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Background The aim of the International Stroke Recovery and Rehabilitation Alliance is to create a world where worldwide collaboration brings major breakthroughs for the millions of people living with stroke. A key pillar of this work is to define globally relevant criteria for centers that aspire to deliver excellent clinical rehabilitation and generate exceptional outcomes for patients. Objectives This paper presents consensus work conducted with an international group of expert stroke recovery and rehabilitation researchers, clinicians, and people living with stroke to identify and define criteria and measurable indicators for Centers of Clinical Excellence (CoCE) in stroke recovery and rehabilitation. These were intentionally developed to be ambitious and internationally relevant, regardless of a country’s development or income status, to drive global improvement in stroke services. Methods Criteria and specific measurable indicators for CoCE were collaboratively developed by an international panel of stroke recovery and rehabilitation experts from 10 countries and consumer groups from 5 countries. Results The criteria and associated indicators, ranked in order of importance, focused upon (i) optimal outcome, (ii) research culture, (iii) working collaboratively with people living with stroke, (iv) knowledge exchange, (v) leadership, (vi) education, and (vii) advocacy. Work is currently underway to user-test the criteria and indicators in 14 rehabilitation centers in 10 different countries. Conclusions We anticipate that use of the criteria and indicators could support individual organizations to further develop their services and, more widely, provide a mechanism by which clinical excellence can be articulated and shared to generate global improvements in stroke care.

Introduction Prehypertension is defined as blood pressure that is above the normal range but not high enough to be classed as hypertension. Prehypertension is a warning of development of hypertension as well as a risk for cardiovascular disease, heart attack and stroke. In the UK, non-pharmacological interventions are recommended for prehypertension management, but no reviews have focused on the effectiveness of these types of interventions solely in people with prehypertension. Therefore, the proposed systematic review will assess the clinical- and cost–effectiveness of non-pharmacological interventions in reducing or maintaining blood pressure in pre-hypertensive people. Methods and analysis This systematic review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The databases/ trial registries that will be searched to identify relevant randomised controlled trials (RCTs) and economic evaluations include Medline, EMBASE, CINAHL, PsycINFO, CENTRAL, the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, Cochrane Library, Scopus, and the International HTA Database. Search terms have been identified by the team including an information specialist. Three reviewers will be involved in the study selection process. Risk of bias will be evaluated using the Cochrane risk-of-bias tool for RCTs, and the Consensus Health Economic Criteria list for economic evaluations. Findings from the included studies will be tabulated and synthesised narratively. Heterogeneity will be assessed through visual inspection of forest plots and the calculation of the Chi2 and I2 statistics, and causes of heterogeneity will be assessed where sufficient data are available. If possible, we plan to investigate differential effects on specific sub-groups and from different types of interventions using meta-regression. Where relevant, the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE)

Background Stroke nurses are adopting extended roles to improve patient care due to limited numbers of vascular neurologists, however, little is known of this experience. We evaluated the impact of an internationally implemented fellowship education program to equip experienced stroke nurses, nationally and internationally, to undertake extended acute stroke roles. Methods We conducted semi-structured interviews with the following groups of individuals associated with the NET SMART Advanced Practice fellowship program: 1) Stroke nurse program graduates; 2) currently enrolled stroke nurse fellows; 3) local physician mentors; 4) service managers of program graduates. Interviews took place between February-August 2018 and were analysed using the Theoretical Domains Framework. Results Interviews were held with stroke nurses (n=11), mentors (n=4) and a service manager (n=1). Four themes were identified: 1) ‘The learning journey’- describing motivations for undertaking the training and course content; 2) ‘Organizational and professional change’- experiencing professional resistance to the new role, or lack of a suitable role to move into after program completion; 3) ‘What hindered the learning journey?’- small hospitals with low patient volume makes completion challenging; 4) ‘What helped the learning journey?’- a supportive team facilitated completion. Conclusion We found overwhelming skill development and professional growth by nurses, and this was echoed by mentors and managers. However, despite expanding their stroke-specific knowledge and skills, non-U.S.A. nurses faced systemic challenges in implementing their skills including lack of acceptance of extended nurse roles from wider professions.

Background: Suspected transient ischaemic attack (TIA) is a diagnostic challenge yet requires timely diagnosis for secondary stroke prevention. Aims: To understand variability of organisational processes, roles, education, and clinical decision-making in UK TIA services. Methods: Healthcare professionals were surveyed online in 2021 with descriptive data analysis. We conducted interviews (2021-2022) with a purposive sample. Three researchers thematically analysed interview data. Findings: Survey responses were received from 43 TIA services. 70% conducted remote consultations, 28% face-to-face, and 2% mixed. Different physician and roles, skills and experience provided TIA services. All services involved a consultant physician with experience in stroke. Ten interviews confirmed the survey results and highlighted variability regarding: clinical decision-making; service composition; resources; learning opportunities; and mode of consultation. Conclusion: Variability in TIA service workforce and service organisation influenced diagnostic decisions. The possible impact of such variability on clinical outcomes, and approaches to reducing it, require further research.

Introduction Around 40% of adults have pre-hypertension (blood pressure between 120–139/80–89), meaning they are at increased risk of developing hypertension and other cardiovascular disease-related conditions. There are limited studies on the management of pre-hypertension; however, guidance recommends that it should be focused on lifestyle modification rather than on medication. Self-monitoring of blood pressure could allow people to monitor and manage their risk status and may allow individuals to modify lifestyle factors. The purpose of this study is to determine the feasibility and acceptability, to both healthcare professionals and people with pre-hypertension, of blood pressure self-monitoring. Methods and analysis A prospective, non-randomised feasibility study, with a mixed-methods approach will be employed. Eligible participants (n=114) will be recruited from general practices, pharmacies and community providers across Lancashire and South Cumbria. Participants will self-monitor their blood pressure at home for 6 months and will complete questionnaires at three timepoints (baseline, 6 and 12 months). Healthcare professionals and participants involved in the study will be invited to take part in follow-up interviews and a focus group. The primary outcomes include the willingness to engage with the concept of pre-hypertension, the acceptability of self-monitoring, and the study processes. Secondary outcomes will inform the design of a potential future trial. A cost-analysis and cost-benefit analysis will be conducted. Ethics and dissemination Ethics approval has been obtained from London–Fulham NHS Research Ethics Committee, the University of Central Lancashire Health Ethics Review Panel and the HRA. The results of the study will be disseminated via peer-reviewed publications, feedback to service users and healthcare professionals, and to professional bodies in primary care and pharmacy.

Introduction: Long COVID (LC), the persistent symptoms ≥12 weeks following acute COVID-19, presents major threats to individual and public health across countries, affecting over 1.5 million people in the UK alone. Evidence-based interventions are urgently required and an integrated care pathway approach in pragmatic trials, which include investigations, treatments and rehabilitation for LC, could provide scalable and generalisable solutions at pace. Methods and analysis: This is a pragmatic, multi-centre, cluster-randomised clinical trial of two components of an integrated care pathway (Coverscan™, a multi-organ MRI, and Living with COVID Recovery™, a digitally enabled rehabilitation platform) with a nested, Phase III, open label, platform randomised drug trial in individuals with LC. Cluster randomisation is at level of primary care networks so that integrated care pathway interventions are delivered as “standard of care” in that area. The drug trial randomisation is at individual level and initial arms are rivaroxaban, colchicine, famotidine/loratadine, compared with no drugs, with potential to add in further drug arms. The trial is being carried out in 6–10 LC clinics in the UK and is evaluating the effectiveness of a pathway of care for adults with LC in reducing fatigue and other physical, psychological and functional outcomes at 3 months. The trial also includes an economic evaluation which will be described separately. Ethics and dissemination: The protocol was reviewed by South Central—Berkshire Research Ethics Committee (reference: 21/SC/0416). All participating sites obtained local approvals prior to recruitment. Coverscan™ has UK certification (UKCA 752965). All participants will provide written consent to take part in the trial. The first participant was recruited in July 2022 and interim/final results will be disseminated in 2023, in a plan co-developed with public and patient representatives. The results will be presented at national and international

Aim: This qualitative study explores with health professionals the provision of, and challenges for, post-discharge stroke care, focussing on eating, drinking and psychological support across India. Design: Qualitative semi-structured interviews. Setting: Seven geographically diverse hospitals taking part in a Global Health Research Programme on Improving Stroke Care in India Participants: A purposive sample of healthcare professionals with current experience of working with stroke patients. Results: Interviews with 66 healthcare professionals (23 nurses (14 staff nurses; 7 senior nurse officers; 1 Intensive Care Unit nurse; 1 palliative care nurse)); 16 doctors (10 neurologists; 6 physicians); 10 physiotherapists; 5 speech and language therapists; 4 occupational therapists; 4 dieticians; 2 psychiatrists; and 2 social workers) resulted in three main themes: Integrated inpatient discharge care planning processes; Post-discharge patient and caregiver role and challenges; Patient and caregiver engagement post-discharge. Conclusions: Discharge planning was integrated and customised, although resources were limited in some sites. Task-shifting compensated for a lack of specialists but was limited by staff education and training. Caregivers faced challenges in accessing and providing post-discharge care. Post-discharge care was mainly hospital-based, supported by tele-services, especially for rural populations. Further research is needed to understand post-discharge care provision and the needs of stroke survivors and their caregivers.

Introduction: Overweight and obesity are growing public health problems worldwide. Both diet and physical activity have been the primary interventions for weight reduction over the past decade. With increasing rates of overweight and obesity, it is evident that a primary focus on diet and exercise has not resulted in sustained obesity reduction within the global population. There is now a case to explore other weight management strategies, focusing on psychological factors that may underpin overweight and obesity. Psychological therapy interventions are gaining recognition for their effectiveness in addressing underlying emotional factors and promoting weight loss. However, there is a dearth of literature that has mapped the types of psychological interventions and the characteristics of these interventions as a means of achieving weight reduction and sustained weight reduction in adults with overweight or obesity. Methods and analysis: The review will combine the methodology outlined by Arksey and O’Malley with the PRISMA-ScR guidelines. A total of six databases will be searched using a comprehensive search strategy. Intervention studies will be included if participants are 18 years and over, classified as overweight or obese (≥BMI 25kg/m2), and have received a psychological therapy intervention. The review will exclude studies that are not available in English, not full text, none peer reviewed or combine a lifestyle and/or pharmacological intervention with a psychological intervention. Data will be synthesised using a narrative synthesis approach. Ethics and dissemination: Ethical approval is not required to conduct this scoping review. The findings will be disseminated through journal publication(s), social media, and a lay summary for key stakeholders.

Introduction: Urinary incontinence (UI) affects over half of people with stroke. It is unclear which methods are accurate in assessing presence and type of UI to inform clinical management. Diagnosis of UI based on inaccurate methods may lead to unnecessary interventions. The aims of this systematic review were to identify, for adults with stroke, clinically accurate methods to determine the presence of UI and type of UI. Method: We searched seven electronic databases and additional conference proceedings. To be included, studies had to be primary research comparing two or more methods, or use a reference test. Results: We identified 3846 studies with eight eligible for inclusion. We identified 11 assessment methods within the eight studies. Only five studies had sufficient comparator data for synthesis. Due to heterogeneity of data, results on the following methods were narratively synthesised: Core Lower Urinary Tract Symptom Score (CLSS), clinical history and physical examination, Barthel Activities of Daily Living Index, International Consultation Incontinence Questionnaire Short Form (ICiQ-SF) and urodynamic studies (UDS). Most studies were small and of low to medium quality. All reported differences in sensitivity, and none compared the same assessment methods. Conclusion: Current evidence is insufficient to support recommendations on the most accurate UI assessment for adults with stroke. Further research is needed.

Background: Dehydration and malnutrition are common in hospitalised patients following stroke leading to poor outcomes including increased mortality. Little is known about hydration and nutrition care practices in hospital to avoid dehydration or malnutrition, and how these practices vary in different countries. This study sought to capture how the hydration and nutrition needs of patients’ post-stroke are assessed and managed in the United Kingdom (UK) and Australia (AUS). Aim: To examine and compare current in-hospital hydration and nutrition care practice for patients with stroke in the UK and Australia. Methods: A cross-sectional survey was conducted between April and November 2019. Questionnaires were mailed to stroke specialist nurses in UK and Australian hospitals providing post-stroke inpatient acute care or rehabilitation. Non-respondents were contacted up to five times. Results: We received 150/174 (86%) completed surveys from hospitals in the UK, and 120/162 (74%) in Australia. Of the 270 responding hospitals, 96% reported undertaking assessment of hydration status during an admission, with nurses most likely to complete assessments (85%). The most common methods of admission assessment were visual assessment of the patient (UK 62%; AUS 58%), weight (UK 52%; AUS 52%), and body mass index (UK 47%; AUS 42%). Almost all (99%) sites reported that nutrition status was assessed at some point during admission, and these were mainly completed by nurses (91%). Use of standardised nutrition screening tools were more common in the UK (91%) than Australia (60%). Similar proportions of hydration management decisions were made by physicians (UK 84%; AUS 83%), and nutrition management decisions by dietitians (UK 98%; AUS 97%). Conclusion: Despite broadly similar hydration and nutrition care practices after stroke in the UK and Australia, some variability was identified. Although nutrition assessment was more often informed by structured screening tools, the routine asse

Dehydration after stroke is associated with poor health outcomes, increased mortality, and poses a significant economic burden to health services. Yet research suggests that monitoring and assessment of hydration status is not routinely undertaken. In this commentary, we critically appraise a systematic review which aimed to synthesise the existing evidence regarding diagnosis and treatment of dehydration after stroke. The review discusses common measures of dehydration, describes studies evaluating rehydration treatments, and highlights the link between dehydration and poorer health outcomes in both human and animal studies. The reviewers suggest, future research should focus on determining a single, validated, objective measure to clinically diagnose dehydration in stroke patients. Research designs should include clearly defined patient characteristics, type and severity of stroke, and type and time point of dehydration measurement, to enable comparison between studies. Management of hydration status is a crucial element of acute stroke care which should be routinely practiced.

Background Person-centred community-based support services (PCCBSS) are an array of non-clinical services provided by organisations such as NHS Trusts, voluntary sector organisations, or local authorities. All PCCBSS involve an individual (variously known as a 'social prescriber’, ‘link worker’, ‘signposter’, ‘navigator’, ‘connector’ or ‘neighbourhood coach’) who talks with a service user before directing them to a range of relevant community sources of social, emotional, and practical support. Despite much recent investment in social prescribing, and its increased prominence within the policy context across England, little is understood about how PCCBSS are implemented. Research is required across different contexts to describe PCCBSS implementation; in particular, how social care providers successfully interact to support the implementation of PCCBSS, and how services responded to circumstances imposed by the COVID-19 pandemic. Purpose The aim of this post-implementation mixed-methods study is to explore how PCCBSS are implemented and become part of usual working practice. Using three services in North West England as case studies, we will examine factors influencing PCCBSS implementation and establish where there is learning for the wider adult social care system. Focus The study comprises two work packages (WPs): WP1: collecting data by reviewing service documents from three PCCBSS case studies; WP2: interviewing staff and service users (≤20 participants per PCCBSS); Key implementation data will be systematically abstracted (from WPs1&2) into a coding frame; combining contextual determinants from the Consolidated Framework for Implementation Research (CFIR) with process-related domains from Normalization Process Theory (NPT). Key outputs The findings from WP1 and WP2 will be presented in the form of an illustrated ‘pen portrait’, developed collaboratively with Applied Research Collaboration North West Coast ARC NWC public advisers, to illustrate how implementati

Introduction: Normalisation Process Theory (NPT) is widely used to explore how new healthcare practices are understood, enacted, reflected upon and embedded in usual practice, typically focussing on professionals’ behaviours. NPT is less commonly used to explore patients’ experiences during implementation of new interventions. The RETurn to work After stroKE (RETAKE) trial used NPT’s four constructs (coherence, cognitive participation, collective action, reflexive monitoring) in comparing experi-ences of stroke survivors who received Early Stroke Specialist Vocational Rehabilitation (ESSVR) with recipients of usual care (UC) only.Method: Semi-structured interviews with 44 stroke survivors (23 who received ESSVR and 21 UC participants). NPT underpinned data collec-tion and analysis.Results: RETAKE OTs helped participants in the ESSVR arm make sense of stroke, accept stroke-related limitations, and develop intervention understanding (coherence) more easily than most UC participants. RETAKE OTs typically involved all stakeholders in return-to-work (RTW) plans, facilitating co-operation and engagement (cognitive participation), whereas UC participants described poor co-ordination between services and limited or no focus on RTW. ESSVR participants completed individu-ally tailored work-related tasks, with RETAKE OTs mediating workplace adjustments and monitoring employment progress (collective action). In contrast, OT involvement in work preparation and employer negotiations for UC participants was rare. RETAKE OTs supported ESSVR participants to reflect on the appropriateness of RTW post-stroke or explore alterna-tives (reflexive monitoring). However, few UC recipients were supported to consider the suitability of their current work roles; consequently, some reported feeling ‘abandoned’ by health services.Conclusion: NPT was useful in exploring participants’ perspectives of a complex intervention in the RETAKE trial.

Introduction: Twenty-five percent of stroke survivors are of working age, yet the likelihood of successful return-to-work is low. This study compared experiences of recipients of Early Stroke Specialist Vocational Rehabilitation (ESSVR), an intervention to help stroke survivors return to work (RTW), with stroke survivors receiving usual care (UC) only. Method: Longitudinal case-study exploring experiences of stroke survivors who received ESSVR and those who received usual care (UC) only. Data were gathered using semi-structured interviews at 6 weeks, and 6- and 12-months post-randomisation. Findings were analysed thematically and mapped onto the APC model (Schwartz et al, 2018) which highlights three basic principles guiding RTW: Adaptiveness, Purposefulness and Cooperativeness in interactions between the person, the workplace and rehabilitation services. Results: Analysis indicates differences between ESSVR and UC participants’ RTW experiences. ESSVR participants report being supported to adapt to new circumstances following stroke by occupational therapists (OTs) providing tailored vocational rehabilitation (VR) and advocating for workplace adaptations and adjustments. Co-ordinated support ensured that stakeholders worked purposefully, with ESSVR OTs providing information and advice over 12 months. This facilitated cooperativeness, enabling a sustained RTW. In contrast, most UC participants reported little or no RTW support. They described a lack of communication and co-ordination between services and feeling ‘abandoned’ following discharge from community services, typically after 12 weeks. Conclusion: The APC model helped highlight the benefits of ESSVR. Specifically, stakeholders working together to adapt to stroke survivors’ changed abilities, being purposeful in delivery and receipt of VR support, and co-operating with OTs’ recommendations to facilitate successful and sustained RTW.

Introduction: Increasing evidence links poor oral health status, dysphagia and development of stroke-associated pneumonia (SAP). The aim of this study is to determine whether a phase 3, randomised controlled trial of oral healthcare (OHC) to prevent SAP in dysphagic acute stroke patients is feasible. Method: This is a randomised feasibility trial with parallel process evaluation. Using a factorial design, we plan to randomise 120 patients with acute stroke and dysphagia within 24 h of admission to either non-foaming toothpaste v 1% chlorhexidine gel and to either manual v powered brushing. Stroke unit nursing staff will receive standardised training to deliver the OHC treatments. Assessment of feasibility will include recruitment and set-up of sites, recruitment and retention of participants, adherence to allocated OHC treatment, acceptability and tolerability. We will also record incident SAP, antibiotic doses received, length of stay and modified Rankin score at 3 months. In the process evaluation we will focus on implementation of, and fidelity to, the OHC by undertaking focus groups at each site and employing behaviour change techniques to establish an implementation package. Results: The trial commenced on 31st August 2021 at 4 North West hospitals with final 3 month follow-up at the end of March 2023. Conclusion: We will establish whether feasibility progression criteria are met for a phase 3 trial, and whether further piloting is required.

After a stroke, physical activity can be key in enhancing the rehabilitation of patients and preventing a secondary stroke. In this commentary, we critically appraise a systematic review which investigated how different types of physical fitness training impact on the mental and physical conditions of stroke survivors. Cardiorespiratory, resistance and mixed training (especially when including walking) can improve key outcomes such as the balance and mobility of stroke survivors, but the most suitable type of training depends on the individual needs and aims of the rehabilitation process. More research is needed to understand how the effects of the different types of training vary by considering the time between stroke and intervention onset, stroke severity, and the dose of intervention.

Objectives Stroke survivors often have unmet physical, psychological and/or social concerns. Patient Concerns Inventories (PCIs) have been developed for other health conditions to address concerns. Our objective was to develop a PCI for stroke care. Methods This was a development study, including Modified Delphi study design, with academic and healthcare professionals with stroke care expertise. In Stage 1, a draft Stroke PCI (Version 1a) was created through identifying patient-reported concerns post-stroke from three previous studies and through expert panel discussions using Nominal Group Technique. In Stage 2, Version 1a was sent to 92 academic and healthcare professionals with stroke care expertise. Participants ranked their top 20 Stroke PCI items in order of importance and provided feedback. Rankings were converted into scores, and, with the feedback, used to amend the Stroke PCI. Two further rounds of feedback followed until consensus was reached between participants. A final draft of the Stroke PCI was created. Results In stage 1, 64 potential Stroke PCI items were generated. In Stage 2, 38 participants (41.3%) responded to the request to rank Stroke PCI items. The three highest ranked items were ‘Risk of another stroke’, ‘Walking’, ‘Recovery’. After three rounds of feedback and amendments, the final draft of the Stroke PCI consisted of 53 items. Conclusions A Stroke PCI has been developed using patient-reported concerns in previous studies and input from academic and healthcare professionals. Future work will involve gathering further feedback on the tool and exploring its acceptability and usability in a pilot study.

Background: There is limited information on long term outcomes after stroke in Sub-Saharan Africa (SSA). Current estimates of case fatality rate (CFR) in SSA are based on small sample sizes with varying study design and report high heterogeneity. Aims: We report CFR and functional outcomes from a large, prospective, longitudinal cohort of stroke patients in Sierra Leone and describe factors associated with mortality and functional outcome. Methods: A prospective longitudinal stroke register was established at both adult tertiary government hospitals in Freetown, Sierra Leone. It recruited all patients ≥18 years with stroke, using the World Health Organization definition, from May 2019 until October 2021. To reduce selection bias onto the register all investigations were paid by the funder and outreach conducted to raise awareness of the study. Sociodemographic data, National Institute of Health Stroke Scale (NIHSS) and Barthel Index (BI) was collected on all patients on admission, at seven days, 90 days, one year and two years post stroke. Cox proportional-hazards models were constructed to identify factors associated with all-cause mortality. A binomial logistic regression model reports odds ratio (OR) for functional independence at one year. Results: 986 patients with stroke were included, of which 847 (85.9%) received neuroimaging. Follow up rate was 81.5% at one year, missing item data was <1% for most variables. Stroke cases were equally split by sex and mean age was 58.9 (SD: 14.0) years. 625 (63%) were ischaemic, 206 (21%) primary intracerebral haemorrhage, 25 (3%) subarachnoid haemorrhage and 130 (13%) were of undetermined stroke type. Median NIHSS was 16 (9-24). CFR at 30 days, 90 days, 1 year and 2 years was 37.1%, 44.4%, 49.7% and 53.2% respectively. Factors associated with increased fatality were male sex HR:1.28 (1.05-1.56), previous stroke HR:1.34 (1.04-1.71), atrial fibrillation HR:1.58(1.06-2.34), subarachnoid haemorrhage HR:2.31 (1.40-3.81), unde

BACKGROUND AND AIM Safe and efficient acute stroke care services, effective training and and context -sensitive research and advocacy are key to reducing the high stroke burden in Africa. However, quantitative data is sparse on stroke care services, training and research priorities in Africa. We describe the status of acute stroke care services and unmask training and research needs in Africa. METHODS A 56-item, pre-tested, multi-lingual online survey tool adapted from the World Stroke Organization (WSO) Roadmap to delivering quality stroke care was sent to stroke experts in each African country through e-mail directories of national stroke organizations, the African Stroke Organization (ASO), the African Academy of Neurology (AFAN) and the WSO-Future Leaders African fellows. Data on stroke services, management guidelines, stroke research, stroke education and training were collected and analyzed using descriptive statistics. RESULTS We surveyed 54 but had responses from 45 (83%) African countries covering 95% of the population of Africa. Only 4% of respondent countries had a national stroke registry or national stroke surveillance system. Thrombolysis was available in 49% of countries, at an estimated 255 centers. 16% of countries had access to endovascular thrombectomy at 69 centers. National stroke-specific training programs were available for 11% of consultants, 9% of general medical practitioners and 4% of nurses. Reperfusion therapy was selected as the most important training need and national stroke registries as the top research priority. CONCLUSION Our study highlights core needs for stroke services improvement, capacity building, context - sensitive research and multi-level advocacy in Africa.

Aims and Objectives To explore healthcare staff’s experiences of how dehydration is identified and managed in hospitalised patients after acute stroke, and facilitators and challenges to optimising hydration. Background Optimal hydration post-stroke reduces the risk of neurological deterioration and other complications. Patients are at risk of dehydration in acute stroke, particularly those with dysphagia. Design A descriptive qualitative study reported following the COREQ guidelines. Methods Semi-structured interviews, utilising patient vignettes, were conducted in 2018 (Apr-Oct) with a purposive sample of 30 multi-disciplinary staff members from two UK stroke units. Interviews were digitally recorded and transcribed verbatim. Content analysis identified common themes which were mapped to the Theoretical Domains Framework and the Behaviour Change Wheel. Results The themes mapped to twelve of the fourteen domains in the Theoretical Domains Framework. Participants believed that inadequate hydration management had potentially serious consequences, and described complex knowledge, skills and cognitive elements to effective hydration care. Participants felt that maintaining hydration was a multidisciplinary responsibility requiring good communication. Although the performance of initial dysphagia screening was reinforced by external audit, other areas of post-stroke hydration management were not; notably, there was no established method of assessing hydration. Barriers to maintaining good hydration included lack of staff, out-of-hours working patterns, low priority given to hydration, patients’ co-morbidities, and complex post-stroke disabilities such as dysphagia, aphasia, inattention and hemiparesis. Conclusion Findings highlighted the importance of assessing and maintaining hydration but identified barriers to, and variation in, clinical practice. To provide optimal care, barriers to the prevention and treatment of dehydration after stroke must be further understood

Background Pulse oximetry was widely used in hospitals and at home to monitor blood oxygen during the COVID-19 pandemic. There have been concerns regarding potential bias in pulse oximetry measurements for people with dark skin. We aimed to assess the effects of skin pigmentation on the accuracy of oxygen saturation measurement by pulse oximetry (SpO2) compared with the gold standard SaO2 measured by CO-oximetry. Methods We searched Ovid MEDLINE, Ovid Embase, and EBSCO CINAHL Plus (up to December 2021), as well as ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (up to August 2021). We identified studies comparing SpO2 values in any population, in any care setting, using any type of pulse oximeter, with SaO2 by standard CO-oximetry; and measuring the impact of skin pigmentation or ethnicity on pulse oximetry accuracy. We performed meta-analyses for mean bias (the primary outcome in this review) and its standard deviations (SDs) across studies included for each subgroup of level of skin pigmentation and ethnicity. We calculated accuracy root-mean-square (Arms) and 95% limits of agreement based on pooled mean bias and pooled SDs for each subgroup. Results We included 32 studies (6505 participants); 27/32 (84.38%) in hospitals and none in people’s homes. Findings of 14/32 studies (43.75%) were judged, via QUADAS-2, at high overall risk of bias. Fifteen studies measured skin pigmentation and 22 referred only to ethnicity. Compared with standard SaO2 measurement, pulse oximetry probably overestimates oxygen saturation in people with dark skin (pooled mean bias 1.11%; 95% confidence interval 0.29% to 1.93%) and people described as Black/African American (pooled mean bias 1.52%; 0.95% to 2.09%) (moderate- and low-certainty evidence). These results suggest that, for people with dark skin, pulse oximetry may overestimate blood oxygen saturation by around 1% on average compared with SaO2. The bias of pulse oximetry meas

Objectives: This mixed-method process evaluation underpinned by normalisation process theory aims to measure fidelity to the intervention, understand the social and structural context in which the intervention is delivered and identify barriers and facilitators to intervention implementation. Setting: RETurn to work After stroKE (RETAKE) is a multicentre individual patient randomised controlled trial to determine whether Early Stroke Specialist Vocational Rehabilitation (ESSVR) plus usual care is a clinically and cost-effective therapy to facilitate return to work after stroke, compared with usual care alone. This protocol paper describes the embedded process evaluation. Participants and outcome measures: Intervention training for therapists will be observed and use of remote mentor support reviewed through documentary analysis. Fidelity will be assessed through participant questionnaires and analysis of therapy records, examining frequency, duration and content of ESSVR sessions. To understand the influence of social and structural contexts, the process evaluation will explore therapists’ attitudes towards evidence-based practice, competency to deliver the intervention and evaluate potential sources of contamination. Longitudinal case studies incorporating non-participant observations will be conducted with a proportion of intervention and usual care participants. Semistructured interviews with stroke survivors, carers, occupational therapists, mentors, service managers and employers will explore their experiences as RETAKE participants. Analysis of qualitative data will draw on thematic and framework approaches. Quantitative data analysis will include regression models and descriptive statistics. Qualitative and quantitative data will be independently analysed by process evaluation and Clinical Trials Research Unit teams, respectively. Linked data, for example, fidelity and describing usual care will be synthesised by comparing and integrating quantitative descrip

Background: As one of the most common non-communicable diseases in India, stroke results in significant residual disability and high mortality rates. Stroke care in India is often fragmented, exacerbated by a lack of public resources, information, and awareness. Stroke survivors experience a range of disabilities and are cared for by their families long-term. Rehabilitation combined with secondary prevention is critical to post-discharge stroke care, in reducing recurrence, mortality, and improve outcomes. This study explores key components, and challenges of post-discharge stroke services with clinical staff. Methods: We undertook ten semi-structured qualitative interviews with a purposive sample from health professionals, representing the multidisciplinary stroke teams from Christian Medical College and Hospital, Ludhiana (CMCL) between July 2021 and January 2022. As a tertiary-level teaching hospital, CMCL serves a diverse patient population. The research team conducted interviews, before translating, transcribing, and thematically analysing data (using NVivo software). Results: Ten participants (3 nurses, 2 neurologists, 2 physiotherapists, 2 occupational therapists, and 1 dietician) indicated the multi-disciplinary stroke team enabled individualised comprehensive post discharge plan. Patient/caregiver training and education is provided during hospitalisation and continues through follow-up, with verbal/written information supported by videos or leaflets in Hindi, Punjabi, and English. Adherence to prescribed medication, diet, rehabilitation, and follow-up visits were impacted by challenges in patient literacy, stroke awareness, financial resources, or post discharge care. Community stroke care was provided through tele-stroke services, home-based physiotherapists, and community health workers. We identified four themes: Integrated Inpatient Discharge Care Planning; Patient and Caregiver Engagement; Post discharge Care and Support; and Working with Challenges. C

Aims and Objectives To explore healthcare staff’s experiences of how dehydration is identified and managed in hospitalised patients after acute stroke, and facilitators and challenges to optimising hydration. Background Optimal hydration post-stroke reduces the risk of neurological deterioration and other complications. Patients are at risk of dehydration in acute stroke, particularly those with dysphagia. Design A descriptive qualitative study reported following the COREQ guidelines. Methods Semi-structured interviews, utilising patient vignettes, were conducted in 2018 (Apr-Oct) with a purposive sample of 30 multi-disciplinary staff members from two UK stroke units. Interviews were digitally recorded and transcribed verbatim. Content analysis identified common themes which were mapped to the Theoretical Domains Framework and the Behaviour Change Wheel. Results The themes mapped to twelve of the fourteen domains in the Theoretical Domains Framework. Participants believed that inadequate hydration management had potentially serious consequences, and described complex knowledge, skills and cognitive elements to effective hydration care. Participants felt that maintaining hydration was a multidisciplinary responsibility requiring good communication. Although the performance of initial dysphagia screening was reinforced by external audit, other areas of post-stroke hydration management were not; notably, there was no established method of assessing hydration. Barriers to maintaining good hydration included lack of staff, out-of-hours working patterns, low priority given to hydration, patients’ co-morbidities, and complex post-stroke disabilities such as dysphagia, aphasia, inattention and hemiparesis. Conclusion Findings highlighted the importance of assessing and maintaining hydration but identified barriers to, and variation in, clinical practice. To provide optimal care, barriers to the prevention and treatment of dehydration after stroke must be further understood

Background: As one of the most common non-communicable diseases in India, stroke results in significant residual disability and high mortality. Stroke care in India is often fragmented, exacerbated by a lack of public resources, information, and awareness. Survivors experience a range of disabilities and are cared for by their families long-term. Rehabilitation combined with secondary prevention is critical to post-discharge stroke care, in reducing recurrence, mortality, and improve outcomes. This study explores key components and challenges of post-discharge stroke services with clinical staff. Methods: We undertook ten semi-structured interviews with a purposive sample from health professionals, representing the multidisciplinary stroke teams (MDTs) from National Institute of Mental Health And Neuro Sciences, Bengaluru (NIMHANS) between September and November 2021. The research team conducted interviews, before translating, transcribing, and thematically analysing data (using NVivo). Institution ethical approval was granted, and informed consent obtained from participants. Results: Ten participants (3 nurses, 2 occupational therapists, 1 physiotherapist, 1doctor, 1 psychiatric social worker, 1 speech pathologist/audiologist, and 1 dietician) indicated that a comprehensive MDT contributed to individualised, comprehensive post-discharge planning; however, there was no specific discharge protocol. Patient/caregiver training and education was provided during hospitalisation and continued through follow-up. Health education material was verbal or written; pamphlets/leaflets were in multiple languages including English, Kannada and Hindi. Patients/caregivers faced various challenges including stigma, financial constraints, availability of supportive family members, patient transportation from rural areas and psychological impact of stroke. Stroke care services in the community were restricted to urban populations, however rural patients that do not have adequate stroke

Background: As one of the most common non-communicable diseases in India, stroke results in significant residual disability and a high mortality rate. Stroke care in India is often fragmented, exacerbated by a lack of public resources, information, and awareness. Stroke survivors experience a range of disabilities and are cared for by their families long-term. Rehabilitation combined with secondary prevention is critical to post-discharge stroke care, in reducing recurrence, mortality, and improving outcomes. This study explores key components and challenges of post-discharge stroke services with clinical staff. Methods: We undertook ten semi-structured qualitative interviews with a purposive sample from health professionals, representing the multidisciplinary stroke teams from Indira Gandhi Medical College and Hospital, Shimla, (IGMC) from October to December 2021. As a tertiary-level teaching hospital, IGMC serves a diverse patient population and demography. The research team conducted interviews, before translating, transcribing, and thematically analysing data (using NVivo software). Results: Ten health professionals (4 doctors, 2 nurses, 1 physiotherapist, 1 speech and language therapist, 1 medical social worker, and 1 psychiatrist) indicated the multi-disciplinary stroke team enabled individualized comprehensive post-discharge plan. Healthcare professionals identified the need for improved post-discharge community support (psychological, speech, and physical rehabilitation) and patient transportation. Limited staff often resulted in task-shifting and innovative use of tele-support due to geographical challenges. Long-term caregiver support is affected by availability, literacy, and finances. Four themes were identified: Integrated Inpatient Discharge Care Planning; Patient and Caregiver Engagement; Post discharge Care and Support; and Working with Challenges. Conclusion: Post-discharge care is a key component in the recovery of stroke patients which can be imp

Background: As one of the most common non-communicable diseases in India, stroke results in significant residual disability and high mortality. Stroke care in India is often fragmented, exacerbated by a lack of public resources, information, and awareness. Stroke survivors experience a range of disabilities and are cared for by their families long-term. Rehabilitation combined with secondary prevention is critical to post-discharge stroke care, in reducing recurrence, mortality, and improve outcomes. This study explores key components, and challenges of post-discharge stroke services with clinical staff. Methods: We undertook ten semi-structured qualitative interviews with a purposive sample from health professionals, representing the multidisciplinary stroke teams (MDTs) from Zydus Hospitals and Healthcare Research Pvt. Ltd., Ahmedabad between 22 Nov 2021 to 24 Dec 2021. Zydus is a private hospital that serves a diverse patient population. The research team conducted interviews, before translating, transcribing, and thematically analysing data (using NVivo). Results: Based on ten participants’ (3 nurses, 2 neurologists, 2 physiotherapist, 1 speech therapist, 1 dietician, 1 medical officer) responses, we identified four themes: Integrated Inpatient Discharge Care Planning; Patient and Caregiver Engagement; Post-discharge Care and Support; and Working with Challenges. Clinical staff highlighted the importance of the various roles of the MDT. A comprehensive discharge summary included the medications, patient progress, complications, follow-up appointments, rehabilitation instructions and lifestyle advice. Despite this, patients/caregivers discussed, with staff, their lack of confidence in post-discharge care and a fear of stroke reoccurrence. Conclusion: The discharge summary provides key information on all aspects of patient care post discharge. Further referral, and advice, as required, are provided at follow-up appointments, as determined by patient’s level of nee

Background: The role of stroke nurses in patient selection and administration of recombinant tissue plasminogen activator (rt-PA) for acute ischaemic stroke is evolving. Objectives: Compare differences in stroke nurses’ practices related to rt-PA administration in Australia and the United Kingdom (UK) and to examine whether these differences influence rt-PA treatment rates. Methods: Cross- sectional, self-administered questionnaire administered to a lead stroke clinician from hospitals known to provide rt-PA for acute ischaemic stroke. Chi-square tests were used to analyse between-country differences in ten pre-specified rt-PA practices. Non-parametric equality of medians test was used to assess within-country differences for likelihood of undertaking practices and association with rt-PA treatment rates. Reporting followed STROBE checklist. Results: Response rate 68%; [Australia: 74% (n=63/85); UK: 65% (n=93/144)]. There were significant differences between countries for 7/10 practices. UK nurses were more likely to: request CT scan; screen patient for rt-PA suitability; gain informed consent; use telemedicine to assess, diagnose or treat; assist in the decision for rt-PA with Emergency Department physician or neurologist; and undergo training in rt-PA administration. Reported median hospital rt-PA treatment rates were 12% in the UK and 7.8% in Australia: (7.8%). In Australia, there was an association between higher treatment rates and nurses involvement in 5/10 practices; read and interpret CT scans; screen patient for rt-PA suitability; gain informed consent; assess suitability for rt-PA with neurologist/stroke physician; undergo training in rt-PA administration. There was no relationship between UK treatment rates and likelihood of a stroke nurse to undertake any of the ten rt-PA practices. Conclusion: Stroke nurses’ active role in rt-PA administration can improve rt-PA treatment rates. Models of care that broaden stroke nurses’ scope of practice to maximise rt-P

Background: The burden of stroke is increasing in India; stroke is now the fourth leading cause of death and the fifth leading cause of disability. Previous research suggests that the incidence of stroke in India ranges between 105 and 152/100,000 people per year. However, there is a paucity of available data and a lack of uniform methods across published studies. Aim: To identify high-quality prospective studies reporting the epidemiology of stroke in India. Summary of review: A search strategy was modified from the Cochrane Stroke Strategy and adapted for a range of bibliographic databases from January 1997 to August 2020. From 7,717 identified records, nine studies were selected for inclusion; three population-based registries, a further three population-based registries also using community-based ascertainment and three community-based door-to-door surveys. Studies represented the four cities of Mumbai, Trivandrum, Ludhiana, Kolkata, the state of Punjab and 12 villages of Baruipur in the state of West Bengal. The total population denominator was 22,479,509 and 11,654 (mean 1,294 SD 1,710) people were identified with incident stroke. Crude incidence of stroke ranged from 108 to 172/100,000 people per year, crude prevalence from 26 to 757/100,000 people per year and one-month case fatality rates from 18% to 42%. Conclusions: Further high-quality evidence is needed across India to guide stroke policy and inform the development and organisation of stroke services. Future researchers should consider the World Health Organisation STEPwise approach to Surveillance (STEPS) framework, including longitudinal data collection, the inclusion of census population data and a combination of hospital-registry and comprehensive community ascertainment strategies to ensure complete stroke identification.

The management of patients with stroke is often multidisciplinary, involving various specialties and healthcare professionals. Given the common shared risk factors for stroke and cardiovascular disease, input may also be required from the cardiovascular teams, as well as patient caregivers and next-of-kin. Ultimately, the patient is central to all this, requiring a coordinated and uniform approach to the priorities of post-stroke management, which can be consistently implemented by different multidisciplinary healthcare professionals, as part of the patient ‘journey’ or ‘patient pathway,’ supported by appropriate education and tele-medicine approaches. All these aspects would ultimately aid delivery of care and improve patient (and caregiver) engagement and empowerment. Given the need to address the multidisciplinary approach to holistic or integrated care of patients with heart disease and stroke, the European Society of Cardiology Council on Stroke convened a Task Force, with the remit to propose a consensus on Integrated care management for optimizing the management of stroke and associated heart disease. The present position paper summarizes the available evidence and proposes consensus statements that may help to define evidence gaps and simple practical approaches to assist in everyday clinical practice. A post-stroke ABC pathway is proposed, as a more holistic approach to integrated stroke care, would include three pillars of management: • A: Appropriate Antithrombotic therapy. • B: Better functional and psychological status. • C: Cardiovascular risk factors and Comorbidity optimization (including lifestyle changes).