with acknowledged risk (EDAR) may be an appropriate strategy but without clear decision making and communication patients may spend unnecessarily long 'nil by mouth' (NBM), they or their family may experience significant anxieties and advance care plans may not be made. METHODS the FORWARD (Feeding via the Oral Route With Acknowledged Risk of Deterioration) care bundle was sequentially co-designed and embedded across different in-patient clinical services using 'plan-do-study-act' methodology to systematise best practice. Care before and after FORWARD's implementation was evaluated using a time-series analysis of 305 'EDAR patients' (19 in 6 months pre-FORWARD; 42 in a 12-month 'pilot'; 244 patients in the subsequent 27 months). RESULTS median (IQR) days patients were NBM without an alternative feeding route reduced significantly from 2 (1-4) pre-FORWARD to 0 (0-2) in the 'pilot' and 0 (0) post-'pilot' (P < 0.05). G-chart analysis demonstrated sustained performance across time and different clinical settings. Implementation of FORWARD significantly improved documentation of capacity assessment (42%→98%), discussions with next of kin (47%→98%) and onward communication of feeding plans (67%→81%). In wards where FORWARD was introduced, rate of aspiration pneumonia (a 'balancing measure' sensitive to harm associated with EDAR) increased at half the rate of dysphagia (0.8%/year versus 1.6%/year). CONCLUSION the FORWARD care bundle supported complex decision-making around EDAR in patients with persistent dysphagia. The benefits of FORWARD were shown to be sustained over time and in a wide in-patient context.