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Background: Poststroke fatigue affects ≈50% of patients with stroke, causing significant personal, societal, and economic burden. In the FASTER (Fatigue After Stroke Educational Recovery) study, we assessed a group-based educational intervention for poststroke fatigue., Methods and Results: Two hundred patients with clinically significant fatigue were included and randomized to either a general stroke education control or fatigue management group (FMG) intervention and assessed at baseline, 6 weeks, and 3 months. The FMG involved weekly psychoeducation sessions over 6 weeks. Coprimary outcomes were the Fatigue Severity Scale and Multidimensional Fatigue Inventory-20 total scores. Adjusted mean total Fatigue Severity Scale scores at 6 weeks (primary end point) were nearly identical for the education control and FMG groups. The adjusted mean difference between treatment groups was -0.13 (SE, 1.4; P =0.92) at 6 weeks and 1.67 (SE, 1.4; P =0.26) at 3 months. Although there were no significant effects, Fatigue Severity Scale outcomes were in the direction of a treatment effect based on the estimated change. Adjusted mean total Multidimensional Fatigue Inventory-20 scores at 6 weeks (primary end point) were similar for the education control and FMG groups. The adjusted mean difference between treatment groups was -0.91 (SE, 1.54; P =0.55) at 6 weeks and -1.26 (SE, 1.8; P =0.49) at 3 months. Both groups had similar secondary outcomes (eg, Multidimensional Fatigue Inventory-20 subscales, sleep, pain, mood, quality of life) at 6 weeks and 3 months., Conclusions: We found no evidence of significant group-level benefits of FMG over and above general stroke education. Educational group-based interventions for poststroke fatigue should continue to be refined and examined, including consideration of potential impacts at an individual level., Registration: URL: https://www.anzctr.org.au/; UnIque identifier: ACTRN12619000626167.

Background: Most strokes and cardiovascular diseases (CVDs) are potentially preventable if their risk factors are identified and well controlled. Digital platforms, such as the PreventS-MD web app (PreventS-MD) may aid health care professionals (HCPs) in assessing and managing risk factors and promoting lifestyle changes for their patients., Methods: This is a mixed-methods cross-sectional two-phase survey using a largely positivist (quantitative and qualitative) framework. During Phase 1, a prototype of PreventS-MD was tested internationally by 59 of 69 consenting HCPs of different backgrounds, age, sex, working experience, and specialties using hypothetical data. Collected comments/suggestions from the study HCPs in Phase 1 were reviewed and implemented. In Phase 2, a near-final version of PreventS-MD was developed and tested by 58 of 72 consenting HCPs using both hypothetical and real patient (n = 10) data. Qualitative semi-structured interviews with real patients (n = 10) were conducted, and 1 month adherence to the preventive recommendations was assessed by self-reporting. The four System Usability Scale (SUS) groups of scores (0-50 unacceptable; 51-68 poor; 68-80.3 good; >80.3 excellent) were used to determine usability of PreventS-MD., Findings: Ninety-nine HCPs from 27 countries (45% from low- to middle-income countries) participated in the study, and out of them, 10 HCPs were involved in the development of PreventS before the study, and therefore were not involved in the survey. Of the remaining 89 HCPs, 69 consented to the first phase of the survey, and 59 of them completed the first phase of the survey (response rate 86%), and 58 completed the second phase of the survey (response rate 84%). The SUS scores supported good usability of the prototype (mean score = 80.2; 95% CI [77.0-84.0]) and excellent usability of the final version of PreventS-MD (mean score = 81.7; 95% CI [79.1-84.3]) in the field. Scores were not affected by the age, sex, working experience, or specialty of the HCPs. One-month follow-up of the patients confirmed the high level of satisfaction/acceptability of PreventS-MD and (100%) adherence to the recommendations., Interpretation: The PreventS-MD web app has a high level of usability, feasibility, and satisfaction by HCPs and individuals at risk of stroke/CVD. Individuals at risk of stroke/CVD demonstrated a high level of confidence and motivation in following and adhering to preventive recommendations generated by PreventS-MD., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: V.L.F., R.K., B.N., S.J.-M., A.M., and M.K. declare that the PreventS-MD web app and the free Stroke Riskometer app are owned and copyrighted by Auckland University of Technology (AUT) Ventures Ltd, New Zealand. Other co-authors reported no conflict of interest.

Rationale: Post-stroke fatigue affects up to 92% of stroke survivors, causing significant burden. Educational cognitive behavioral therapy fatigue groups show positive results in other health conditions., Aims: FASTER will determine if educational cognitive behavioral therapy fatigue management group reduces subjective fatigue in adults post-stroke., Design: Prospective, multi-centre, two-arm, single-blind, phase III RCT (parallel, superiority design), with blinded assessments at baseline, six weeks, and three months post-program commencement. With n  = 200 (100 per group, 20% drop-out), the trial will have 85% power (2-sided, p  = 0.05) to detect minimally clinically important differences of 0.60 (SD = 1.27) in fatigue severity scale and 1.70 points (SD = 3.6) in multidimensional fatigue inventory-20 at three months., Outcomes: Primary outcomes are self-reported fatigue severity and dimensionality (i.e. types of fatigue experienced - physical, psychological and/or cognitive) post-intervention (six weeks). Secondary outcomes include subjective fatigue at three months, and health-related quality of life, disability, sleep, pain, mood, service use/costs, and caregiver burden at each follow-up., Discussion: FASTER will determine whether fatigue management group reduces fatigue post-stroke.Registered with the Australian New Zealand Clinical Trials Registry (ACTRN12619000626167).

There is increasing evidence that both hypertension and stroke play important roles in the development of cognitive decline and dementia. Despite five high-quality randomised controlled trials (RCTs) in this area to date, there remains uncertainty about the role of blood pressure lowering therapy in the prevention of cognitive decline and dementia. It appears that lack of definitive results from these trials can be explained on the basis of (a) insufficient power to detect modest treatment effects; (b) measurement error in the diagnosis of dementia; (c) variations in the treatment effects between different types of antihypertensive agents; and (d) bias due to missing data, variation in baseline factors such as levels of blood pressure, and the inclusion of patients with cognitive impairment at entry. Preliminary meta-analysis of RCTs supports the hypothesis that blood pressure lowering may prevent dementia in high-risk patients, that is those with vascular disease. However, a meta-analysis of individual patient data (IPD) from these, and other relevant trials in patients with vascular disease, would provide much more reliable data. If the hypothesis were confirmed, it would certainly be of considerable importance not only in terms of our understanding of the aetiology of dementia, but also in promoting blood pressure lowering strategies for broader public health good.

Aim: Despite strong evidence of benefit, few stroke units exist in New Zealand. In this paper, we describe the process and outcome for the country's first, comprehensive Acute Stroke Unit (ASU), established at Middlemore Hospital in 2001., Methods: The evaluation comprised: (a) two independent 'before and after' audits of medical records of a random selection of patients (2 x n=100) identified from Diagnostic Related Group (DRG) discharge codes for stroke in 1999 (12 months) and 2001-02 (9 months); (b) a review of all DRG stroke outcome data and internal cost analyses for the study periods; and (c) a 'time-in-motion' study of nursing care requirements., Results: The DRG data showed an increase in separations (538 vs 613); stable re-admissions (8% vs 7%); and declines in average length of stay (6.1 vs 5.4 days), deaths (14.0% vs 8.8%), and referrals for rehabilitation (127 vs 67); while the audit indicated shorter times from admission to brain imaging, and swallow and allied health assessments, for stroke f rom 1999 to 2001-02. A 1:4 nurse:patient ratio seems to provide an optimum level of care for costs., Conclusions: The introduction of the ASU has been associated with improvements in several key indicators of quality of care for patients with stroke.

Objective: To measure the occurrence of shoulder pain after stroke. To identify the factors that predict risk of shoulder pain after stroke., Design: Auckland Stroke Study, population-based case-cohort study., Setting and Subjects: All cases of stroke, including those managed outside hospital, over a 12-month period ending February 1992 were considered in Auckland., Outcome Measures: Self-reported shoulder pain at one week, one month and six months after the onset of stroke for each person., Results: A total of 1,761 stroke events were identified. Self-reported shoulder pain among survivors increased from 256/1474 (17%) at one week, to 261/1,336 (20%) at one month and 284/1,201 (23%) at six months. Shoulder pain was positively associated with motor deficit, side of deficit and severity of deficit. In those surviving to six months after stroke, the risk of shoulder pain was higher in those with severe upper limb motor deficit (odds ratio (OR) 4.94; 95% confidence interval (CI) 3.06-7.98) and in diabetics (OR 1.57, 95% CI 1.15-2.14). Risk of shoulder pain increased with time and was lower for those in institutional care., Conclusion: Shoulder pain after stroke is common, especially in patients with severe sensorimotor deficits, diabetics and those living at home. Appropriate management may reduce the rate of occurrence.

Blood pressure levels are strongly predictive of the risks of first-ever and recurrent stroke. The benefits of blood pressure-lowering therapy for the prevention of fatal and non-fatal stroke in middle-aged individuals are well established. However, until recently, there has been uncertainty about the consistency of such benefits across different patient groups and in particular, for older people and in those with a history of stroke. This paper discusses the evidence surrounding the effectiveness of blood pressure-lowering therapy, specifically in older patients with a history of stroke, with particular attention paid to the results from the Perindopril Protection Against Recurrent Stroke Study (PROGRESS). PROGRESS was a randomised, double-blind, placebo-controlled trial of 6105 individuals with a history of cerebrovascular disease recruited from 172 hospital outpatient clinics in ten countries. Participants (mean age 64 years; range 26-91 years) were randomly assigned to receive active treatment with an ACE inhibitor-based blood pressure-lowering regimen (perindopril) with or without addition of the diuretic indapamide, or matched placebo. At the end of follow up (mean of 4 years), active treatment reduced the incidence of total stroke by 28% (95% CI 17-38%) and the rate of major vascular events by 26% (95% CI 16-34%). Importantly, benefits of treatment were consistent across key patient subgroups, including those with and without hypertension, patients who were Asian and non-Asian, and for both ischaemic and haemorrhagic strokes subtypes. Current evidence is now strong for clinicians to consider blood pressure-lowering therapy as pivotal in the prevention of stroke, especially in patients with a known history of cerebrovascular disease (and vascular disease, in general), irrespective of blood pressure levels, as soon as patients are clinically stable after an acute stroke or other vascular event. Additional age-specific analyses of the PROGRESS data, together with those from other completed trials, will provide more reliable information about the size of the benefits of blood pressure-lowering therapy, specifically for different age groups, and particularly in the oldest old (those aged >80 years). In the meantime though, an ACE inhibitor plus diuretic treatment regimen that maximises the degree of blood pressure reduction has a good safety profile and is an effective treatment that should be considered in all patients with stroke, including the elderly.