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A polypill-type strategy for primary prevention was first published at the turn of the century and advised that a multi-ingredient pill applied to an adult population would prevent up to 80% of cardiovascular and stroke events. Such a pill should contain small doses of antihypertensives, lipid-lowering drugs, and some nutrients. The startling increase of the global stroke burden has led to a revival of this concept and the propagation of a population-based prevention strategy. Recent cardiovascular fixed-dose combination trials have shown a significant effect in reducing not only blood pressure and cholesterol levels but also in reducing cardiovascular and stroke events. In most of the studies, the study population was for secondary prevention and the total number of strokes was small. Nevertheless, it is now clear that a large proportion of primary prevention must take this path. It is especially promising when combined with community health workers interventions for modifying risk behavior. While a polypill-type approach seems most efficacious in underserved regions of high-income countries as well as in low- and middle-income countries, it seems to have a large overall effect in spite of some problems with nonadherence or potential side effects. It should be available and affordable for large target populations. Larger phase 4 studies are under way.

The optimal management of post-stroke cognitive impairment remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making around prevention, diagnosis, treatment and prognosis. These guidelines were developed according to ESO standard operating procedure and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and, where possible, meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. There was limited randomised controlled trial evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Interventions to improve lifestyle and treat vascular risk factors may have many health benefits but a beneficial effect on cognition is not proven. We found no evidence around routine cognitive screening following stroke but recognise the importance of targeted cognitive assessment. We described the accuracy of various cognitive screening tests but found no clearly superior approach to testing. There was insufficient evidence to make a recommendation for use of cholinesterase inhibitors, memantine nootropics or cognitive rehabilitation. There was limited evidence on the use of prediction tools for post-stroke cognitive syndromes (cognitive impairment, dementia and delirium). The association between post-stroke cognitive impairment and most acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on acute MRI brain may help predict cognitive outcomes. These guidelines have highlighted fundamental areas where robust evidence is lacking. Further, definitive randomised controlled trials are needed, and we suggest priority areas for future research. ispartof: European Stroke Journal vol:6 issue:3 pages:1-177 ispartof: location:England status: Published online

Background Regularly updated data on stroke and its pathological types, including data on their incidence, prevalence, mortality, disability, risk factors, and epidemiological trends, are important for evidence-based stroke care planning and resource allocation. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) aims to provide a standardised and comprehensive measurement of these metrics at global, regional, and national levels. Methods We applied GBD 2019 analytical tools to calculate stroke incidence, prevalence, mortality, disability-adjusted life-years (DALYs), and the population attributable fraction (PAF) of DALYs (with corresponding 95% uncertainty intervals [UIs]) associated with 19 risk factors, for 204 countries and territories from 1990 to 2019. These estimates were provided for ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage, and all strokes combined, and stratified by sex, age group, and World Bank country income level. Findings In 2019, there were 12·2 million (95% UI 11·0–13·6) incident cases of stroke, 101 million (93·2–111) prevalent cases of stroke, 143 million (133–153) DALYs due to stroke, and 6·55 million (6·00–7·02) deaths from stroke. Globally, stroke remained the second-leading cause of death (11·6% [10·8–12·2] of total deaths) and the third-leading cause of death and disability combined (5·7% [5·1–6·2] of total DALYs) in 2019. From 1990 to 2019, the absolute number of incident strokes increased by 70·0% (67·0–73·0), prevalent strokes increased by 85·0% (83·0–88·0), deaths from stroke increased by 43·0% (31·0–55·0), and DALYs due to stroke increased by 32·0% (22·0–42·0). During the same period, age-standardised rates of stroke incidence decreased by 17·0% (15·0–18·0), mortality decreased by 36·0% (31·0–42·0), prevalence decreased by 6·0% (5·0–7·0), and DALYs decreased by 36·0% (31·0–42·0). However, among people younger than 70 years, prevalence rates increased by 22·0% (21·0–24·0) and incidence rates increased by 15·0% (12·0–18·0). In 2019, the age-standardised stroke-related mortality rate was 3·6 (3·5–3·8) times higher in the World Bank low-income group than in the World Bank high-income group, and the age-standardised stroke-related DALY rate was 3·7 (3·5–3·9) times higher in the low-income group than the high-income group. Ischaemic stroke constituted 62·4% of all incident strokes in 2019 (7·63 million [6·57–8·96]), while intracerebral haemorrhage constituted 27·9% (3·41 million [2·97–3·91]) and subarachnoid haemorrhage constituted 9·7% (1·18 million [1·01–1·39]). In 2019, the five leading risk factors for stroke were high systolic blood pressure (contributing to 79·6 million [67·7–90·8] DALYs or 55·5% [48·2–62·0] of total stroke DALYs), high body-mass index (34·9 million [22·3–48·6] DALYs or 24·3% [15·7–33·2]), high fasting plasma glucose (28·9 million [19·8–41·5] DALYs or 20·2% [13·8–29·1]), ambient particulate matter pollution (28·7 million [23·4–33·4] DALYs or 20·1% [16·6–23·0]), and smoking (25·3 million [22·6–28·2] DALYs or 17·6% [16·4–19·0]). Interpretation The annual number of strokes and deaths due to stroke increased substantially from 1990 to 2019, despite substantial reductions in age-standardised rates, particularly among people older than 70 years. The highest age-standardised stroke-related mortality and DALY rates were in the World Bank low-income group. The fastest-growing risk factor for stroke between 1990 and 2019 was high body-mass index. Without urgent implementation of effective primary prevention strategies, the stroke burden will probably continue to grow across the world, particularly in low-income countries. Funding Bill & Melinda Gates Foundation.

The increasing burden of stroke and dementia emphasizes the need for new, well-tolerated and cost-effective primary prevention strategies that can reduce the risks of stroke and dementia worldwide, and specifically in low- and middle-income countries (LMICs). This paper outlines conceptual frameworks of three primary stroke prevention strategies: (a) the “polypill” strategy; (b) a “population-wide” strategy; and (c) a “motivational population-wide” strategy. (a) A polypill containing generic low-dose ingredients of blood pressure and lipid-lowering medications (e.g. candesartan 16 mg, amlodipine 2.5 mg, and rosuvastatin 10 mg) seems a safe and cost-effective approach for primary prevention of stroke and dementia. (b) A population-wide strategy reducing cardiovascular risk factors in the whole population, regardless of the level of risk is the most effective primary prevention strategy. A motivational population-wide strategy for the modification of health behaviors (e.g. smoking, diet, physical activity) should be based on the principles of cognitive behavioral therapy. Mobile technologies, such as smartphones, offer an ideal interface for behavioral interventions (e.g. Stroke Riskometer app) even in LMICs. (c) Community health workers can improve the maintenance of lifestyle changes as well as the adherence to medication, especially in resource poor areas. An adequate training of community health workers is a key point. Conclusion An effective primary stroke prevention strategy on a global scale should integrate pharmacological (polypill) and lifestyle modifications (motivational population-wide strategy) interventions. Side effects of such an integrative approach are expected to be minimal and the benefits among individuals at low-to-moderate risk of stroke could be significant. In the future, pragmatic field trials will provide more evidence.

Background Botulinum toxin A (BoNT-A) is considered a safe and effective treatment for spasticity and dystonia. Individual interinjection intervals are critical for the maintenance of the effect. In Austria, BoNT outpatient clinics were shutdown from November to December 2020 during COVID-19 control measures, leading to rescheduling of BoNT-A injections. This survey aimed at investigating the influence of injection delays on symptoms, physical functioning, and quality of life (QoL) of the affected patients. Methods Between April and July 2021, 32 outpatients (21 females, mean age: 63.4 ± 12.1 years) treated ≥ 12 months at the BoNT outpatient clinic Horn-Allentsteig (Austria) and experienced ≥ 2 week injection delays, completed a structured face-to-face questionnaire. Results Indications were dystonia (34%), spasticity (63%), and hyperhidrosis (3%). Injections were delayed by 10 weeks (median, range: 2–15). Muscle cramps increased in 95% of patients with spasticity, muscle twitches in 91% of those with dystonia, and pain in 9% and 60% for dystonia and spasticity, respectively. Overall, 75% reported functional worsening, and deterioration in QoL by 62.6% ± 16.8 (mean ± SD). The impact on QoL correlated with the subjective global improvement induced by BoNT-A (Rs: 0.625; p Conclusions COVID-19-related delays in BoNT-A injections illustrate the importance of this therapy for symptom relief, functional outcome, and QoL in patients suffering from involuntary muscle hyperactivity. BoNT-A therapy is essential and has to be guaranteed even in circumstances such as the COVID-19 pandemic.

Background Diabetes is an increasingly important risk factor for ischemic stroke and worsens stroke prognosis. Yet a large proportion of stroke patients who are eventually diabetic are undiagnosed. Therefore, it is important to have sensitive assessment of unrecognized hyperglycaemia in stroke patients. Design Secondary outcome analysis of a randomized controlled trial focussing on parameters of glucose metabolism and detection of diabetes and prediabetes in patients with acute ischemic stroke (AIS). Methods A total of 130 consecutively admitted patients with AIS without previously known type 2 diabetes mellitus (T2DM) were screened for diabetes or prediabetes as part of secondary outcome analysis of a randomized controlled trial that tested lifestyle intervention to prevent post-stroke cognitive decline. Patients had the oral glucose tolerance test (OGTT) and glycated hemoglobin (HbA1c) measurements in the second week after stroke onset and after 1 year. The detection rates of diabetes and prediabetes based on the OGTT or HbA1c values were compared. Results By any of the applied tests at the second week after stroke onset 62 of 130 patients (48%) had prediabetes or T2DM. Seventy-five patients had results from both tests available, the OGTT and HbA1c; according to the OGTT 40 (53.3%) patients had normal glucose metabolism, 33 (44%) had prediabetes, two (2.7%) T2DM. In 50 (66.7%) patients the HbA1c results were normal, 24 (32%) in the prediabetic and one (1.3%) in the diabetic range. The detection rate for disorders of glucose metabolism was 10% higher (absolute difference; relative difference 29%) with the OGTT compared with HbA1c. After 1 year the detection rate for prediabetes or T2DM was 7% higher with the OGTT (26% relative difference). The study intervention led to a more favourable evolution of glycemic status after 1 year. Conclusion The OGTT is a more sensitive screening tool than HbA1c for the detection of previously unrecognized glycemic disorders in patients with acute stroke with an at least a 25% relative difference in detection rate. Therefore, an OGTT should be performed in all patients with stroke with no history of diabetes. Trial registrationhttp://clinicaltrials.gov. Unique identifier: NCT01109836.

Background and purpose The aim of this pooled patient-level data analysis was to test if multidomain interventions, addressing several modifiable vascular risk factors simultaneously, are more effective than usual post-stroke care for the prevention of cognitive decline after stroke. Methods This pooled patient-level data analysis included two randomized controlled trials using a multidomain approach to target vascular risk factors in stroke patients and cognition as primary outcome. Changes from baseline to 12 months in the trail making test (TMT)-A, TMT-B and 10-words test were analysed using stepwise backward linear mixed models with study as random factor. Two analyses were based on the intention-to-treat (ITT) principle using different imputation approaches and one was based on complete cases. Results Data from 322 patients (157 assigned to multidomain intervention and 165 to standard care) were analysed. Differences between randomization groups for TMT-A scores were found in one ITT model (P = 0.014) and approached significance in the second ITT model (P = 0.087) and for complete cases (P = 0.091). No significant intervention effects were found for any of the other cognitive variables. Conclusion We found indications that multidomain interventions compared with standard care can improve the scores in TMT-A at 1 year after stroke but not those for TMT-B or the 10-words test. These results have to be interpreted with caution due to the small number of patients.

This review summarizes the potential for polypill therapies for stroke prevention. While a number of studies applying different approaches regarding polypill have been performed, none of them has had a focus on stroke as the main outcome. A combination pill containing drugs such as statins, diuretics, and other antihypertensives is currently available in various formats. Estimates focusing mostly on primary prevention show that using such a combination drug a reduction in the 5-year stroke incidence by 50% can be achieved – especially in low- and middle-income countries with a high prevalence of risk factors even among people at young ages. A combination of a large supporting population-wide program with a registry-based quality control is the most likely perspective and can be achieved within a reasonable time frame and potentially have significant influence in young stroke populations.

SUMMARYThe evolutionary potential of organisms depends on the presence of sufficient genetic variation for traits subject to selection, as well as on the genetic covariances among them. While genetic variation ultimately derives from mutation, theory predicts the depletion of genetic (co)variation under consistent directional or stabilizing selection in natural populations. We estimated and compared additive genetic (co)variances for several standard life history traits, including some for which this has never been assessed, before and after 24 generations of artificial selection on male size in the yellow dung flyScathophaga stercoraria(Diptera: Scathophagidae) using a series of standard half-sib breeding experiments. As predicted, genetic variances (VA), heritabilities (h2) and evolvabilities (IA) of body size, development time, first clutch size, and female age at first clutch were lower after selection. As independent selection lines were crossed prior to testing, we can rule out that this reduction is due to genetic drift. In contrast to the variances, and against expectation, the additive genetic correlations between the sexes for development time and body size remained strong and positive (rA =0.8–0.9), while the genetic correlation between these traits within the sexes tended to strengthen (but not significantly so). Our study documents that the effect of selection on genetic variance is predictable, whereas that on genetic correlations is not.

Definition of stroke In epidemiological studies, stroke is defined by clinical findings and symptoms [1]: rapidly developed signs of focal (or global) disturbance of cerebral function lasting more than 24 hours (unless interrupted by surgery or death), with no apparent cause other than a vascular origin. This approach is supplemented with neuroimaging but even with advanced imaging techniques the diagnosis is based on clinical signs. Therefore, precise definitions of clinical signs are needed. WHO definitions are [1]: Definite focal signs: unilateral or bilateral motor impairment (including dyscoordination) unilateral or bilateral sensory impairment aphasis/dysphasis (non-fluent speech) hemianopia (half-sided impairment of visual fields) diplopia forced gaze (conjugate deviation) dysphagia of acute onset apraxia of acute onset ataxia of acute onset perception deficit of acute onset. Not acceptable as sole evidence of focal dysfunction: dizziness, vertigo localized headache blurred vision of both eyes dysarthria (slurred speech) impaired cognitive function (including confusion) impaired consciousness seizures. (Although strokes can present in this way, these signs are not specific and cannot therefore be accepted as definite evidence of stroke.) Neuroimaging studies are needed for classification of stroke by subtypes: subarachnoid hemorrhage, intracerebral hemorrhage and brain infarction (necrosis). Although there may be large variations in stroke subtype distributions between populations, thrombotic and embolic strokes are responsible for about 80–85% of all strokes in the Indo-European populations, and as low as 65% in some Asian populations. Subarachnoid hemorrhage represents 5–10% of all strokes, and occurs more often in younger subjects, while both intracerebral and especially thrombotic and embolic stroke increase markedly with age.

The aim of primary prevention is to reduce the risk of first-ever stroke in asymptomatic people. Seven factors are regarded as potentially modifiable risk factors for vascular diseases: high blood pressure, high cholesterol, smoking, excessive or heavy regular alcohol consumption, physical inactivity, overweight and dietary factors. The strategy in primary prevention is to lower stroke risk attributed to these factors through education, lifestyle changes and medication. Non-modifiable risk factors arising from diseases such as atrial fibrillation or diabetes mellitus can be lowered by controlling and treating the underlying disorder. Targets of primary stroke prevention can be the entire population or high-risk – but stroke-free – individuals partly suffering from disorders such as hypertension or diabetes mellitus. Lifestyle factors Stroke prevalence has been associated with individual lifestyle factors (e.g. smoking, exercise, body mass index (BMI), alcohol consumption) in several studies. Healthy lifestyle in general was considered in one large prospective cohort study of healthy women. In this study, healthy lifestyle, consisting of abstinence from smoking, low-normal body mass index, moderate alcohol consumption, regular exercise and healthy diet, was found to be associated with a reduction in ischemic stroke (RR 0.3; 95% CI 0.1–0.6) [1]. Using the data of two large cohort studies, the Nurses' Health Study (71 243 women) and the Health Professionals Follow-up Study (43 685 men), Chiuve et al. [2] defined a low-risk lifestyle score based on the five lifestyle components non-smoking, moderate activity ≥ 30 min/day, healthy diet, body mass index 2 and modest alcohol consumption (men 5–30 g/day, women 5–15 g/day).

Background and aim Behavioral and lifestyle interventions in stroke patients need to be intense enough to result in sustainable treatment differences among groups of a randomized trial. Therefore, we report the effects of multidomain interventions on lifestyle and laboratory parameters after 12 and 24 months from a trial that examined whether intensive risk factor management can prevent cognitive decline in ischemic stroke patients. Methods This prospective randomized, open-label, blinded endpoint trial recruited patients within three months after acute stroke in five Austrian neurological clinics during June 2010 and November 2012. One hundred and one patients were randomized into multidomain intervention and 101 into standard care. Lifestyle interventions were individualized to match predefined targets of regular physical activity, healthy diet, and adequate physiological risk factor control. Results A total of 167 participants (80 intervention, 87 control) completed the 12-month visit and 155 (76 intervention, 79 control) the 24-month visit. During the first 12 months, adherence to healthy lifestyle and adequately controlled physiological parameters (measured by summary scores) improved significantly in the intervention group compared to controls (p Conclusions These results demonstrate that intensified individualized multidomain lifestyle interventions in stroke patients are effective in promoting healthy lifestyle in stroke care.

Background and Purpose— Cognitive impairment occurs in ≤30% of all stroke survivors. However, effective therapies aimed at preventing poststroke cognitive decline are lacking. We assessed the efficacy of a multidomain intervention on preventing cognitive decline after stroke. Methods— In this randomized, observer-blind trial patients were recruited within 3 months after an acute stroke in 5 Austrian neurological centers. Patients were assigned to a 24-month lifestyle-based multidomain intervention or standard stroke care. Primary outcomes were the cognitive subscale of the Alzheimer Disease Assessment Scale (ADAS-cog) and occurrence of cognitive decline in the composite scores of at least 2 of 5 cognitive domains at 24 months. Results— A total of 101 patients were randomized into multi-intervention and 101 into standard care during June 2010 and November 2012. Of them, 76 patients in the intervention group and 83 in the control group were included in the final intention-to-treat analysis. At 24 months, 8 of 76 (10.5%) patients in the intervention group and 10 of 83 (12.0%) patients in the control group showed cognitive decline corresponding to a relative risk reduction of 0.874 (95% confidence interval, 0.364–2.098). The change in ADAS-cog from baseline to 24 months was not different either (median 0 [IQR, −1 to 2] in both groups; P =0.808). Conclusions— This trial found no benefit of 24-month multidomain intervention with focus on improvement in lifestyle and vascular risk factors on the incidence of poststroke cognitive decline in comparison with standard stroke care. Studies with a larger sample size are needed. Clinical Trial Registration— URL: http://clinicaltrials.gov . Unique identifier: NCT01109836.

Background Cognitive impairment after stroke is a considerable burden to patients and their caregivers and occurs in one-third of stroke survivors. No strategy to prevent cognitive decline after stroke exists thus far. Established vascular risk factors have been associated with cognitive decline and may be a target for therapeutic interventions in stroke survivors. Aim To test whether intensive multifactorial non-pharmacologic interventions based on lifestyle modification can reduce the risk of cognitive decline in patients who recently suffered ischemic stroke. Methods A randomized, controlled, multicenter, observer-blind trial was designed. The reference group obtains stroke care according to standard guidelines. The intervention group additionally receives intensive control and motivation for better compliance with prescribed evidence-based medication, regular blood pressure measurements, healthy diet, regular physical activity and cognitive training. Primary outcomes are the rate of cognitive decline at 24 months, assessed by a neuropsychological test battery and the cognitive subscale of the Alzheimer's Disease Assessment Scale. Results 202 patients (29% women), aged 62 ± 9 years, were recruited during 2010 to 2012. Stroke related impairment at inclusion was low (mean National Institutes of Health Stroke Scale: 1.9±1.8, median modified Rankin Scale: 1 (0-1)). At baseline, groups did not differ significantly in demographic, clinical or lifestyle characteristics. Conclusion The recruitment was successful and the groups are balanced regarding potential confounding variables. The study will provide essential data about the feasibility and efficacy of lifestyle intervention after stroke in order to develop a new approach to prevent cognitive decline in patients with mild ischemic stroke.

Background and purpose Diabetes is a predictor for poor outcome after thrombolysis in stroke patients, and early post-stroke glycaemia is associated with higher rates of post-thrombolytic symptomatic intracerebral haemorrhages (SICHs). Diabetic stroke patients may nevertheless profit from thrombolysis. Here, we compared outcome data of matched thrombolysed and non-thrombolysed diabetic and non-diabetic stroke patients from a national database. Methods The outcomes of 1079 matched quadruples, each consisting of a thrombolysed diabetic, a non-thrombolysed diabetic, a thrombolysed non-diabetic and a non-thrombolysed non-diabetic case (a total of 4316 cases), enrolled in the Austrian Stroke Unit Registry (2004–2013), were compared. Patients were matched according to sex, age, stroke severity, pre-stroke disability and prior stroke. Results A regression model with improvement as depending variable found no effect of diabetes (P = 0.158) or the interaction diabetes × thrombolysis (P = 0.507), whereas the effect of thrombolysis itself was highly significant (P

Background As type 2 diabetes (T2D) patients have a high risk for coronary heart disease (CHD) and all-cause mortality and smoking is a major single risk factor for total and CHD mortality, it is important to understand the impact of smoking to the outcome events in comparison to people without T2D. Studies of excess risk of CHD incidence and mortality, and all-cause mortality in T2D patients related to smoking are controversial. We aimed to assess the risk of CHD incidence and mortality, and all-cause mortality in a large Finnish population cohort consisting of people with and without T2Daccording to smoking status. Methods Prospective follow-up of 28 712 men and 30 700 women aged 25–64 years living in eastern and south-western Finland. The data on mortality were obtained from the nationwide death register using the unique national personal identification number. Follow-up information regarding CHD was based on the Finnish Hospital Discharge Register for non-fatal outcomes. The Cox proportional hazards models were used to estimate the association between diabetes and smoking subgroups and the risk for total and CHD mortality. Results T2D patients who were smoking had higher all-cause mortality in both men (HR 3.76; 95% CI 2.95-4.78) and women (HR 4.51; 95% CI 2.91-7.00) than non-smoking diabetic men (HR 2.03; 95% CI 1.51-2.74) and women (HR 2.11; 95% CI 1.71-2.59). The CHD mortality risk for smoking men with T2D was higher (HR 6.15; 95% CI 4.22-8.96) than in non-smoking diabetic men (HR 2.62; 95% CI 1.60-4.29). Similar results were found in women revealing corresponding HR for CHD mortality of 6.92 (95% CI 2.79-17.19) for smoking, T2D women and 4.06 (95% CI 2.83-5.82) for non-smoking T2D women, respectively. Even though the risk of CHD incidence in T2D patients who had stopped smoking was statistically significantly higher than in their non-smoking non-diabetic counterparts, their CHD incidence was lower than in smoking T2D patients (HR in men 3.00; HR in women 2.80). Conclusion It is important to address tobacco consumption in T2D patients, especially during primary health care contacts in order to reduce their high risk of CHD and all-cause mortality., published version, peerReviewed

Contains fulltext : 170402.pdf (Publisher’s version ) (Open Access) Post-stroke dementia (PSD) or post-stroke cognitive impairment (PSCI) may affect up to one third of stroke survivors. Various definitions of PSCI and PSD have been described. We propose PSD as a label for any dementia following stroke in temporal relation. Various tools are available to screen and assess cognition, with few PSD-specific instruments. Choice will depend on purpose of assessment, with differing instruments needed for brief screening (e.g., Montreal Cognitive Assessment) or diagnostic formulation (e.g., NINDS VCI battery). A comprehensive evaluation should include assessment of pre-stroke cognition (e.g., using Informant Questionnaire for Cognitive Decline in the Elderly), mood (e.g., using Hospital Anxiety and Depression Scale), and functional consequences of cognitive impairments (e.g., using modified Rankin Scale). A large number of biomarkers for PSD, including indicators for genetic polymorphisms, biomarkers in the cerebrospinal fluid and in the serum, inflammatory mediators, and peripheral microRNA profiles have been proposed. Currently, no specific biomarkers have been proven to robustly discriminate vulnerable patients ('at risk brains') from those with better prognosis or to discriminate Alzheimer's disease dementia from PSD. Further, neuroimaging is an important diagnostic tool in PSD. The role of computerized tomography is limited to demonstrating type and location of the underlying primary lesion and indicating atrophy and severe white matter changes. Magnetic resonance imaging is the key neuroimaging modality and has high sensitivity and specificity for detecting pathological changes, including small vessel disease. Advanced multi-modal imaging includes diffusion tensor imaging for fiber tracking, by which changes in networks can be detected. Quantitative imaging of cerebral blood flow and metabolism by positron emission tomography can differentiate between vascular dementia and degenerative dementia and show the interaction between vascular and metabolic changes. Additionally, inflammatory changes after ischemia in the brain can be detected, which may play a role together with amyloid deposition in the development of PSD. Prevention of PSD can be achieved by prevention of stroke. As treatment strategies to inhibit the development and mitigate the course of PSD, lowering of blood pressure, statins, neuroprotective drugs, and anti-inflammatory agents have all been studied without convincing evidence of efficacy. Lifestyle interventions, physical activity, and cognitive training have been recently tested, but large controlled trials are still missing.

Background:Dysphagia is a common complication after stroke. Early assessment of swallowing can prevent severe consequences such as aspiration pneumonia. The Gugging Swallowing Screen (GUSS), a valid and widely-used bedside-screen, has been criticised to overestimate the necessity of nasogastric tubes (NGT) compared to fiberoptic endoscopic evaluation of swallowing (FEES) in severe stroke patients. This cross-sectional study compares the diet recommendations of GUSS and FEES as well as the actually implemented diet in severe stroke patients and investigates if they differ because of the items u201evigilanceu201c and u201evoluntary coughu201c in the GUSS-pretest.Methods:The diet-recommendations given by FEES, GUSS and the actually implemented diet were compared for 20 patients with severe acute stroke (National Institute of Health Stroke Scale [NIHSS] u2265 15).Results:The GUSS recommended nothing per os (NPO) for all severe strokes; in 50% of these, FEES recommended equally NPO. For the other ten patients, the FEES recommended a less strict level-1 diet. This diet was implemented in five cases, all other patients received NPO. Eleven out of 15 patients with NPO showed insufficient vigilance whereas all five patients with level-1 diet were awake (p=0.008). Only 1/15 (7%) patients administered to NPO could cough voluntary compared to 2/5 (40%) with diet level-1 (p=0.140).Conclusion:GUSS is a suitable diagnostic-tool for dysphagia in severe stroke patients. In clinical practice, the decision for NPO is based on vigilance but not on the ability of voluntary coughing. The additional use of FEES may prevent NGT in severe stroke with good vigilance.

SUMMARY Aims: This study aims to identify factors associated with participation in and adherence to a low-intensity diabetes prevention program. Methods: A total of 644 subjects who were at an intermediate-to-high risk for developing diabetes were enrolled in this study, aiming to acheive weight reduction, diet changes and regular physical activity. Results: Attendance at the baseline medical examination (n = 198) was associated with higher diabetes risk, being more anxious, lower fat intake and being unsatisfied more often with bodyweight compared with nonattendance. Workshops were attended by 142 individuals who were older and had lower levels of low-density lipoprotein cholesterol than nonattendees. Participants at the final medical examinations (n = 80) had a higher level of education, better self-rated fitness, fewer signs of depression and lower diastolic blood pressure than nonparticipants. Conclusion: Self-perceived diabetes risk can thus motivate people to participate in a diabetes prevention pro...

Background and Purpose— Acute stroke management requires minimization of prehospital time. This study addresses the value of helicopter transport compared with other means of transportation to a stroke unit and compares their rates of thrombolysis on a nationwide basis. Methods— Prospective data collection and prespecified evaluation of data from 32 stroke units between 2003 and 2009 were used. We distinguished between patients transported either directly to a stroke unit or transferred indirectly via a peripheral hospital. Thus, there were 6 transport groups: helicopter emergency service (HEMS) direct and indirect, ambulance accompanied by an emergency physician direct and indirect, and ambulance without physician direct and indirect. Demographic and clinical factors, time delays, and rates of thrombolysis of patients transported by helicopter were compared with factors of patients transported otherwise. Results— Of 21 712 ischemic stroke patients, 905 patients (4.1%) were transported by helicopter. Of these, 752 patients (3.4%) were transported by direct HEMS, and 153 patients (0.7%) were transported by indirect HEMS. Thrombolysis rates were highest for HEMS (24% direct, 29% indirect) transport, followed by ambulance accompanied by an emergency physician (18% direct, 15% indirect). The probability of receiving thrombolysis was highest for indirect HEMS transport (OR 3.6, 2.2–6.0), followed by indirect ambulance accompanied by an emergency physician transport (OR 1.5, 1.1–1.9). The shortest times, 90 minutes or less from stroke onset to hospital arrival, were achieved with direct AMBP and direct HEMS transport. Conclusions— The shortest hospital arrival times and highest thrombolysis rates were seen in ischemic stroke patients transported by helicopter.

Most life history traits are positively influenced by body size, while disadvantages of large size are poorly documented. To investigate presumed intrinsic costs of large body size in yellow dung flies (Scathophaga stercoraria; Diptera: Scathophagidae), we allowed larvae from replicate lines artificially selected for small and large body size for 21 generations to compete directly with each other at 20°C (benign) and 25°C (stressful) and low and high food (dung) availability. Greater mortality of large line flies was evident at low food independent of temperature, suggesting a cost of fast growth and/or long development for genetically large flies during larval scramble competition under food limitation. Our results are congruent with a previous study assessing mortality when competing within body size lines, so no additional mechanisms affecting scramble or contest behavior of larvae need be invoked to explain the results obtained beyond the costs of longer development and faster growth. Thus, artificial selection producing larger yellow dung flies than occur in nature revealed some, albeit weak mortality costs of large body size that otherwise might have remained cryptic. We conclude, however, that these costs are insufficient to explain the evolutionary limits of large body size in this species given persistently strong fecundity and sexual selection favoring large size in both sexes.

The massive numbers of sperm males transfer during a single mating are physiologically costly and the amount of sperm that can be stored is limited. Therefore, males can perform only a finite number of successive copulations without loss of fertility, and males should allocate sperm prudently. We investigated sperm availability and depletion in male black scavenger flies, Sepsis cynipsea (Diptera: Sepsidae), asking whether males adjust copula duration according to nutrition, their sperm stores, their own and their partner’s body size, as predicted by theory. We created a gradient of sperm limitation by restricting dung (their protein resource as adults) and subjecting males to a varying number of copulations. While male fertility did not depend on access to fresh dung (contrary to females), it did decline after three copulations, and more so when males were small. Larger females tended to lay more unfertilized eggs after copulating with previously mated males. However, copula duration was not influenced by a male’s number of previous copulations, and therefore apparently not by his current sperm stores. Nevertheless, copula duration varied with male size, with small males copulating longer, and with female size, as copulations lasted longer with larger females, suggesting that males are investing more sperm in larger, more fecund females. While male copula adjustments to their own nutrition and body size may be simple (proximate) physiological responses, responses to female size indicate more strategic and sophisticated sperm-allocation strategies than previously thought.

BackgroundTime is essential for the treatment of acute stroke. Much time is lost outside the hospital, either due to failure in identifying stroke symptoms or due to a delay in notification or transport. We review studies reporting factors associated with better stroke knowledge and shorter time delays. We summarise the evidences for the effect of stroke knowledge and education on people's reaction in the acute situation of stroke.MethodsWe searched MEDLINE for studies reporting factors associated with prehospital time of stroke patients, or knowledge of stroke symptoms. Further, we searched for studies reporting educational interventions aimed at increasing stroke symptom knowledge in the population.FindingsWe included a total of 182 studies. Surprisingly, those factors associated with better stroke knowledge such as education and sociodemographic variables were not related to shorter time delays. Few studies report shorter time delays or better stroke knowledge in persons having suffered a previous stroke. Factors associated with shorter time delays were more severe stroke and symptoms regarded as serious, but not better knowledge about the most frequent symptoms such as hemiparesis or disorders of speech. Only 25–56% of patients recognised their own symptoms as stroke. While stroke education increases the knowledge of warning signs, a few population studies measured the impact of education on time delays; in such studies, time delays decreased after education. This may partly be mediated by better organisation of EMS and hospitals.InterpretationThere is a discrepancy between theoretical stroke knowledge and the reaction in an acute situation. Help-seeking behaviour is more dependent on the perceived severity of symptoms than on symptom knowledge. Bystanders play an important role in the decision to call for help and should be included in stroke education. Education is effective and should be culturally adapted and presented in a social context. It is unclear which educational concept is best suited to enhance symptom recognition in the acute situation of stroke, especially in view of discrepancies between knowledge and action.

The aim of our study was to identify factors influencing time from stroke onset to Stroke Unit (SU) admission. Retrospectively, we analysed the data of all stroke patients registered in the Austrian SU-Registry between 01/03 and 02/07. The influence of mode of transportation on time from stroke onset to admission to SU and on rate of thrombolysis was investigated. Further, we analysed changes in time delays and rate of thrombolysis over the years. A total of 15,746 patients with acute stroke were admitted to one of the 26 participating SU. Direct admission to the hospital equipped with a SU increased the relative chance of thrombolytic treatment by odds 1.8 compared to patients transferred from another hospital. Over the years, the median pre-hospital time did not change significantly, but the rate of patients admitted in a 2-h time window improved from 30 to 42%; the rate of thrombolysis increased from 4.8% (2003) to 9.5% (2007, p

Females of the obligate brood parasitic common cuckoo Cuculus canorus are assumed to lay eggs of consistent colour and pattern and egg characteristics have been used to separate between different individuals. We tested the “constant egg-type hypothesis” in blind tests using test persons who grouped cuckoo eggs into “potential clutches” based on similarity in appearance. A correct classification of eggs laid by known (radiotagged) females supported the hypothesis. However, comparisons between maternity based on visual assessments and DNA-based parentage analyses revealed rather poor concordance between the two methods. Our findings indicate that egg characteristics cannot be used to separate between cuckoo females, even if they lay eggs with constant appearance. The reason is probably that there are only small or negligible variations in egg appearance between some females like mothers and daughters or other closely related individuals.

Introduction: Multiple, complex interventions are increasingly tested in randomized, clinical trials without enabling a clear view of the strength of the intervention, especially its probability to influence outcome. Such interventions have to be strong enough to create group differences, be acceptable by patients, be realistically designed and deliverable within the health system, and ethical. If found to have a positive effect, it should have a sustainable effect after the trial is drawn to a close. It is necessary to adapt the intensity of the intervention to contrast with guideline-based treated controls and to ensure sufficient means to carry through to the end of the trial. Method: Using a multiple domain life-style based intervention in a randomized trial to prevent cognitive decline following stroke (ClinicalTrials.gov Identifier: NCT01109836), our focus was on nutrition and physical exercise in addition to risk factor management. We performed single component analysis as well as the use of a life-style summary score and a laboratory supported life-style summary score. Results: 80 participants in the intervention group and 87 in the control group completed the 12 months visit. We found a significant improvement in adherence to healthy lifestyle factors and adequately controlled physiological parameters as well as significant differences for both summary scores, all p 2 and currently non-smoking. Laboratory values included blood pressure Conclusion: Complex interventions used for secondary prevention stroke trials have to be intense enough to become effective when comparing to treatment according to current guidelines.

Background and Purpose— Acute-onset dysphagia after stroke is frequently associated with an increased risk of aspiration pneumonia. Because most screening tools are complex and biased toward fluid swallowing, we developed a simple, stepwise bedside screen that allows a graded rating with separate evaluations for nonfluid and fluid nutrition starting with nonfluid textures. The Gugging Swallowing Screen (GUSS) aims at reducing the risk of aspiration during the test to a minimum; it assesses the severity of aspiration risk and recommends a special diet accordingly. Methods— Fifty acute-stroke patients were assessed prospectively. The validity of the GUSS was established by fiberoptic endoscopic evaluation of swallowing. For interrater reliability, 2 independent therapists evaluated 20 patients within a 2-hour period. For external validity, another group of 30 patients was tested by stroke nurses. For content validity, the liquid score of the fiberoptic endoscopic evaluation of swallowing was compared with the semisolid score. Results— Interrater reliability yielded excellent agreement between both raters (κ=0.835, P P =0.001), therefore confirming the subtest sequence of GUSS. Conclusions— The GUSS offers a quick and reliable method to identify stroke patients with dysphagia and aspiration risk. Such a graded assessment considers the pathophysiology of voluntary swallowing in a more differentiated fashion and provides less discomfort for those patients who can continue with their oral feeding routine for semisolid food while refraining from drinking fluids.

Previous univariate studies of the fly Sepsis cynipsea (Diptera: Sepsidae) have demonstrated spatiotemporally variable and consequently overall weak sexual selection favouring large male size, which is nevertheless stronger on average than fecundity selection favouring larger females. To identify specific target(s) of selection on body size and additional traits possibly affecting mating success, two multivariate field studies of sexual selection were conducted. In one study using seasonal replicates from three populations, we assessed 15 morphological traits. No clear targets of sexual selection on male size could be detected, perhaps because spatiotemporal variation in selection was again strong. In particular, there was no (current) selection on male abdomen length or fore coxa length, the only traits for which S. cynipsea males are not smaller than females. Interestingly, copulating males had a consistently shorter fore femur base, a secondary sexual trait, and a wider clasper (hypopygium) gap, an external genital trait. In a second study using daily and seasonal replicates from one population, we included physiological measures of energy reserves (lipids, glucose, glycogen), in addition to hind tibia length and fluctuating asymmetry (FA) of all pairs of legs. This study again confirmed the mating advantage of large males, and additionally suggests independent positive influences of lipids (the long-term energy stores), with effects of glucose and glycogen (the short-term energy stores) tending to be negative. FA of paired traits was not associated with male mating success. Our study suggests that inclusion of physiological measures and genital traits in phenomenological studies of selection, which is rare, would be fruitful in other species.

In brood parasites, knowledge of spacing behaviour, habitat use and territoriality may reveal cues about how parasites find and use their hosts. To study the use of space and habitat of European cuckoos, Cuculus canorus, we radio-tagged 16 females during four consecutive reproductive seasons. We hypothesized that during the laying period cuckoo females should (1) use habitats selectively, and (2) attempt to monopolize potential egg laying areas to reduce competition for host nests. Our data are consistent with the first hypothesis: the use of pond edges compared to forest and transitional habitats was significantly greater than expected from the habitat availability in the total area and within individual female home ranges. All 26 directly observed egg layings and 27 nest visits without laying occurred at pond edges in nests of Acrocephalus spp. Females spent significantly more time at pond edges on egglaying days than on non-laying days. The second hypothesis was not supported: female home ranges overlapped similarly in all three major habitat categories of the potential egg laying areas, and only little aggression was observed between females. We discuss whether female cuckoos may lack territorial behaviour because they are not able to defend egg laying areas economically or because defence is not necessary due to sufficient availability of suitable host nests.

We radiotracked 13 common cuckoo females in the southeastern part of the Czech Republic. Seven females laid eggs in the nests of reed warblers, Acrocephalus scirpaceus, sedge warblers, A. schoenobaenus, and marsh warblers, A. palustris. We observed 53 nest visits, of which 26 involved egg laying. Cuckoos spent significantly more time within 50 m of the host nest on the laying day than on the 5 prelaying days. The vantage point used when parasitizing or visiting a nest was on average four times further from the nest than the closest possible vantage point, but there was a positive correlation between these two distances. Cuckoos spent on average 20 min observing host nests from their vantage points before they visited a nest. Comparison of cuckoos’ visits to host nests with and without egg laying revealed no significant differences in the duration of visits or in other measures of behaviour. There was significant variation in behaviour between cuckoos, particularly in the time of day when eggs were laid in host nests. This variation can be attributed to the strong, but not absolute, host and habitat specificity of individuals.

Egg mimicry is an important adaptation of common cuckoos, Cuculus canorus, against rejection of eggs by their respective hosts. A precondition for the maintenance of egg mimicry is that female cuckoos find hosts with a matching egg type. Experimental evidence indicated that habitat imprinting may be important for host selection. We tested whether the spacing and laying patterns of female cuckoos in the field are compatible with the supposed habitat-imprinting mechanism. We observed 16 females, with the help of radiotelemetry; of seven females, we observed directly 26 egg layings and 27 nest visits without laying. As expected if females were imprinted on different vegetation types, (1) the distribution of vegetation types differed between female home ranges, (2) female habitat use differed from average habitat availability within the egg-laying area (habitat preference), (3) females visited nests and deposited their eggs in the habitat they preferred, and (4) females laid their eggs consistently in a particular habitat type, irrespective of the host species. These results indicate that cuckoo females show habitat preference when searching for suitable host nests. Hence our data are compatible with the habitat-imprinting hypothesis, but owing to the habitat specificity of hosts the data cannot disprove a potential role of host specificity in cuckoo females.

Finding, assessing, rejecting, and copulating with a mate is assumed to carry fitness costs, particularly for females, that have to be traded off against fitness benefits of mating such as increased fecundity, fertility, longevity, or better quality offspring. Female dung flies, Sepsis cynipsea (Diptera: Sepsidae), typically attempt to dislodge mounted males harassing them by vigorous shaking. Shaking duration has been shown to reflect both direct and indirect female choice in this species. The latter is an expression of the females' general reluctance to mate due to presumed costs of mating. We investigated the costs of copulation in the laboratory. Females were randomly assigned to one of three treatment groups and allowed to copulate either not at all, once, or twice. The males' armored genitalia injured females internally during copula. Injuries were visible as sclerotized scars in the female ovipositor, and their occurrence increased with mating frequency. Presumably due to these injuries, mated females showed higher mortality. This effect was statistically independent from additional costs of reproduction related to oviposition, as copulation also increased lifetime egg production and tended to augment oviposition rate (eggs per day), while fertility (proportion of offspring emerged) was unaffected. We thus found high mortality costs of copulating, indicating substantial sexual conflict, which helps explain female reluctance to mate in this species. Copyright 2002.

Although a number of hypotheses have been proposed for how European cuckoo, Cuculus canorus, females may find hosts belonging to their foster parents' species, clear evidence is lacking for any of them. Here, we propose 'habitat imprinting' as an alternative mechanism for host selection and provide evidence that cuckoos are able to remember acquired information about a familiar habitat. We hand-reared seven cuckoos in one of five different artificial habitats and tested them as adults in habitat choice experiments. In each test habitat, a pair of zebra finches, Taeniopygia guttuta, was presented as 'hosts'. We tested cuckoos of both sexes because the genotype of males may influence egg colour, and therefore egg mimicry; alternatively, habitat imprinting may be a general mechanism existing in both sexes but affecting egg mimicry only via females. Test cuckoos spent significantly more time looking at their respective familiar habitats than at other habitats in 1 of 2 test years. How long cuckoos were reared in the artificial habitats correlated positively with how long they spent in this habitat during the choice experiments. Additionally, test cuckoos remained longer with zebra finches that showed more nest-building behaviour but had lower levels of general activity, and they also observed these 'hosts' more frequently. If cuckoos choose to breed in habitats resembling those on which they were imprinted and search randomly for hosts in these habitats, they would increase their probability of parasitizing nests of their foster species. We propose that host specificity would be strengthened, however, if cuckoos use a sequence of several mechanisms, rather than just one, to find their hosts. (c) 1998 The Association for the Study of Animal Behaviour.

Background and Purpose— Demographic changes, increased awareness of vascular risk factors, better diagnostic, progress in medical care, and increasing primary stroke prevention influence the profile of patients admitted to stroke-units. Changes in patient population and stroke type have important consequences on outcome and management at stroke-units. Methods— Data from the national database of the Austrian Stroke Unit Registry were analyzed for time-trends in demography, risk factors, cause, and stroke severity. Results— Data of 48 038 ischemic and 5088 hemorrhagic strokes were analyzed. Between 2003 and 2011, median age increased significantly for ischemic strokes from 68 to 71 years in men and from 76 to 78 years in women, respectively. Ischemic stroke patients showed significantly increased rates of hypertension, hypercholesterolemia, and atrial fibrillation. In hemorrhagic strokes an increase for hypercholesterolemia and cardiac diseases other than atrial fibrillation and myocardial infarction were only found in men. A small but significant decrease in stroke severity was found for ischemic strokes from 4 to 3 points on the National Institutes of Health Stroke Scale in men and from 5 to 4 in women, and for hemorrhagic strokes from 9 to 6 points in men and from 9 to 7 in women. Cardioembolic strokes increased slightly, whereas macroangiopathy decreased. Conclusions— Significant time trends were seen for characteristics of ischemic and hemorrhagic stroke patients admitted to acute stroke-units in Austria. These include trends for older age and toward milder strokes with more cardioembolic causes. This signals a need for increased resources for managing multimorbidity and enabling early mobilization.

Background and purpose Despite a high prevalence of post-stroke cognitive impairment, therapeutic possibilities are still limited. Stroke and dementia share the same cluster of modifiable risk factors. Thus, lifestyle interventions and strict adherence to medication may not only decrease the risk of recurrent stroke but also the risk of post-stroke cognitive decline. Methods We performed a systematic literature search for randomized clinical trials (RCTs) targeting modifiable risk factors for the prevention of cognitive decline following stroke. Results We identified 25 non-pharmacological interventions and eight multiple risk factor interventions in stroke patients using cognition as outcome measure. None of the published trials investigated interventions aimed at the prevention of post-stroke cognitive decline. However, a number of ongoing trials aim at risk factor reduction and include measures on cognition. Conclusion Evidence for risk factor modification for the prevention of cognitive decline after stroke is scarce and comes mainly from observational studies. There is a need for more RCTs targeting the prevention of post-stroke dementia using lifestyle interventions and a multiple risk factor approach.

Background: Diabetes has been known to be a predictor for poor outcome after thrombolysis in stroke patients, and early poststroke glycaemia is known to be associated with higher rates of postthrombolytic symptomatic intracerebral haemorrhages. Therefore, diabetic stroke patients are often excluded from thrombolytic treatment. Up to now comparisons exist only from clinical trials (e.g. VISTA collaboration) and registry data of thrombolysed paients (e.g. SITS registry). No nation-wide data have been investigated for the outcomes of thrombolysis in diabetics and non-diabetics. Methods: National database of the Austrian Stroke Unit Registry, 2003-2010 , comprising 34 acute stroke units, comparison of outcome data of thrombolysed and non-thrombolysed diabetic and non-diabetic stroke. Stratification according to sex, age, stroke severity, functional impairment before stroke and recurrent stroke to non-thrombolysed diabetic strokes and to non-diabetic thrombolysed and non-thrombolysed controls. Improvement was defined as the difference between stroke severity at admission and at discharge. Results: A modelled cohort of 1,988 r-tPA thrombolysed diabetic stroke patients from 13,246 ischaemic stroke patients were compared according to sex, age, stroke severity, and prestroke disability. A regression model with improvement as depending variable and age, sex, stroke severity, aetiology of stroke, risk factors (including diabetes) and treatment (including thrombolysis) found no effect of diabetes (p=0.854) or the interaction diabetes x thrombolysis (p=0.277), whereas the effect of thrombolysis itself was highly significant (p=0.0001). No differences were found in the number of symptomatic intracerebral haemorrhages after thrombolytic treatment between diabetic strokes (5.2%) and non-diabetic strokes (4.0%). Both groups had a higher risk of intracerebral haemorrhages compared to the non-thrombolysed groups (diabetic 2.9%, non-diabetic 2.6%). Conclusion: Data from this nation-wide survey show that diabetic stroke patients have a substantial benefit from thrombolysis and therefore diabetic strokes should not be excluded from thrombolysis treatment.

Mating is generally assumed to be costly, but mating costs differ between the sexes. Although mating itself is considered cheaper for males, mate search and mate competition are cheaper for females. Nevertheless, studies increasingly reveal considerable mating costs for males, and these costs should depend on the body size of the individual. We investigated size-dependent predation (ecological) and energetic (physiological) mating costs in male black scavenger flies, Sepsis cynipsea (Diptera: Sepsidae), a model organism for studies of reproductive behavior. We addressed costs of mating by assessing predation risk for differently sized flies in male, female, and mixed-sex groups. Males were not more likely to be predated in mating or matesearch situations. Scathophaga stercoraria (Diptera: Scathophagidae) predators preferred smaller females and males as prey. Male movement in these different social situations does not proximately explain this size-selective predation, as small individuals were not more mobile. We addressed energetic costs of mating by measuring residual longevity (or starvation resistance) of starved males exposed to different mating situations. Copulation, courtship, interaction with reluctant females, or brief interactions with other males, all presumably increasing energy demand, did not significantly reduce longevity of males compared with males not interacting with other individuals. In general, small males died sooner when starved. Overall, we found no direct costs of mating for male S. cynipsea, but both predation and physiological costs were size dependent. Key words: body size, energetic costs, food limitation, mating behavior, mortality, predation, starvation resistance. [Behav Ecol]

Mating success not only depends on genetic quality, but also equally on environmental factors, most prominently food availability. We investigated the interactive effects of nutritional state and body size on mating success and copula duration in yellow dung fly males (Scathophaga stercoraria; Diptera: Scathophagidae) of three body size selection lines in the laboratory in both non-competitive (single) and competitive (group) situations. Adults require protein and lipids from prey to reproduce, as well as sugars as an energy source for reproductive activity. We expected mating success to decrease with time because of sperm depletion (sugar treatment) and ⁄ or energy shortage (water treatment) relative to the control, prey plus sugar treatment. Based on physiological scaling, we also expected large-line males to become depleted either sooner because of their higher energy and sperm demands, or later because of their more efficient energy use. Average mating success indeed declined over a period of 5–7 d (or 5–15 potential copulations per male), but equally for all food treatments and body size classes. Surprisingly, water-fed and small-line males had the highest mating probability in the non-competitive setting, while in the competitive setting large-line males had the highest success. Energy-depleted males showed apparent terminal investment. Small males acquired females more readily but eventually lost them to larger males in the competitive situation. As shown before, copula duration was inversely related to body size and increased with copulation number, independent of food treatment. We conclude that sugar or prey shortage has little effect on mating success in the short term, and does not differentially affect males of different sizes.

The aim of our study was to identify factors influencing time from stroke onset to Stroke Unit (SU) admission. Retrospectively, we analysed the data of all stroke patients registered in the Austrian SU-Registry between 01/03 and 02/07. The influence of mode of transportation on time from stroke onset to admission to SU and on rate of thrombolysis was investigated. Further, we analysed changes in time delays and rate of thrombolysis over the years. A total of 15,746 patients with acute stroke were admitted to one of the 26 participating SU. Direct admission to the hospital equipped with a SU increased the relative chance of thrombolytic treatment by odds 1.8 compared to patients transferred from another hospital. Over the years, the median pre-hospital time did not change significantly, but the rate of patients admitted in a 2-h time window improved from 30 to 42%; the rate of thrombolysis increased from 4.8% (2003) to 9.5% (2007, p0.001).

Summary Developing countries have some of the highest stroke mortality rates in the world that account for over two-thirds of stroke deaths worldwide. Hospital-based studies suggest that the patterns of stroke types and causes of stroke differ between developing and developed countries, resulting in differing needs for acute and long-term care. Data on stroke care provision in developing countries are sparse and most of the available studies are biased towards urban settings in reasonably resourced health-care systems. A general overview shows that the quality and quantity of stroke care is largely patchy in low-income and middle-income countries, with areas of excellence intermixed with areas of severe need, depending upon patients' location, socioeconomic status, education, and cultural beliefs. Here we review the available literature on acute and long-term stroke management in developing countries. On the basis of available studies, largely from developed countries, we discuss the need to develop basic organised stroke-unit care in developing countries.

A female's willingness to copulate (i.e. her receptivity) can depend on several endogenous, environmental and social factors. The black scavenger or dung fly, Sepsis cynipsea (Diptera: Sepsidae), is a classic example of strong female reluctance to mate and sexual conflict over mating. Laboratory studies have found high variability in female receptivity and even virgins unwilling to mate. The aim of this study was to determine the proximate factors influencing female receptivity. Fresh dung was necessary for egg production. Female receptivity strongly depended on a female's egg-laying cycle rather than age: receptivity was highest when females had no ripe eggs. The absence of eggs in the female's reproductive tract is probably required for spermatophore transfer, leading to the unusual precopulatory guarding and postoviposition mating of sepsids. Nonvirgins were less receptive than virgins, except when they were in need of sperm, and more receptive when they were larger and had previously laid more eggs. Only when not in need of sperm did females copulate with males larger than their previous mate. This suggests sequential female choice, but females typically copulated with the first of up to 10 presented males or not at all, provided that they were at the appropriate stage of their laying cycle. Female unwillingness to mate in this and probably other species therefore has various, sometimes physiological (intrinsic) causes. These must be controlled in experiments assessing mate choice, costs and benefits of mating, or sexual conflict. Not taking into account female egg-laying state can mask female choice, bias data and suggest wrong associations.