A telehealth intervention to promote healthy lifestyles after stroke: The Stroke Coach protocol Cost-effectiveness of a text message programme for the prevention of recurrent cardiovascular events World Salt Awareness Week. Randomised controlled trial of a healthy lifestyle intervention among smokers with psychotic disorders: Outcomes to 36 months Program of rehabilitative exercise and education to avert vascular events after non-disabling stroke or transient ischemic attack (PREVENT Trial): a multi-centred, randomised controlled trial Reducing Recurrent Stroke: Methodology of the Motivational Interviewing in Stroke (MIST) Randomized Clinical Trial Long-Term Disability After First-Ever Stroke and Related Prognostic Factors in the Perth Community Stroke Study, 1989–1990 Promoting physical activity after stroke via self-management: a feasibility study The Secondary Prevention of Small Subcortical Strokes (SPS3) Study Long-term risk of first recurrent stroke in the Perth Community Stroke Study. Recurrent stroke and cardiac risks after first ischemic stroke The ExStroke Pilot Trial: rationale, design, and baseline data of a randomized multicenter trial comparing physical training versus usual care after an ischemic stroke. The Adherence eValuation After Ischemic Stroke Longitudinal (AVAIL) registry: design, rationale, and baseline patient characteristics. Stop Stroke: development of an innovative intervention to improve risk factor management after stroke. Peer education for secondary stroke prevention in inner-city minorities: design and methods of the prevent recurrence of all inner-city strokes through education randomized controlled trial. Design and baseline characteristics of the 10 Small Steps Study: a randomised controlled trial of an intervention to promote healthy behaviour using a lifestyle score and personalised feedback Integrated care improves risk-factor modification after stroke: initial results of the Integrated Care for the Reduction of Secondary Stroke model Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS study): a prospective population-based sequential comparison Increased prevalence of sleep apnea in patients with recurring ischemic stroke compared with first stroke victims Stroke recurrence Time frame and predictors of recovery from disability following recurrent ischemic stroke Alcohol Consumption and Risk for Coronary Heart Disease among Men with Hypertension Do sugar-sweetened beverages cause adverse health outcomes in children? A systematic review protocol Risk factors for early recurrence after ischemic stroke: the role of stroke syndrome and subtype. Alcohol and Risk for Ischemic Stroke in Men: The Role of Drinking Patterns and Usual Beverage Discontinuation of secondary preventive treatment of stroke: An unexplored scenario in India Human neural stem cells in patients with chronic ischaemic stroke (PISCES): a phase 1, first-in-man study Cardiac rehabilitation adapted to transient ischaemic attack and stroke (CRAFTS): a randomised controlled trial Primary Prevention of Stroke by Healthy Lifestyle
Rationale Recurrent stroke is prevalent and associated with high mortality rates , disability , and social and economic costs . Adequate management of risk factors may reduce recurrent stroke ; however , many stroke survivors have poor control of risk factors . We have developed a theoretically sound and evidence -based lifestyle modification program called the Stroke Coach , a telephone-based self-management program to improve control of risk factors . Hypothesis Individuals who participate in Stroke Coach will achieve more lifestyle improvements than individuals in an attention controlled Memory Training Program . Design In this single blind r and omized controlled trial , 126 community-living stroke survivors will be r and omized to Stroke Coach or the attention control group . Participants r and omized to the six-month Stroke Coach will receive seven telephone lifestyle coaching sessions , self-management education and practice , and a self-monitoring kit , comprised of a health report card , with blood pressure and activity monitors . Study Outcomes The primary outcome will be measured using the Health Promoting Lifestyle Profile II . Secondary outcomes include behavioral and physiological risk factors , quality of life , cognitive status , health and social service use . Measurements will be taken at baseline , immediately after the intervention and six-month post-intervention . Summary The results of this trial will add to our underst and ing of the use of self-management to improve control of risk factors , and may facilitate the development of a larger trial evaluating the effect of Stroke Coach on endpoints such as recurrent stroke or cardiac events as the primary outcome Objective To estimate the cost-effectiveness of Tobacco , Exercise and Diet Messages ( TEXT ME ) , a text message-based intervention that provides advice , motivation , information and support to improve health-related behaviours . Methods A lifetime Markov model was used to estimate major vascular events ( myocardial infa rct ions and strokes ) avoided , quality -adjusted life years ( QALYs ) gained , costs to the health system and the incremental cost per QALY gained . The model was informed by data from a r and omised controlled trial of TEXT ME , with evidence from systematic review s and meta-analyses used to estimate the effects of changes in risk factors on the risk of major vascular events . Expected costs and health outcomes were estimated with uncertainty surrounding these characterised using probabilistic sensitivity analysis and a number of scenario analyses . Results For a target population of 50 000 patients with documented coronary heart disease , the intervention is expected to lead to 563 fewer myocardial infa rct ions , 361 fewer strokes and 1143 additional QALYs .  TEXT ME is expected to lead to an overall saving of $ 10.56 million for the health system over the patients ’ lifetimes . The intervention can therefore be considered cost-saving and health-improving . Neither parameter nor structural uncertainty had a significant impact on the conclusion that TEXT ME is cost-effective . Conclusions The provision of TEXT ME is predicted to lead to better health outcomes and an overall saving in costs for the health system . Trial registration number anzctr.org.au identifier : ACTRN12611000161921 Cardiovascular disease ( CVD ) , including stroke , heart attack and heart failure , is the leading cause of death and disability worldwide . Raised blood pressure ( BP ) is a major cause of CVD , responsible for 62 % of stroke and 49 % of coronary heart disease cases . There is much evidence for a causal relationship between salt intake and BP . The current salt intake in many countries around the world is between 9 g ⁄d and 12 g ⁄d ( ie , 3.6–4.8 g of sodium ) . R and omized trials have demonstrated that a modest reduction in salt intake lowers BP in individuals with raised BP and also in those with ‘ ‘ normal ’ ’ BP . Furthermore , there is a dose-response relationship . Within the range of 12 g ⁄d to 3 g ⁄d , the lower the salt intake , the lower the BP . Because raised BP throughout its range is a major cause of CVD , salt reduction would reduce cardiovascular risk . It was estimated that a reduction of 6 g ⁄d in salt intake would reduce stroke by 24 % and coronary heart disease by 18 % . This would prevent approximately 35,000 stroke and coronary heart disease deaths a year in the United Kingdom and approximately 2.5 million deaths worldwide . Both prospect i ve studies and outcome trials have demonstrated that a lower salt intake is related to a reduced risk of CVD .  Salt reduction is one of the most cost-effective interventions to reduce CVD in both developed and developing countries . For example , the UK salt reduction campaign , which result ed in a fall in salt intake by approximately 10 % ( ie , from 9.5 g ⁄d in 2003 to 8.6 g ⁄d by May 2008 ) , cost just £ 15 million and led to approximately 6000 fewer CVD deaths per year , saving the UK economy approximately £ 1.5 billion per annum according to the recent report by the UK government ’s health advisory agency , the National Institute for Health and Clinical Excellence . In most developed countries , approximately 80 % of salt consumed is added to foods at the stage of manufacturing , and the consumers have no say over how much salt is added . Therefore , to achieve a reduction in population salt intake , it is imperative that the food industry make a gradual and sustained reduction in the amount of salt that is added to all foods . This approach has been successful in the United Kingdom and is now being exp and ed worldwide . World Salt Awareness Week was introduced by the salt reduction action group World Action on Salt and Health ( WASH ) in 2008 . The event serves as a platform for international experts in the fields of hypertension and nephrology to raise the profile of the importance of salt reduction to both the public and health professionals worldwide Objective : People living with psychotic disorders ( schizophrenia spectrum and bipolar disorders ) have high rates of cardiovascular disease risk behaviours , including smoking , physical inactivity and poor diet . We report cardiovascular disease risk , smoking cessation and other risk behaviour outcomes over 36 months following recruitment into a two-arm r and omised controlled trial among smokers with psychotic disorders . Methods : Participants ( N = 235 ) drawn from three sites were r and omised to receive nicotine replacement therapy plus ( 1 ) a Healthy Lifestyles intervention  delivered over approximately 9 months or ( 2 ) a largely telephone-delivered intervention ( design ed to control for nicotine replacement therapy provision , session frequency and other monitoring ) . The primary outcome variables were 10-year cardiovascular disease risk and smoking status , while the secondary outcomes included weekly physical activity , unhealthy eating , waist circumference , psychiatric symptomatology , depression and global functioning . Results : Significant reductions in cardiovascular disease risk and smoking were detected across the 36-month follow-up period in both intervention conditions , with no significant differences between conditions . One-quarter ( 25.5 % ) of participants reported reducing cigarettes per day by 50 % or more at multiple post-treatment assessment s ; however , few ( 8.9 % ) managed to sustain this across the majority of time points . Changes in other health behaviours or lifestyle factors were modest ; however , significant improvements in depression and global functioning were detected over time in both conditions . Participants experiencing worse ‘ social discomfort ’ at baseline ( e.g. anxiety , mania , poor self-esteem and social disability ) had on average significantly worse global functioning , lower scores on the 12-Item Short Form Health Survey physical scale and significantly greater waist circumference . Conclusion : Although the telephone-delivered intervention was design ed as a comparison condition , it achieved excellent retention and comparable outcomes . Telephone-delivered smoking cessation support may potentially help to reduce smoking rates among people with psychotic disorders . Discomfort in social situations may also be a useful target for future health interventions , addressing confidence and social skills , and promoting social networks that reduce inactivity Background Despite lack of outward signs , most individuals after non-disabling stroke ( NDS ) and transient ischemic attack ( TIA ) have significant cardiovascular and cerebrovascular disease and are at high risk of a major stroke , hospitalization for other vascular events , or death . Most have multiple modifiable risk factors ( e.g. , hypertension , physical inactivity , hyperlipidaemia , diabetes , tobacco consumption , psychological stress ) . In addition , accelerated rates of depression , cognitive decline , and poor quality of sleep have been reported following TIA , which correlate with poor functional outcomes and reduced quality of life . Thus , NSD and TIA are important warning signs that should not be overlooked . The challenge is not unlike that facing other ' silent ' conditions - to identify a model of care that is effective in changing people 's current behaviors in order to avert further morbidity . Methods / Design A single blind , r and omized controlled trial will be conducted at two sites to compare the effectiveness of a program of rehabilitative exercise and education versus usual care in modifying vascular risk factors in adults after NDS/TIA . 250 adults within 90 days of being diagnosed with NDS/TIA will be r and omly allocated to a 12-week program of exercise and education ( PREVENT ) or to an outpatient clinic assessment and discussion of secondary prevention recommendations with return clinic visits as indicated ( USUAL CARE ) . Primary outcome measures will include blood pressure , waist circumference , 12-hour fasting lipid profile , and 12-hour fasting glucose/hemoglobin A1c . Secondary measures will include exercise capacity , walking endurance , physical activity , cognitive function , depression , goal attainment and health-related quality of life . Outcome assessment will be conducted at baseline , post-intervention , and 6- and 12-month follow-ups . Direct health care costs incurred over one year by PREVENT versus USUAL CARE participants will also be compared . Ethical approval for the trial has been obtained from the relevant Human Research Ethics Boards . Discussion Whether timely delivery of an adapted cardiac rehabilitation model is effective in attaining and maintaining vascular risk reduction targets in adults after NDS/TIA is not yet known . We anticipate that the findings of this trial will make a meaningful contribution to the knowledge base regarding secondary stroke prevention . Trial registration This trial is registered with the Clinical Trials.gov Registry ( NCT00885456 ) Rationale Recurrent stroke is prevalent in both developed and developing countries , contributing significantly to disability and death . Recurrent stroke rates can be reduced by adequate risk factor management . However , adherence to prescribed medications and lifestyle changes recommended by physicians at discharge after stroke is poor , leading to a large number of preventable recurrent strokes . Using behavior change methods such as Motivational Interviewing early after stroke occurrence has the potential to prevent recurrent stroke . Aims and /or hypothesis The overall aim of the study is to determine the effectiveness of motivational interviewing in improving adherence to medication and lifestyle changes recommended by treating physicians at and after hospital discharge in stroke patients 12 months poststroke to reduce risk factors for recurrent stroke . Design Recruitment of 430 first-ever stroke participants will occur in the Auckl and and Waikato regions . R and omization will be to intervention or usual care groups . Participants r and omized to intervention will receive four motivational interviews and five follow-up assessment s over 12 months . Nonintervention participants will be assessed at the same time points . Study outcomes Primary outcome measures are changes in systolic blood pressure and low-density lipoprotein levels 12 months poststroke . Secondary outcomes include self-reported adherence and barriers to prescribed medications , new cardiovascular events ( including stroke ) , changes in quality of life , and mood . Discussion The results of the motivational interviewing in stroke trial will add to our underst and ing of whether motivational interviewing may be potentially beneficial in the management of stroke and other diseases where similar lifestyle factors or medication adherence are relevant Background and Purpose — Few reliable estimates of the long-term functional outcome after stroke are available . This population -based study aim ed to describe disability , dependency , and related independent prognostic factors at 5 years after a first-ever stroke in patients in Perth , Western Australia . Methods — All individuals with a suspected acute stroke who were resident in a geographically defined region ( population , 138 708 ) of Perth , Western Australia , were registered prospect ively and assessed according to st and ardized diagnostic criteria over a period of 18 months in 1989 to 1990 . Patients were followed up prospect ively at 4 and 12 months and 5 years after the index event . Results — There were 370 cases of first-ever stroke , and 277 patients survived to 30 days . Of these early survivors , 152 ( 55 % ) were alive at 5 years , and among those who were neither institutionalized ( n=146 ) nor disabled ( n=129 ) at the time of their stroke , 21 ( 14 % ) were institutionalized in a nursing home , and 47 ( 36 % ) were disabled . The most important predictors of death or disability at 5 years were increasing age , baseline disability defined by a Barthel Index score of < 20/20 ( odds ratio [ OR ] , 6.3 ; 95 % confidence interval [ CI ] , 2.7 to 14 ) , moderate hemiparesis ( OR , 2.7 ; 95 % CI , 1.1 to 6.2 ) , severe hemiparesis ( OR , 4.5 ; 95 % CI , 1.1 to 19 ) , and recurrent stroke ( OR , 9.4 ; 95 % CI , 3.0 to 30 ) . A low level of activity before the stroke was a significant predictor of institutionalization , and subsequent recurrent stroke was a consistent , independent predictor of institutionalization , disability , and death or institutionalization , increasing the odds of each of these 3 adverse outcomes by 5- to 15-fold . Conclusions — Among 30-day survivors of first-ever stroke , about half survive 5 years ; of survivors , one third remain disabled , and 1 in 7 are in permanent institutional care . The major modifiable predictors of poor long-term outcome are a low level of activity before the stroke and subsequent recurrent stroke . Efforts to increase physical activity among the elderly and to prevent recurrent stroke in survivors of a first stroke are likely to reduce the long-term burden of cerebrovascular disease Abstract Background : Many people with mild disability after stroke are physically inactive despite the risk of recurrent stroke . A self-management program may be one strategy to increase physical activity in stroke survivors . Objectives : To investigate the feasibility of a self-management program , and determine whether self-management can increase daily physical activity levels and self-efficacy for exercise , decrease cardiovascular risk , and improve walking ability , participation , and quality of life in people with mild disability after stroke . Method : A Phase I , single-group , pre-post intervention study was carried out with twenty stroke survivors who had mild disability and were discharged directly home from acute stroke units . A self-management program was delivered via five home-based sessions over 3 months , incorporating : education , goal setting , barrier identification , self-monitoring , and feedback .  Feasibility of the intervention was determined by examining adherence , duration , usefulness , and safety . Clinical outcomes were amount of physical activity ( duration of moderate physical activity in min/day and counts of physical activity in steps/day ) , self-efficacy , cardiovascular risk , walking ability , participation , and quality of life . Results : The intervention was feasible with 96 % of sessions being delivered , each taking less than an hour ( 41 min , SD 12 ) . Participants perceived the self-management program to be useful and there were few adverse events . At 3 months , participants completed 27 min/day ( 95 % CI 4–49 ) more moderate physical activity than at baseline and 16 min/day ( 95 % CI −10 to 42 ) at 6 months . Conclusion : Self-management appears to be feasible and has the potential to increase physical activity in people with mild disability after stroke . A Phase II r and omized trial is warranted Background Small subcortical strokes , also known as lacunar strokes , comprise more than 25 % of brain infa rcts , and the underlying vasculopathy is the most common cause of vascular cognitive impairment . How to optimally prevent stroke recurrence and cognitive decline in S3 patients is unclear . The aim of the Secondary Prevention of Small Subcortical Strokes study ( Trial registration : NCT00059306 ) is to define strategies for reducing stroke recurrence , cognitive decline , and major vascular events . Methods Secondary Prevention of Small Subcortical Strokes is a r and omised , multicentre clinical trial ( n=3000 ) being conducted in seven countries , and sponsored by the US NINDS/NIH . Patients with symptomatic small subcortical strokes in the six-months before and an eligible lesion on magnetic resonance imaging are simultaneously r and omised , in a 2 × 2 factorial design , to antiplatelet therapy – 325 mg aspirin daily plus 75 mg clopidogrel daily , vs. 325 mg aspirin daily plus placebo , double-blind – and to one of two levels of systolic blood pressure targets –‘intensive ’ ( < 130 mmHg ) vs. ‘ usual ’ ( 130–149 mmHg ) . Participants are followed for an average of four-years . Time to recurrent stroke ( ischaemic or haemorrhagic ) is the primary outcome and will be analysed separately for each intervention . The secondary outcomes are the rate of cognitive decline and major vascular events . The primary and most secondary outcomes are adjudicated central ly by those unaware of treatment assignment . Conclusions Secondary Prevention of Small Subcortical Strokes will address several important clinical and scientific questions by testing two interventions in patients with recent magnetic resonance imaging-defined lacunar infa rcts , which are likely due to small vessel disease . The results will inform the management of millions of patients with this common vascular disorder BACKGROUND AND PURPOSE Few community-based studies have examined the long-term risk of recurrent stroke after an acute first-ever stroke . This study aim ed to determine the absolute and relative risks of a first recurrent stroke over the first 5 years after a first-ever stroke and the predictors of such recurrence in a population -based series of people with first-ever stroke in Perth , Western Australia . METHODS Between February 1989 and August 1990 , all people with a suspected acute stroke or transient ischemic attack of the brain who were resident in a geographically defined region of Perth , Western Australia , with a population of 138 708 people , were registered prospect ively and assessed according to st and ardized diagnostic criteria . Patients were followed up prospect ively at 4 months , 12 months , and 5 years after the index event . RESULTS Three hundred seventy patients with a first-ever stroke were registered , of whom 351 survived > 2 days . Data were available for 98 % of the cohort at 5 years , by which time 199 patients ( 58 % ) had died and 52 ( 15 % ) had experienced a recurrent stroke , 12 ( 23 % ) of which were fatal within 28 days . The 5-year cumulative risk of first recurrent stroke was 22.5 % ( 95 % confidence limits [ CL ] , 16.8 % , 28.1 % ) . The risk of recurrent stroke was greatest in the first 6 months after stroke , at 8.8 % ( 95 % CL , 5.4 % , 12.1 % ) . After adjustment for age and sex , the prognostic factors for recurrent stroke were advanced , but not extreme , age ( 75 to 84 years ) ( hazard ratio [ HR ] , 2.6 ; 95 % CL , 1.1 , 6.2 ) , hemorrhagic index stroke ( HR , 2.1 ; 95 % CL , 0.98 , 4.4 ) , and diabetes mellitus ( HR , 2.1 ; 95 % CL , 0.95 , 4.4 ) . CONCLUSIONS Approximately 1 in 6 survivors ( 15 % ) of a first-ever stroke experience a recurrent stroke over the next 5 years , of which 25 % are fatal within 28 days . The pathological subtype of the recurrent stroke is the same as that of the index stroke in 88 % of cases . The predictors of first recurrent stroke in this study were advanced age , hemorrhagic index stroke , and diabetes mellitus , but numbers of recurrent events were modest . Because the risk of recurrent stroke is highest ( 8.8 % ) in the first 6 months after stroke , strategies for secondary prevention  should be initiated as soon as possible after the index event Background : Few population -based studies with long-term follow-up have compared risk of recurrent stroke and cardiac events after first ischemic stroke . The relative risk of these two outcomes may inform treatment decisions . Methods : In the population -based Northern Manhattan Study , first ischemic stroke patients age 40 or older were prospect ively followed for recurrent stroke , myocardial infa rct ion ( MI ) , and cause-specific mortality . Fatal cardiac events were defined as death secondary to MI , congestive heart failure , sudden death/arrhythmia , and cardiopulmonary arrest . Risk of events ( with 95 % CIs ) was calculated using Kaplan – Meier survival analysis and adjusted for sex and age using Cox proportional hazard models . Results : Mean age ( n = 655 ; median follow-up 4.0 years ) was 69.7 ± 12.7 years .  The risk of recurrent stroke was more than twice that of cardiac events ( including nonfatal MI ) at 30 days and approximately twice cardiac risk at 5 years . The age- and sex-adjusted 5-year risk of fatal or nonfatal recurrent stroke was 18.3 % ( 14.8 to 21.7 % ) , and the 5-year risk of MI or fatal cardiac event was 8.6 % ( 6.0 to 11.2 % ) . The adjusted 5-year risk of nonfatal stroke ( 14.8 % , 11.6 to 17.9 % ) was approximately twice as high as fatal cardiac events ( 6.4 % , 4.1 to 8.6 % ) and four times higher than risk of fatal stroke ( 3.7 % , 2.1 to 5.4 % ) . Conclusions : Cardiac mortality is nearly twice as high as mortality owing to recurrent stroke , but long-term risk of all stroke , fatal or nonfatal , is approximately twice the risk of all cardiac events . The high risk of nonfatal recurrent stroke reinforces the importance of therapies aim ed at preventing stroke recurrence in addition to preventing cardiac events INTRODUCTION A high level of physical activity is associated with a decreased risk of first stroke and physical activity modifies recognized stroke risk factors and is recommended for stroke survivors . Available research shows that stroke patients can increase their level of physical performance over a short period . When the intervention period is over , physical performance often declines towards baseline level . Currently , there is no evidence on the association between physical activity and the risk of recurrent stroke . The ExStroke Pilot Trial is a r and omized clinical trial with the aim of increasing stroke patients ' level of physical activity and secondarily to associate the level of physical activity to the risk of recurrent stroke , myocardial infa rct ion , and all-cause mortality in the two groups . We describe the rationale , design , and baseline data of the ExStroke Pilot Trial . METHODS Patients with ischemic stroke above 39 years were r and omized to intervention or control group . The intervention group will , over a 2-year period , receive information on and verbal instruction to exercise by a physiotherapist or a physician . The control group will receive the department 's usual care . Physical activity  is assessed in both groups seven times during follow-up using the  Physical Activity Scale for the Elderly ( PASE ) question naire , which quantifies the amount of physical activity done in the last seven days prior to interview . The PASE score constitutes the primary outcome measure . The secondary outcome is the time from r and omization to recurrent stroke , myocardial infa rct ion , or all-cause mortality . Further outcome measures include : time from r and omization to recurrent stroke , myocardial infa rct ion , and vascular death ; recurrent stroke ; modified Rankin Scale ; quality of life ; occurrence of falls and fractures . TRIAL STATUS From 9 centers in 4 countries , 314 patients were included and follow-up is ongoing . Mean age and st and ard deviation ( SD ) of the study participants was 68.4 ( 11.9 ) years and 56.4 % were male . Mean ( SD ) PASE score was 84.1 ( 55.9 ) and median ( interquartile range ) Sc and inavian Stroke Scale score was 54 ( 51 - 58 ) BACKGROUND Approximately one third of the 780,000 people in the United States who have a stroke each year have recurrent events . Although efficacious secondary prevention measures are available , levels of adherence to these strategies in patients who have had stroke are largely unknown . Underst and ing medication-taking behavior in this population is an important step to optimizing the appropriate use of proven secondary preventive therapies and reducing the risk of recurrent stroke . METHODS The Adherence eValuation After Ischemic Stroke Longitudinal ( AVAIL ) registry is a prospect i ve study of adherence to stroke prevention medications from hospital discharge to 1 year in patients admitted with stroke or transient ischemic attack . The primary outcomes are medication usage as determined by patient interviews after 3 and 12 months . Potential patient- , provider- , and system-level barriers to persistence of medication use are also collected . Secondary outcomes include the rates of recurrent stroke or transient ischemic attack , vascular events , and rehospitalization and functional status as measured by the modified Rankin score . RESULTS The AVAIL enrolled about 2,900 subjects from 106 hospitals from July 2006 through July 2008 . The 12-month follow-up will be completed in August 2009 . CONCLUSIONS The AVAIL registry will document the current state of adherence and persistence to stroke prevention medications among a nationwide sample of patients . These data will be used to design interventions to improve the quality of care post acute hospitalization and reduce the risks of future stroke and cardiovascular events OBJECTIVE Stroke survivors are at high risk of stroke recurrence yet current strategies to reduce recurrence risk are sub-optimal . The UK Medical Research Council ( MRC ) have proposed a framework for developing and evaluating complex interventions , such as community management of stroke secondary prevention . The Framework outlines a five-phased approach from theory through to implementation of effective interventions . This paper reports Phases I-III of the development of a novel intervention to improve risk factor management after stroke . METHODS The pre- clinical /theoretical phase entailed review ing the literature and undertaking quantitative and qualitative studies to identify current practice s and barriers to secondary prevention . In Phase I ( modelling ) , findings were used to design an intervention with the potential to overcome barriers to effective stroke secondary prevention management . The feasibility of delivering the intervention and its acceptability were tested in the Phase II exploratory trial involving 25 stroke survivors and their general practitioners . RESULTS This led to the development of the definitive risk factor management  intervention . This comprises multiple components and involves using an on-going population stroke register to target patients , carers and health care professionals with tailored secondary prevention advice . Clinical , socio-demographic and service use data collected by the stroke register are transformed to provide an individualised secondary prevention package for patients , carers and health care professionals at three time points : within 10 weeks , 3 and 6 months post-stroke . CONCLUSION The intervention is currently being evaluated in a r and omised controlled trial . Further research is needed to test generalisability to other aspects of stroke management and for other chronic diseases . PRACTICE IMPLICATION S The MRC Framework for complex interventions provides a structured approach to guide the development of novel interventions in public health . Implication s for practice in stroke secondary prevention will emerge when the results of our r and omised controlled trial are published BACKGROUND The highest risk for stroke is among survivors of strokes or transient ischemic attacks ( TIA ) . However , use of proven-effective cardiovascular medications to control stroke risk is suboptimal , particularly among the Black and Latino population s disproportionately impacted by stroke . METHODS A partnership of Harlem and Bronx community representatives , stroke survivors , research ers , clinicians , outreach workers and patient educators used community-based participatory research to conceive and develop the Prevent Recurrence of All Inner-city Strokes through Education ( PRAISE ) trial . Using data from focus groups with stroke survivors , they tailored a peer-led , community-based chronic disease self-management program to address stroke risk factors . PRAISE will test , in a r and omized controlled trial , whether this stroke education intervention improves blood pressure control and a composite outcome of blood pressure control , lipid control , and use of antithrombotic medications . RESULTS Of the 582 survivors of stroke and TIA enrolled thus far , 81 % are Black or Latino and 56 % have an annual income less than $ 15,000 . Many ( 33 % ) do not have blood pressures in the target range , and most ( 66 % ) do not have control of all three major stroke risk factors . CONCLUSIONS Rates of stroke recurrence risk factors remain suboptimal in the high risk , urban , predominantly minority communities studied . With a community-partnered approach , PRAISE has recruited a large number of stroke and TIA survivors to date , and may prove successful in engaging those at highest risk for stroke and reducing disparities in stroke outcomes in inner-city communities Background Non-communicable diseases ( NCDs ) are the leading causes of death globally and are associated with a limited set of common , modifiable health behaviours : tobacco use , physical inactivity , harmful use of alcohol and unhealthy diet . General practice offers an ideal avenue for addressing such health behaviours on a population -wide basis . This paper describes the protocol of a multiple health behaviour change intervention design ed for implementation in general practice and summarises the baseline characteristics of its participants . Method / Design The 10 Small Steps ( 10SS ) study , a r and omised controlled trial , involved 4,678 adult general practice patients in Queensl and , Australia .  Self-reported data were collected to establish the proportion of participants meeting recommended guidelines for ten health behaviours : physical activity , body mass index , alcohol , smoking and six dietary behaviours . Participants were r and omised to four groups : contact at baseline only ( ' single intervention ' and corresponding control group ) and contact at baseline and 3 months ( ' dual intervention ' and corresponding control group ) . At each contact the participants received a computer-tailored feedback and one page information sheet according to their allocation to intervention or control groups . Change in the intervention group compared to the control group was assessed at 3 and 12 months after baseline data collection .Responses were summed to calculate an individual lifestyle score ( the Prudence Score ) , which ranged from 0 to 10 . The baseline response was 56.5 % ( 4678 of 8343 invited participants ) and the study sample was primarily female ( 68.7 % ) with an average age of 47 years . The mean Prudence Score was 5.8 ( 95%CI 5.75 - 5.85 ) . Discussion Baseline data from the 10SS study show that nearly all participants engage in some health behaviours but relatively few adhere simultaneously to a core set of dietary and lifestyle behaviours associated with risk of NCDs . Ample scope exists to improve health behaviour to reduce NCDs in the general practice setting and the 10SS study trial will provide data on the extent to which a minimal computer-tailored intervention can meet this objective . The protocol developed for the 10SS study has potential for translation into routine general practice as it has minimal impact on practice routine whilst contributing to primary prevention objectives .Trial Registration The Australian New Zeal and Clinical Trials Registry Objective : Despite evidence demonstrating that risk-factor management is effective in reducing recurrent cerebrovascular disease , there are very few structured care programmes for stroke survivors . The aim was to implement and evaluate an integrated care programme in stroke . Methods : 186 patients with stroke were r and omised to either the treatment ( integrated care ) or control ( usual care ) group and were followed up over 12 months . The Integrated Care for the Reduction of Secondary Stroke ( ICARUSS ) model of integrated care involved collaboration between a specialist stroke service , a hospital coordinator and a patient ’s general practitioner . The primary aim was to promote the management of vascular risk factors through ongoing patient contact and education . Results : In the 12 months poststroke , systolic blood pressure ( sBP ) decreased in the treatment group but increased in controls . The group difference was significant , and remained so when age , sex , disability and sBP at discharge were accounted for ( p = 0.04 ) . Treatment patients also exhibited better modification of body mass index ( p = 0.007 ) and number of walks taken ( p<0.001 ) than controls . Rankin scores indicated significantly reduced disability in treatment patients relative to controls in the year poststroke ( p = 0.003 ) . Conclusions : Through an integrated system of education , advice and support to both patient and GP , the ICARUSS model was effective in modifying a variety of vascular risk factors and therefore should decrease the likelihood or recurrent stroke or vascular event BACKGROUND Evidence is available on the effectiveness and costs of treatments to reduce stroke risk in long-term secondary prevention . However , there are few data on the costs and outcomes of urgent assessment and treatment after the onset of transient ischaemic attack ( TIA ) or minor stroke . The Early use of eXisting PREventive Strategies for Stroke ( EXPRESS ) study showed that urgent assessment and treatment reduced the 90-day risk of recurrent stroke by about 80 % . We now report the effect of the EXPRESS intervention on admissions to hospital , costs , and disability . METHODS EXPRESS was a prospect i ve population -based before ( phase 1 : April 1 , 2002 , to Sept 30 , 2004 ) versus after ( phase 2 : Oct 1 , 2004 , to March 31 , 2007 ) study of the effect of early assessment and treatment of TIA or minor stroke on the risk of early recurrent stroke . This report assesses the effect of the introduction of the phase 2 clinic on admissions to hospital within 90 days , hospital bed-days , hospital costs , and 6-month new disability ( progression from no disability before event [ modified Rankin scale score < or = 2 points ] to disability at 6 months [ modified Rankin scale score > 2 points ] ) or death , compared with the phase 1 clinic . To assess the main predictors of these outcomes , multivariate regression analyses were done . FINDINGS The 90-day risk of fatal or disabling stroke was reduced in phase 2 ( 1 of 281 vs 16 of 310 ; p=0.0005 ) . Hospital admissions for recurrent stroke were also lower in phase 2 than in phase 1 ( 5 vs 25 ; p=0.001 ) , which reduced the overall number of hospital bed-days compared with phase 1 ( 672 vs 1957 days ; p=0.017 ) . Hospital bed-days for admissions to hospital due to vascular causes were also lower in phase 2 ( 427 vs 1365 days ; p=0.016 ) , which generated savings of 624 pounds per patient referred to the phase 2 clinic ( p=0.028 ) . Results from the multivariate analyses showed that assessment in phase 2 was an independent predictor of reduced disability , days in hospital , and costs . INTERPRETATION Urgent assessment and treatment of patients with TIA or minor stroke who were referred to a specialist outpatient clinic reduced subsequent hospital bed-days , acute costs , and 6-month disability Abstract Since sleep apnea ( SA ) and stroke have many shared risk factors an independent contribution of SA to the overall risk of stroke is not easily proven and has been question ed recently . To contribute to this controversy , we analysed the frequency of SA  in groups of patients with first and recurring ischemic stroke . We prospect ively studied 102 patients admitted to our stroke unit . The prevalence of vascular risk factors and a history of previous stroke were recorded . All patients received cardio – respiratory polygraphy during the first 72 hours after admission .  CT and MRI scans were evaluated for the location of the acute stroke and the presence of older vascular lesions . Thirty – four women and 68 men with a mean age of 64.5 ± 13.7 years were included in the study . Cerebral lesions attributable to a previous stroke were identified in 25 patients , of whom 19 reported to have suffered a stroke before . Patients with stroke recurrence had a higher mean apnea – hypopnea index ( AHI ) ( 26.6/h vs. 15.1/h , p<0.05 ) and more often presented with a sleep apnea syndrome ( SA ) defined by an AHI ≥ 10/h ( 80 vs. 52 % , p < 0.05 ) than patients with first ever stroke . Logistic regression analysis including the variables " age " , " gender " , " cumulative risk factors " , " AHI ≥ 10/h " , and " diabetes " identified diabetes ( Odd ’s ratio [ OR ] = 4.5 ) and AHI ≥ 10/h ( OR = 3.5 ) as independent risk – factors for stroke recurrence . According to our results SA is an independent risk factor for stroke recurrence . We therefore advocate routine sleep – apnea screening in all patients having suffered an ischemic stroke We compared stroke severity , risk factors , and prognosis in patients with recurrent versus first-ever stroke . In the Copenhagen Stroke Study , we prospect ively studied 1,138 unselected patients with acute stroke . Stroke was recurrent in 265 ( 23 % ) despite most of these patients being given prophylactic treatment prior to recurrence . Only 12 % of patients with atrial fibrillation were receiving anticoagulant treatment prior to recurrence . In multivariate analysis , recurrence was more frequently associated with a history of TIA , atrial fibrillation , male gender , and hypertension , but not with age , daily alcohol consumption , smoking , diabetes , ischemic heart disease , serum cholesterol , or hematocrit . Mortality was almost doubled compared with patients with a first-ever stroke . In survivors , however , both neurologic and functional outcomes and the speed of recovery were , in general , similar in the two groups . Despite similar neurologic impairments , patients with recurrence contralateral to their first stroke had markedly more severe functional disability after completed rehabilitation than patients with ipsilateral recurrence , implying that the ability to compensate functionally is decreased in patients with contralateral recurrence . Our findings emphasize the importance of consistent anticoagulant treatment for stroke patients with atrial fibrillation and close blood pressure control in stroke patients with hypertension . Other prophylactic measures are needed in patients in whom ASA fails to prevent recurrence . Patients with recurrent stroke have a markedly higher mortality than patients with a first-ever stroke , but those who survive recover as well and as fast as patients with a first-ever stroke . However , if recurrence is contralateral to the first stroke , functional recovery is poorer Objective : To assess the rate , degree , and predictors of recovery from a disabled to nondisabled state in patients disabled after recurrent ischemic stroke . Methods : Patients with ischemic stroke enrolled in the Management of Atherothrombosis with Clopidogrel in High Risk Patients ( MATCH ) Study underwent prospect i ve assessment of their modified Rankin score ( mRS ) at 1 , 3 , 6 , 12 , and 18 months after enrollment and after recurrent stroke . Patients disabled ( defined as mRS ≥ 3 ) after recurrence were analyzed for recovery ( defined as mRS < 3 ) during the 18 months , and predictors of recovery were sought using a Cox proportional-hazard multiple regression analysis . Results : Three hundred forty-five ( 54 % ) of 637 patients were disabled after recurrent ischemic stroke ; 115 ( 33 % ) patients had been disabled and 230 ( 66 % ) nondisabled before stroke recurrence . At recurrence , the degree of disability was moderate ( mRS 3 ) in 135 ( 39 % ) patients , severe ( mRS 4 ) in 139 ( 40 % ) , and very severe ( mRS 5 ) in 71 ( 21 % ) . After 12 months ' median follow-up , 117 ( 34 % , 95 % CI : 29 to 39 % ) had recovered : 68 ( 50 % , 42 to 59 % ) of 135 moderately disabled , 45 ( 32 % , 25 to 41 % ) of 139 severely disabled , and 4 ( 6 % , 2 to 14 % ) of 71 very severely disabled ; 70 ( 20.3 % ) patients died . From recurrence , median time to recovery was 6 months ( mRS 3 ) and 18 months ( mRS 4 ) ; 94 % with very severe disability had not recovered at 18 months . Independent predictors of recovery were moderate disability at recurrence ( mRS 3 ) compared with severe ( mRS 4 : hazard ratio [ HR ] 1.5 ; 95 % CI 1.04 to 2.3 ) or very severe disability ( mRS 5 : HR 7.6 ; 2.7 to 20 ) and a nondisabled vs disabled state before recurrence ( HR 4.0 ; 2.3 to 6.8 ) . Conclusions : The rate of recovery from recurrent ischemic stroke was greatest in the first 6 months ; one-third of patients recovered within 12 months . The significant predictors of recovery were a nondisabled state before recurrence and increasing severity of the recurrent stroke Context Heavy alcohol consumption may increase risk for hypertension , but does it increase risk for cardiovascular disease ? Contributions In this 16-year prospect i ve study , 11711 male health professionals with hypertension reported their average alcohol consumption every 4 years . Compared with men who abstained from alcohol , men who consumed 10 to 14 g/d ( about 1 drink per day ) , 15 to 29 g/d , 30 to 49 g/d , and more than 49 g/d of alcohol had decreased risk for myocardial infa rct ion . Alcohol intake seemed unrelated to total death or death due to cardiovascular disease . Caution s Alcohol intake and hypertension were self-reported . Few outcomes limited ability to determine precise relationships between alcohol and stroke . The Editors Hypertension is a major public health burden in the United States . In 1999 , 65 million adults had the condition , an approximately 30 % increase from 1991 ( 1 ) . Hypertension is associated with a doubled risk for cardiovascular disease ( CVD ) and may account for 30 % of events associated with CVD ( 2 ) . Moderate alcohol consumption is inversely associated with CVD and total death ( 3 , 4 ) . However , intake of more than 30 grams of alcohol ( that is , more than 2 drinks ) per day is associated with an increased risk for hypertension ( 5 , 6 ) . Guidelines for alcohol consumption among patients with hypertension range from a limit of 2 to 3 drinks per day to complete abstention from alcohol ( 79 ) . These contradictory recommendations may reflect the paucity of information on the relation between alcohol consumption and risk for CVD among patients with hypertension . To our knowledge , only 3 studies have addressed the relationship of alcohol intake and death due to CVD among patients with hypertension ( 1012 ) . Although the studies reported lower numbers of death due to CVD with moderate alcohol consumption , none assessed specific incidence of MI . Of importance , the studies were limited to alcohol consumption assessed after diagnosis of hypertension and were unable to account for changes of alcohol consumption after the diagnosis . To address these issues , we investigated whether  alcohol consumption is inversely associated with CVD and death among 11711 men with hypertension participating in the Health Professionals Follow-Up Study ( HPFS ) , a prospect i ve cohort of male health professionals in the United States . Methods The HPFS enrolled 51529 male dentists , veterinarians , optometrists , pharmacists , osteopathic physicians , and podiatrists from the United States who were 40 to 75 years of age and who returned a mailed question naire about diet and medical history in  1986 . Follow-up question naires were sent biennially to up date information on exposures and newly diagnosed illnesses . Hypertensive status was determined from the biennial question naires . In 1986 , participants were asked if they had ever been diagnosed with hypertension and , if so , when . On subsequent question naires , participants reported whether they had been diagnosed with hypertension in the past 2 years and , if so , the year of diagnosis . For this analysis , we included 9016 men with hypertension whose condition was diagnosed during follow-up ( that is , men with incident hypertension ) and 2695 men with hypertension at baseline whose condition was diagnosed between 1975 and 1986 and who reported not changing their alcohol consumption during that time ( that is , men with prevalent hypertension ) . From the full cohort of 51529 men , we excluded 4397 who reported a baseline history of cardiovascular disease , stroke , or cancer ( other than nonmelanoma skin cancer ) ; 81 with hypertension diagnosed after a CVD event ; 1653 who had missing or implausible nutritional information at baseline ( including missing alcohol consumption,70 missing food items , or estimated daily energy intake 800 or 4200 kcal [ only 438 of these participants were actually hypertensive ] ) ; 271 with missing information for smoking , physical activity , or body mass index ( BMI ) ; and 95 whose initial question naire had other technical problems . We also excluded 6548 men at baseline because we could not determine their drinking history , because hypertension was diagnosed before 1975 , or because they reported substantially changing their alcohol consumption within 10 years before enrollment . Of the remaining men , we identified 11711 patients with hypertension at baseline or during follow-up who were eligible for analysis . Although our sample size was set by the size of the original HPFS cohort assembled in 1986 , a sample size calculation showed that 1700 participants in the abstaining and moderate-drinking categories would detect a relative risk of 0.6 , as observed by Malinski and colleagues ( 10 ) , with 80 % power and accepting a false-positive rate of 0.05 . We assessed alcohol consumption by using a 131-item semiquantitative food-frequency question naire with separate items for beer , white wine , red wine , and liquor . We specified st and ard portions as a glass , bottle , or can of beer ; a 4-ounce glass of wine ; and a shot of liquor . For each beverage , participants were asked how often on average over the past year they consumed that amount . We calculated ethanol intake by multiplying the frequency of consumption of each beverage by the alcohol content of the specified portion size ( 12.8 g for beer , 11.0 g for wine , and 14.0 g for liquor ) and summing across beverages ( 13 ) . This process was repeated for the years 1990 , 1994 , and 1998 , with an added item about light beer in 1994 . In 1986 , men also reported the number of days per week that they typically drank any form of alcohol . We examined associations between alcohol consumption estimated by using the food-frequency question naire with consumption estimated by using 2 one-week dietary records collected approximately 6 months apart from 136 participants residing in eastern Massachusetts ( 14 , 15 ) . The Spearman correlation coefficient between these 2 measures was 0.86 . Estimated mean alcohol intake was 12.8 grams per day using dietary records and 12.5 grams per day using the food-frequency question naire , with no evidence of systematic bias . The correlation coefficient for drinking frequency between our question naire and diet records was 0.79 . Outcomes and Measurements Our primary end points were incident nonfatal MI and fatal coronary heart disease or stroke . Myocardial infa rct ion and stroke were first identified by self-reports on biennial question naires and then confirmed by medical records with World Health Organization or National Survey of Stroke criteria ( 16 ) . Fatal MI and stroke were confirmed by medical records or autopsy reports . All end points were confirmed by a physician blinded to exposure status . Approximately 80 % of participants had MI that was considered definite ; the remaining patients had MI that was considered probable and were excluded as end points in sensitivity analyses . Further details of the confirmation of end points are published elsewhere ( 17 , 18 ) . Other end points were total death ; death due to CVD ; and death augmented by alcohol intake , including cirrhosis , alcohol-related types of cancer , accidents and other external causes , cancer of the colon and rectum , pneumonia , and hemorrhagic stroke according to Thun and colleagues ( 19 ) . Covariate information was derived from biennial question naires . Nutritional information was derived from food-frequency question naires . Participants self-reported cardiovascular risk factors ( self-report of physician-diagnosed diabetes and hypercholesterolemia , cigarette smoking , physical activity , and weight ) every 2 years . Aspirin use included use of aspirin and aspirin-containing products at least twice weekly . Regular use of lipid-lowering therapy and several categories of antihypertensive medication ( for example , diuretics , -blockers , calcium-channel blockers , and -blockers ) was also recorded biennially . Nutritional variables , anthropomorphic  measures ,  aspirin use , and self-reported CVD risk factors have been vali date d ( 2025 ) . We calculated person-years of follow-up from the date of return of the 1986 question naire ( for men with hypertension at baseline ) or date of diagnosis of hypertension ( for incident cases of hypertension ) to the date of the first CVD event , the date of death , or 31 January 2002 . We used Cox proportional hazards models with time-varying covariates to estimate hazard ratios for categories of alcohol intake relative to abstainers ( 26 ) . We simultaneously controlled for age ; smoking ( never , former , 1 to 14 cigarettes per day , 15 to 24 cigarettes per day , and 25 cigarettes per day ) ; BMI ( in quintiles ) ; diabetes ; hypercholesterolemia ; parental history of MI ; aspirin use ; lipid-lowering therapy ; 5 categories of leisure-time physical activity ; quintiles of energy intake ; and quintiles of energy-adjusted intake of saturated fat , trans fatty acids , folate , vitamin E , magnesium , sodium , potassium , -3 fatty acids , and dietary fiber . Alcohol consumption and dietary variables  were up date d every 4 years ; other potential confounders were up date d every 2 years . We stopped updating participants alcohol use if they developed cancer ( other than nonmelanoma skin cancer ) for all analyses . In secondary analyses for coronary heart disease outcomes , we censored participants when they developed cancer . To examine possible confounding by sociodemographic status , we adjusted for marital and employment status ( full-time , part-time , or retired ) , profession , and ethnicity in the multivariate model . We conducted tests of linear trend across categories of increasing alcohol consumption by treating the midpoints of consumption in categories as a continuous variable . The possibility of a nonlinear relation between alcohol consumption and risk for MI was examined with restricted cubic splines ( 27 ) and tested with the likelihood ratio test , comparing models with only the linear term to models with linear and cubic spline terms . None of the nonlinear models provided a statistically significantly better model-fit than Background Cardiovascular disease and type 2 diabetes are examples of chronic diseases that impose significant morbidity and mortality in the general population worldwide . Most chronic diseases are associated with underlying preventable risk factors , such as elevated blood pressure , high blood glucose or glucose intolerance , high lipid levels , physical inactivity , excessive sedentary behaviours , and overweight/obesity . The occurrence of intermediate outcomes during childhood increases the risk of disease in adulthood . Sugar-sweetened beverages are known to be significant sources of additional caloric intake , and given recent attention to their contribution in the development of chronic diseases , a systematic review is warranted . We will assess whether the consumption of sugar-sweetened beverages in children is associated with adverse health outcomes and what the potential moderating factors are . Methods / Design Of interest are studies addressing sugar-sweetened beverage consumption , taking a broad perspective . Both direct consumption studies as well as those evaluating interventions that influence consumption ( e.g. school policy , educational ) will be relevant . Non-specific or multi-faceted behavioural , educational , or policy interventions may also be included subject to the level of evidence that exists for the other interventions /exposures . Comparisons of interest and endpoints of interest are pre-specified . We will include r and omized controlled trials , controlled clinical trials , interrupted time series studies , controlled before-after studies , prospect i ve and retrospective comparative cohort studies , case – control studies , and nested case – control design s. The MEDLINE ® , Embase , The Cochrane Library , CINAHL , ERIC , and PsycINFO ® data bases and grey literature sources will be search ed . The processes for selecting studies , abstract ing data , and resolving conflicts are described . We will assess risk of bias using design -specific tools . To determine sets of confounding variables that should be adjusted for , we have developed causal directed acyclic graphs and will use those to inform our risk of bias assessment s. Meta- analysis will be conducted where appropriate ; parameters for exploring statistical heterogeneity and effect modifiers are pre-specified . The Grading of Recommendations Assessment , Development and Evaluation ( GRADE ) approach will be used to determine the quality of evidence for outcomes . Systematic review registration PROSPERO CRD42014009641 BACKGROUND AND PURPOSE Information regarding risk factors for early recurrence is limited . Our aim was to identify the clinical predictors of early recurrence after ischemic stroke . METHODS We prospect ively examined 297 patients ( mean age , 72.0+/-8.4 years ) hospitalized with ischemic stroke to identify recurrent strokes occurring within 90 days of the index stroke .  Survival free of recurrence was estimated using Kaplan-Meier analysis stratified by demographic variables ; vascular risk factors ; stroke syndrome , subtype , vascular territory , and severity ; scores on the Barthel Index and Mini-Mental State Examination during hospitalization ; blood pressure on admission ; and selected laboratory data . We estimated the relative risk ( RR ) of early recurrence associated with those variables using proportional hazards analysis . RESULTS We identified 22 recurrent events in the first 90 days after the index stroke , result ing in an early stroke recurrence rate of 7.4 % , and death occurred immediately after recurrence in 6 of the 22 patients . A major hemispheric stroke syndrome ( RR=2.9 ; 95 % confidence interval [CI]=1.2 to 7.1 ) , atherothrombotic stroke mechanism ( RR=3.3 ; CI=1.3 to 8.3 ) , and atrial fibrillation ( RR=2.2 ; CI=0.8 to 6.1 ) were independent predictors of early recurrence , after adjustment for demographic variables . Conclusions -Early recurrence was frequent and result ed in increased mortality . Attention to the clinical features of the index stroke , including the presenting syndrome and the ischemic mechanism , and the recognition of atrial fibrillation may help in the selection of patients for the initiation of targeted interventions to prevent early recurrence and subsequent mortality Context Past studies do n't clearly show that alcohol consumption affects the risk for ischemic stroke . Contribution This prospect i ve cohort study involving 38156 male health professionals followed for 14 years found that consuming more than 2 drinks daily was associated with an increased risk for ischemic stroke . Two drinks or fewer were not associated with increased risk .  Consuming red wine , but not other beverage types , was associated with a lower risk . Caution s The study had limited power to determine the precise drinking patterns that were associated with stroke risk . Implication s These findings support public health recommendations to avoid consuming more than 2 drinks daily . The Editors Although epidemiologic studies consistently link moderate alcohol consumption with a lower risk for myocardial infa rct ion ( 1 ) , the relationship between alcohol consumption and ischemic stroke is less clear . However , previous studies of alcohol consumption and ischemic stroke have often had important limitations , including failure to assess drinking pattern , assessment s of alcohol intake that have not been vali date d , failure to distinguish stroke subtypes , insufficient follow-up to incorporate changes in alcohol use over time , and lack of control for various healthy lifestyle features associated with moderate drinking ( 2 , 3 ) . Another area of controversy is the role of beverage type . Red wine contains specific phenolic compounds that may prevent oxidation of low-density lipoprotein cholesterol and inhibit smooth-muscle cell proliferation ( 4 , 5 ) . In keeping with these experimental findings , the Copenhagen City Heart Study reported that consumption of wine , but not of beer or liquor , was associated with a lower risk for stroke ( mostly ischemic ) ( 6 ) . However , a healthier lifestyle among wine drinkers , rather than the nonalcoholic components of wine , may explain the apparent benefits attributable to wine ( 7 ) . Most previous studies of alcohol and ischemic stroke did not account for dietary and other lifestyle differences among wine drinkers , drinkers of other alcoholic beverages , and abstainers . To address these questions , we studied the relationship between alcohol consumption and incident ischemic stroke over a 14-year period among 38156 participants of the Health Professionals Follow-up Study ( 8) , a prospect i ve cohort of male health professionals in the United States . In these analyses , we assessed how drinking pattern , baseline and up date d measures of alcohol consumption , and individual beverage types influence the association of alcohol consumption with risk for ischemic stroke . Methods The Health Professionals Follow-up Study enrolled 51529 U.S. male dentists , veterinarians , optometrists , pharmacists , osteopathic physicians , and podiatrists 40 to 75 years of age who returned a mailed question naire regarding diet and medical history in 1986 . Follow-up question naires were sent biennially to up date information on exposures and newly diagnosed illnesses . For this analysis , we excluded 5544 men who reported a baseline history of cardiovascular disease or cancer ( other than nonmelanoma skin cancer ) , 1706 who had missing or implausible nutritional information at baseline ( including missing alcohol consumption , 70 missing food items , or estimated daily energy intake 800 or 4200 kcal ) , and 89 whose initial question naires had other technical problems . To minimize the inclusion of sick quitters , we also excluded 6034 men who consumed no alcohol at baseline but who reported that they had consumed alcohol in the previous 10 years , leaving 38156 men eligible for analysis . We assessed alcohol consumption within a 131-item semi-quantitative food-frequency question naire . The question naire included separate items about beer , white wine , red wine , and liquor . We specified st and ard portions as a glass , bottle , or can of beer ; a 4-ounce glass of wine ; and a shot of liquor . For each beverage , participants were asked how often , on average over the past year , they consumed that amount . We calculated ethanol intake by multiplying the frequency of consumption of each beverage by the alcohol content of the specified portion size ( 12.8 g for beer , 11.0 g for wine , and 14.0 g for liquor ) and summing across beverages ( 9 ) . This process was repeated in 1990 , 1994 , and 1998 , with an added item about light beer in 1994 . In 1986 , men also reported the number of days per week that they typically drank any form of alcohol . We previously assessed the validity of alcohol consumption estimated with the food-frequency question naire by comparing it with intake from two 1-week dietary records collected approximately 6 months apart among 136 participants residing in eastern Massachusetts ( 10 , 11 ) ; the Spearman correlation coefficient between these 2 measures was 0.86 . Estimated mean alcohol intake was 12.8 g/d using dietary records and 12.5 g/d with the food-frequency question naire , with no evidence of apparent systematic bias . The correlation coefficient for drinking frequency between our question naire and diet records was 0.79 . Alcohol consumption estimated from the question naires also correlated well with serum high-density lipoprotein cholesterol concentrations , with a Spearman correlation coefficient of 0.31 to 0.35 . We wrote to participants who reported an incident stroke on the follow-up question naires to confirm the report and request permission to review medical records . We defined a stroke as confirmed if it produced a typical neurologic deficit of rapid or sudden onset lasting 24 hours or more and was attributable to a cerebrovascular event . Physicians blinded to risk factor status conducted the medical record review . We defined a stroke as probable if we could not obtain medical records but the participant required hospitalization and the diagnosis was corroborated by supplementary correspondence ; only 1.2 % of included cases were considered probable rather than confirmed , and their exclusion did not affect our results . We categorized stroke types according to National Survey of Stroke criteria ( 12 ) , with categories of ischemic ( embolic or thrombotic ) , hemorrhagic ( subarachnoid or intracerebral ) , and unknown . We confirmed fatal strokes by using medical records ( 84 % ) , autopsy reports ( 2 % ) , or death certificates supplemented by confirmatory evidence from family members or previously collected medical history when medical records and autopsy reports were unavailable ( 14 % ) . There were too few cases of hemorrhagic stroke to study it separately in these analyses . Deaths were reported by families and postal officials and through the National Death Index . Follow-up for deaths was over 98 % complete when these sources were combined in a similar study among women ( 13 ) . Covariate information was generally derived from biennial question naires . Nutritional information ( energy , saturated fat , trans fatty acids , folate , vitamin E , magnesium , potassium , -3 fatty acids , dietary fiber , and caffeine ) was derived from food-frequency question naires administered every 4 years . Participants reported the presence of cardiovascular risk factors ( physician-diagnosed hypertension , diabetes , and hypercholesterolemia ; cigarette smoking ; and parental history of myocardial infa rct ion ) . Aspirin use included use of aspirin and aspirin-containing products at least twice weekly . Nutritional variables , anthropomorphic measures , aspirin use , and self-reported cardiovascular risk factors have been vali date d ( 14 - 19 ) . We calculated person-years for each participant from the date of return of the 1986 question naire to the date of the first stroke , the date of death , or January 2000 . We calculated incidence rates by dividing the number of ischemic strokes in each category by person-years of follow-up in that category . The relative risk was computed as the rate in a specific category of alcohol consumption divided by the rate in abstainers , with direct adjustment for age in 5-year categories and smoking in 6 categories ( never , former , 1 to 14 cigarettes/d , 15 to 24 cigarettes/d , 25 cigarettes/d , and missing ) . As in previous multivariate analyses ( 20 ) , we used pooled logistic regression and up date d covariates ( 21 ) . We simultaneously controlled for age ; smoking ; body mass index ( in quintiles ) ; aspirin use ; diabetes ; hypercholesterolemia ; average daily exertion ( in 5 categories ) ; energy intake ( in quintiles ) ; parental history of myocardial infa rct ion at or before age 60 years ; and energy-adjusted intake of saturated fat , trans fatty acids , folate , vitamin E , and dietary fiber ( each in quintiles ) , along with geographic region ( in 4 categories ) ( 22 ) and energy-adjusted intake of magnesium and potassium ( 23 ) and -3 fatty acids ( 24 ) . We did not include hypertension as a covariate in primary analyses but included it in sensitivity analyses to assess the degree to which it may mediate a positive association between alcohol use and risk for stroke . Dietary variables  were up date d every 4 years ; other potential confounding variables were up date d every 2 years . We assigned indicator variables where smoking or exercise information was missing , accounting for 12 % and 15 % of cumulative person-time , respectively . We stopped updating alcohol use at development of cancer ( other than nonmelanoma skin cancer ) , cardiovascular disease ( other than stroke ) , or hypertension ; analyses that censored participants at diagnosis of cancer or cardiovascular disease yielded similar results ( Appendix Table 1 ) . We conducted tests of linear trend across increasing categories of alcohol consumption by treating the midpoints of consumption in categories as a continuous variable . In most analyses , we categorized participants as abstainers , light drinkers ( 0.1 to 9.9 g/d ) , moderate drinkers ( 10 to 29.9 g/d ) , and heavier drinkers ( 30.0 g/d ) . These categories approximately correspond to average intake of no alcohol , less than 1 st and ard drink per day , 1 to 2 drinks per day , and more than 2 drinks per day . We performed primary analyses by OBJECTIVE This prospect i ve study will evaluate the socioeconomic factors responsible for the discontinuation of secondary preventive treatment of stroke in India and its outcome . DESIGN S METHODS : A total of 1212 stroke patients ( male=708 , mean age 58 ± 2 years ; female=504 , mean age 56 ± 2 years ; intra-cerebral haemorrhage=496 ; ischaemic=716 ) were enrolled in the stroke clinic for secondary preventive treatment from 1st January 2006 to 1st January 2008 and were followed up at 4 - 6-week intervals . Among them , 512 patients were grouped as being below the poverty line .  Discontinuation of treatment for more than 2 weeks by a patient placed that patient in a group labelled discontinued . Outcomes of discontinuation of secondary preventive treatment were evaluated with respect to ( 1 ) control of risk factors , ( 2 ) recurrence of stroke , and ( 3 ) mortality rate . Reasons for the discontinuation were comparatively analysed with respect to awareness , education , economy , distance , and daily cost of treatment , types of stroke and disability status . RESULTS AND ANALYSIS During the study period of 2 years , the following was observed : 420 patients ( 34.65 % ) discontinued secondary preventive treatment ; 112 patients ( 9.24 % ) dropped out ; 680 patients ( 56.10 % ) continued . Chi-square and null hypothesis procedures were applied for statistical analysis . Distance , economy , poor awareness on stroke , low educational level , types of stroke , cost of treatment and disability status all were significant factors in the discontinuation of treatment . The discontinued group had poor control of risk factors , higher recurrence of both types of stroke and higher mortality . CONCLUSIONS Discontinuation of secondary preventive treatment due to diverse socioeconomic factors results in greater recurrence and disabilities among stroke survivors , and these findings should be reported to national and international planning authorities to strengthen preventive measures to achieve better outcomes and reductions of the stroke burden globally BACKGROUND CTX0E03 is an immortalised human neural stem-cell line from which a drug product ( CTX-DP ) was developed for allogeneic therapy . Dose-dependent improvement in sensorimotor function in rats implanted with CTX-DP 4 weeks after middle cerebral artery occlusion stroke prompted investigation of the safety and tolerability of this treatment in stroke patients . METHODS We did an open-label , single-site , dose-escalation study . Men aged 60 years or older with stable disability ( National Institutes of Health Stroke Scale [ NIHSS ] score ≥6 and modified Rankin Scale score 2 - 4 ) 6 - 60 months after ischaemic stroke  were implanted with single doses of 2 million , 5 million , 10 million , or 20 million cells by stereotactic ipsilateral putamen injection . Clinical and brain imaging data were collected over 2 years . The primary endpoint was safety ( adverse events and neurological change ) . This trial is registered with Clinical Trials.gov , number NCT01151124 . FINDINGS 13 men were recruited between September , 2010 , and January , 2013 , of whom 11 ( mean age 69 years , range 60 - 82 ) received CTX-DP  . Median NIHSS score before implantation was 7 ( IQR 6 - 8 ) and the mean time from stroke was 29 ( SD 14 ) months . Three men had subcortical infa rcts only and seven had right-hemisphere infa rcts .  No immunological or cell-related adverse events were seen . Other adverse events were related to the procedure or comorbidities . Hyperintensity around the injection tracts on T2-weighted fluid-attenuation inversion recovery MRI was seen in five patients . At 2 years , improvement in NIHSS score ranged from 0 to 5 ( median 2 ) points . INTERPRETATION Single intracerebral doses of CTX-DP up to 20 million cells induced no adverse events and were associated with improved neurological function . Our observations support further investigation of CTX-DP in stroke patients . FUNDING ReNeuron Limited Background Coronary Heart Disease and Cerebrovascular Disease share many predisposing , modifiable risk factors ( hypertension , abnormal blood lipids and lipoproteins , cigarette smoking , physical inactivity , obesity and diabetes mellitus ) . Lifestyle interventions and pharmacological therapy are recognised as the cornerstones of secondary prevention . Cochrane review has proven the benefits of programmes incorporating exercise and lifestyle counselling in the cardiac disease population . A Cochrane review highlighted as priority , the need to establish feasibility and efficacy of exercise based interventions for Cerebrovascular Disease . Methods A single blind r and omised controlled trial is proposed to examine a primary care cardiac rehabilitation programme for adults post transient ischemic attack ( TIA ) and stroke in effecting a positive change in the primary outcome measures of cardiac risk scores derived from Blood Pressure , lipid profile , smoking and diabetic status and lifestyle factors of habitual smoking , exercise and healthy eating participation . Secondary outcomes of interest include health related quality of life as measured by the Hospital Anxiety and Depression Scale , the Stroke Specific Quality of Life scale and WONCA COOP Functional Health Status charts and cardiovascular fitness as measured by a sub-maximal fitness test .  A total of 144 patients , over 18 years of age with confirmed diagnosis of ischaemic stroke or TIA , will be recruited from Dublin community stroke services and two tertiary T.I.A clinics . Exclusion criteria will include oxygen dependence , unstable cardiac conditions , uncontrolled diabetes , major medical conditions , claudication , febrile illness , pregnancy or cognitive impairment . Participants will be block-statified , r and omly allocated to one of two groups using a pre-prepared computer generated r and omisation schedule . Both groups will receive a two hour education class on  risk reduction  post stroke  .  The intervention group will receive a 10 week programme of supervised aerobic exercises ( twice weekly ) and individually tailored brief intervention lifestyle counselling . Both groups will be tested on week one and week ten of the programme . Follow-up at 1 year will assess longer term benefits . Analysis will test for significant changes in the key variables indicated . Discussion Application of the Cardiac Rehabilitation paradigm to patients with ischaemic stroke or TIA has not been explored despite the obvious overlap in aetiology . It is hoped the anticipated improvement in vascular risk factors and fitness result ing from such a programme will enhance health and social gain in this population .Trial Registration Current Controlled Trials ISCTRN90272638 Background — The combination of healthy lifestyle factors is associated with lower risk of coronary heart disease , diabetes , and total cardiovascular disease . Little is known about the impact of multiple lifestyle factors on the risk of stroke . Methods and Results — We conducted a prospect i ve cohort study among 43 685 men from the Health Professionals Follow-up Study and 71 243 women from the Nurses ’ Health Study .  Diet and other lifestyle factors  were up date d from self-reported question naires . We defined a low-risk lifestyle as not smoking , a body mass index < 25 kg/m2 , ≥30 min/d of moderate activity , modest alcohol consumption ( men , 5 to 30 g/d ; women , 5 to 15 g/d ) , and scoring within the top 40 % of a healthy diet score . We documented 1559 strokes ( 853 ischemic , 278 hemorrhagic ) among women and 994 strokes ( 600 ischemic , 161 hemorrhagic ) among men during follow-up . Women with all 5 low-risk factors had a relative risk of 0.21 ( 95 % confidence interval [ CI ] , 0.12 , 0.36 ) for total and 0.19 ( 95 % CI , 0.09 , 0.40 ) for ischemic stroke compared with women who had none of these factors . Among men , the relative risks were 0.31 ( 95 % CI , 0.19 , 0.53 ) for total and 0.20 ( 95 % CI , 0.10 , 0.42 ) for ischemic stroke for the same comparison . Among the women , 47 % ( 95 % CI , 18 to 69 ) of total and 54 % ( 95 % CI , 15 to 78 % ) of ischemic stroke cases were attributable to lack of adherence to a low-risk lifestyle ; among the men , 35 % ( 95 % CI , 7 to 58 ) of total and 52 % ( 95 % CI , 19 to 75 ) of ischemic stroke may have been prevented . Conclusion — A low-risk lifestyle that is associated with a reduced risk of multiple chronic diseases also may be beneficial in the prevention of stroke , especially ischemic stroke
Conclusions Stroke secondary prevention lifestyle interventions are effective in terms of affecting positive change in relation to lifestyle behaviours , physiological and secondary outcomes .
However , there was insufficient evidence to determine the effect of intervention on incidence of stroke recurrence .
EXECUTIVE SUMMARY Background Each year , approximately 15 million people worldwide have a stroke ; of these , five million die and another five million are chronically disabled .
Stroke recurs in approximately 25 % of patients during the first five years post-stroke ; recurrence may result in death , increased disability or institutionalisation .
Modifiable risk factors for recurrent stroke have been identified , and may be addressed by means of behavioural health promotion interventions .
Objectives This systematic review sought to establish the effectiveness of secondary prevention behavioural interventions , which address one or more modifiable lifestyle risk factors for recurrent stroke i.e. tobacco use , unhealthy diet , physical inactivity and excessive alcohol consumption .