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Background Throughout the COVID-19 pandemic, older adults have been prioritized in public health campaigns to limit social interactions and ‘cocoon’ in their homes. This limits the autonomy of older people and may have unintended adverse consequences. Aims To ascertain the self-reported physical and psychological effects of ‘cocooning’ and the expressed priorities of older adults themselves during the pandemic. Methods This is a cross-sectional, survey-based study involving 93 patients aged 65 and older, attending geriatric medicine out-patient and ambulatory day hospital services or our in-patient rehabilitation units. Demographic data was obtained from the medical records. Frailty level was calculated using the Clinical Frailty Scale (CFS), and disease burden was calculated with the Charlson Comorbidity Index. Results Mean age was 79.1 (range 66–96), 24% had dementia, and most were mildly frail (CFS 0.001). Respondents worried more about the risks of COVID-19 to their family than themselves. Expressed priorities varied from ‘enjoying life as much as possible’ to ‘protecting the development of children’. Conclusions Adverse consequences of ‘cocooning’ were commonly expressed amongst older adults. Public health policy should take into account the heterogeneity of this population and be sensitive to their self-expressed wishes and priorities. Supplementary information The online version contains supplementary material available at 10.1007/s11845-021-02804-y.

AIMS Recent increases in the number of patients with atrial fibrillation (AF) prescribed oral anticoagulants (OAC) are evident in Ireland and internationally, largely due to the availability of direct oral anticoagulants (DOACs). This study aimed to determine the rate of stroke in the context of increasing anticoagulation utilisation, with a focus on AF-related ischaemic stroke (IS). METHODS Dispensing data for OACs were identified for the period 2010-2018 as well as hospital discharges for IS (2005-2018). Irish National Stroke Register data were used to elucidate the characteristics of patients with acute ischaemic stroke. RESULTS The number of patients prescribed OACs increased by 94% from 2010-2018 with a significant change from 2013 (β = 2.57, P = .038), associated with a large increase in the number of patients on DOACs. There was 3.3-fold increase in expenditure on OACs nationally from 2013 to 2018, of which 94% was DOAC related. Using the 2013 timepoint, ischaemic stroke rates until 2018 did not show a significant deviation from the previous trend (β = 0.00, P = .898). The percentage of AF-related ischaemic stroke was stable from 2013 to 2017 with a 4.5% decrease in 2018. The percentage of ischaemic stroke patients with previously diagnosed AF decreased from 2013 to 2018; however, there was an increase in the percentage of ischaemic strokes while on OAC in this cohort. CONCLUSION Large increases in OAC utilisation have not resulted in changes in ischaemic stroke rates at a national level. The percentage of ischaemic strokes with a previous diagnosis of AF has decreased indicating a possible benefit from greater OAC utilisation. However, the percentage presenting with an ischaemic stroke while on OAC treatment is increasing. The increase in patients presenting with stroke while treated with OAC may largely reflect the national increase in patients prescribed DOACs but the findings raise concerns about treatment failures. The real-world effectiveness of DOACs requires further examination.

Background Recent randomised trials showed benefit for anti-inflammatory therapies in coronary disease but excluded stroke. The prognostic value of blood inflammatory markers after stroke is uncertain and guidelines do not recommend their routine measurement for risk stratification. Methods We performed a systematic review and meta-analysis of studies investigating the association of C-reactive protein (CRP), interleukin-6 (IL-6) and fibrinogen and risk of recurrent stroke or major vascular events (MVEs). We searched EMBASE and Ovid Medline until 10/1/19. Random-effects meta-analysis was performed for studies reporting comparable effect measures. Results Of 2,515 reports identified, 39 met eligibility criteria (IL-6, n = 10; CRP, n = 33; fibrinogen, n = 16). An association with recurrent stroke was reported in 12/26 studies (CRP), 2/11 (fibrinogen) and 3/6 (IL-6). On random-effects meta-analysis of comparable studies, CRP was associated with an increased risk of recurrent stroke [pooled hazard ratio (HR) per 1 standard-deviation (SD) increase in loge-CRP (1.14, 95% CI 1.06-1.22, p Conclusion Despite evidence suggesting an association between inflammatory markers and post-stroke vascular recurrence, substantial methodological heterogeneity was apparent between studies. Individual-patient pooled analysis and standardisation of methods are needed to determine the prognostic role of blood inflammatory markers and to improve patient selection for randomised trials of inflammatory therapies.

Introduction Evidence regarding safety and efficacy of oral anticoagulants for the treatment of atrial fibrillation (AFib) in older adults has been assessed regarding the age appropriateness of oral anticoagulants (OAC) according to the FORTA (Fit fOR The Aged) classification (OAC-FORTA). Three years after its first version (OAC-FORTA 2016), an update was initiated to create OAC-FORTA 2019. Methods A structured review of randomized controlled clinical trials and summaries of individual product characteristics was performed to detect newly emerged evidence on oral anticoagulants in older patients with AFib. This review was used by an interdisciplinary panel of European experts (N = 10) in a Delphi process to label OACs according to FORTA. Results A total of 202 records were identified and 11 studies finally included. We found four new trials providing relevant data on efficacy and safety of warfarin, apixaban, dabigatran or rivaroxaban in older patients with AFib. In the majority of studies comparing the non-vitamin-K oral anticoagulants (NOACs) with warfarin, NOACs were superior to warfarin regarding at least one relevant clinical endpoint. The mean consensus coefficient significantly increased from 0.867 (OAC-FORTA 2016) to 0.931 (p 0.8). Warfarin, dabigatran, edoxaban and rivaroxaban were assigned to the FORTA B label, acenocoumarol, fluindione and phenprocoumon were labeled FORTA C and only apixaban was rated as FORTA A. Conclusion OAC-FORTA 2019 confirms that AFib can be successfully treated with positively labeled antithrombotics at advanced age. Electronic supplementary material The online version of this article (10.1007/s40266-020-00771-0) contains supplementary material, which is available to authorized users.

Background Inflammation is thought to play an important role in atherosclerotic stroke mechanisms. There is growing interest in the prognostic role of inflammatory biomarkers as risk factors for recurrent vascular events, after ischaemic stroke or transient ischaemic attack (TIA). Elevated fibrinogen levels are independently-associated with the risk of first-ever stroke. However, the prognostic value of fibrinogen, after ischaemic cerebrovascular events is uncertain. Methods We searched EMBASE and Ovid Medline, from 1970-January 2019, for any study that measured Fibrinogen after stroke or TIA, and related it to the risk of recurrent stroke or recurrent vascular events. All records were assessed by 2 independent reviewers. Any disagreements between authors regarding eligibility were resolved by consensus. Results We identified 2,520 publications, of which, 15 articles from 16 individual studies were eligible (11 observational cohorts, 3 cohort studies within randomized control trials, 2 case-control studies). The sample size for recurrent stroke and recurrent vascular events was 9,963 and 7,381 patients, in 11 and 10 studies, respectively. The time from event to phlebotomy was 90 days in 5 studies, respectively. There was marked heterogeneity in statistical methodologies employed to examine the relationship between fibrinogen and outcomes, which did not allow valid meta-analysis (above/below specified threshold (n=4), differences in means/medians (n=5), risk per unit increase (n=1), per standard deviation (n=3), per quartile (n=1), per decile (n=1) or not specified (n=1)). 4 studies adjusted for all conventional vascular risk factors (age, smoking, diabetes, hypercholesterolaemia/statin use, and hypertension). 2 of 11 studies found a positive association with recurrent stroke. 5 of 10 studies found a positive association with recurrent vascular events. Conclusion The prognostic value of Fibrinogen after stroke or TIA remains unclear. Standardised methods and fully-adjusted multivariable analysis are needed in future prognostic studies.

Background Executive skills refer to a set of cognitive skills that allow individuals to engage in goal directed behavior. They encompass planning, initiation, inhibition, monitoring and flexibility in approach to tasks, and are necessary for functional competence. Executive skills are vulnerable to disruption with damage to the brain, as occurs with dementia. Methods Participants were recruited from a tertiary memory assessment and support Service. The Assessment of Motor & Process Skills (AMPS), a standardised observational assessment of occupational performance (1Fischer, 2003) was administered by trained Occupational Therapists. In addition, the EXIT-25, a pen & paper based assessment of executive skills (2Royall et al, 1992) was administered. Process scores from the AMPS, and overall score from the EXIT 25 were utilised for correlation analysis. Results 22 participants, 12 male and 10 females, age range 60-91 (mean 75.5 years), was analysed using Spearman’s Rho correlation (-.2). Results did not identify a strong correlation Conclusion Dementia is commonly regarded as a disorder of memory. However, diagnosis is dependent on functional decline related to cognitive decline. The AMPS provides a formal assessment of functional skills, in terms of motor & process skills with cut off scores regarding safe independent living. The results of this study indicate that the AMPS is not associated with executive scores on formal cognitive assessments, highlighting the value of an extensive multi-component MDT approach (also incorporating history taking, imaging, bio marker testing etc.) in assessing and diagnosing a dementia.

Background Approximately one in ten strokes occur in hospital whilst the patient is hospitalised for another reason. Existing research suggests that delays in recognition of in-hospital stroke (IHS) result in poorer outcomes compared to those with community-onset stroke. We aim to describe the characteristics of an IHS population and to phenotype the patient and/or environmental factors most likely to account for delays in recognition and response times. Methods Patients diagnosed with having an ischemic stroke while admitted to hospital for a non-stroke reason were identified through our hospital's stroke registry. We collected patient demographics along with the ward and service they were admitted under and if they underwent any invasive procedures prior to the stroke event. The patient cohort was dichotomised based on patient specific or environmental factors. We then calculated the likelihood of symptom recognition, medical review, and neuroimaging occurring within the 4.5 hour thrombolysis window between the two groups using the chi squared test. Results Fifty IHS occurred in the study time period. 52% were male, average age 74 (SD 12.7 years). 34 (68%) were admitted medically, and 16 (32%) surgically. 27 (54%) were assessed within the time frame for thrombolysis. Of these, seven received acute stroke treatment and the remaining 19 had contraindications to treatment. Patients presenting with collapse (67% vs 4%, p=0.011), limb weakness (85% vs 52%, p=0.011) or aphasia (63% vs 9%, p=0.019) were more likely to be recognised. Patients whose symptoms were recognised by a non-staff member (52% vs 78%, p=0.026) and those presenting out of hours (56% vs 70%, p=0.047) or with delirium (85% vs 39%, 0.051) were more likely to be missed. Conclusion In-hospital strokes are frequently missed due to the complexities of the patients involved. Education programs targeted at enhancing stroke pickup among hospital staff could potentially decrease delays and improve patient outcomes.

Background Current evidence strongly implicates the burden of vascular risk factors (VRF) in the development of stroke, cognitive decline and dementia. This effect is mediated through several mechanisms, including amyloidogenesis, chronic neuroinflamation, cerebral perfusion and white-matter changes. Vascular risk profiling is well-embedded in stroke and cardiac services, but less so in memory services. Methods A review of established modifiable VRF (hypercholesterolemia, Body Mass Index (BMI), hypertension, HbA1c, smoking and alcohol habits) of people with mild cognitive complaints (mild cognitive impairment and subjective memory decline) in a memory service was performed. Risk factors measured in clinic were classified as: systolic ≥140mmHg / diastolic ≥90mmHg hypertension; LDL cholesterol >3mmol/l; HbA1c >39mmol/mol; weekly alcohol >21units; smoking and BMI >24.9kg/m2. Data was recorded and analysed using Microsoft Excel. Results Thirty-seven people, including 16 females (mean age 71.4, range of 49-83 years), were reviewed. 13/37 (35%) were aged ≤69 years. A total of 91 VRFs were identified in the study population. 29/37 (78%) had ≥2 VRF present. 3/37 (8%) had five VRF. 18/37 (49%) had prior history of either stroke, vascular or heart disease. Five of thirty-seven, (13.5%) and 13/37 (35%) were current and ex-smokers respectively, 2/37 (5%) consumed excess alcohol, 24/37 (65%) had elevated BMI and 11/37 (30%) had elevated LDL cholesterol. 21/37 (57%) had hypertension. Of these, 11/21 were known but poorly-controlled and 10/21 were identified de novo. All of the 32% (12/37) who had hyperglycaemia were de novo. Conclusion This study highlights the high prevalence of unidentified or poorly controlled VRF in people with mild cognitive symptoms attending a memory service. Given its importance to brain health and mitigation of future cognitive decline, a structured focus on identifying and managing these VRF in this setting is necessary. Exercise-based lifestyle programs should be embedded in post-diagnostic services for this population.

Background Stroke aetiology, risk factors and outcomes vary among ethnic groups. The profile of patients presenting to hospital with stroke in Ireland is changing as immigration increases. We aim to describe differences that exist between a multi-ethnic immigrant population and native Irish residents. Methods Using our hospital's stroke registry we identified all non-Irish (NI) patients admitted to the stroke unit over a two year period through surname recognition (N=44). Country of birth was confirmed by a chart review. The Irish patients admitted over the same time frame were used as a comparison group (N=437). Data was collected on stroke subtype and outcomes, comorbidities, and socioeconomic factors. Patients were grouped based on ethnicity and stroke subtype. Chi squared test was used to analyze the relationship between groups. Results NI patients made up 9.1% of all stroke unit admissions. NI patients were younger than Irish patients (average age 57.5 vs 69.6 years, p Conclusion Our study demonstrates that NI stroke patients have a different risk factor and stroke sub-type profile compared to Irish patients. NI patients are more likely to be young, hypertensive, male, and have higher rates of ICH. Cultural and linguistic barriers may adversely influence health seeking behaviour in this group. These findings underscore the need to identify the root causes of these ethnic differences so targeted primary prevention campaigns can be established.

Background Speech and Language Therapy (SLT) is recognised as having a unique role in contributing to the overall neuropsychological assessment of people living with dementia and cognitive impairment. The role of the SLT within a memory clinic has become more widely understood. It is now recognised that speech and language characteristics are reported to be amongst the most reliable behavioural markers for distinguishing amongst different dementia subtypes, and specific analysis of a language production and delivery facilitates timely and more accurate diagnosis. Methods Patients with a language predominant presentation or those with subjective complaints of speech/language difficulties were referred for SLT assessment through the tertiary memory assessment and support service from January 2018 – March 2019. Assessment of speech and language skills, and overall cognitive communications skills were reviewed, and this information was used to aid with differential diagnosis and contribute to the person’s overall cognitive profile. The SLT attends weekly memory service interdisciplinary consensus diagnosis conference. Data was collected on these patients to observe the profiles of those patients referred to SLT. Results 22 patients were seen for full SLT assessment during this period, 13 women, 9 men; mean age 69.5 (range 48- 80). Diagnoses include: AD (32%), FTD behavioural variant (14%), Primary Progressive Aphasia (14%), Non-amnestic MCI (18%), Amnestic MCI (14%), Other neurological disorder (8%). 68% of these patients required ongoing SLT intervention for their cognitive communication difficulties following diagnosis. Conclusion SLTs fulfil an integral role in supporting both the diagnostic and post-diagnostic care pathways of people living with dementia and cognitive impairment attending memory services. SLTs have a unique role and skillset in identifying the specific nature of language difficulties for a person with dementia or cognitive impairment and in reducing the impact of the communication difficulties for the person and for their family members.

WOS: 000469346800032, PubMed: 30626285, Background and Purpose-Increased blood pressure (BP), heart rate, and their derivatives (variability, pulse pressure, rate-pressure product) are associated with poor clinical outcome in acute stroke. We assessed the effects of glyceryl trinitrate (GTN) on hemodynamic parameters and these on outcome in participants in the ENOS trial (Efficacy of Nitric Oxide in Stroke). Methods-Four thousand and eleven patients with acute stroke and raised BP were randomized within 48 hours of onset to transdermal GTN or no GTN for 7 days. Peripheral hemodynamics were measured at baseline (3 measures) and daily (2 measures) during treatment. Between-visit BP variability over days 1 to 7 (as SD) was assessed in quintiles. Functional outcome was assessed as modified Rankin Scale and cognition as telephone mini-mental state examination at day 90. Analyses were adjusted for baseline prognostic variables. Data are mean difference or odds ratios with 95% CI. Results-Increased baseline BP (diastolic, variability), heart rate, and rate-pressure product were each associated with unfavorable functional outcome at day 90. Increased between-visit systolic BP variability was associated with an unfavourable shift in modified Rankin Scale (highest quintile adjusted odds ratio, 1.65; 95% CI, 1.37-1.99), worse cognitive scores (telephone mini-mental state examination: highest quintile adjusted mean difference, -2.03; 95% CI, -2.84 to -1.22), and increased odds of death at day 90 (highest quintile adjusted odds ratio, 1.57; 95% CI, 1.12-2.19). GTN lowered BP and rate-pressure product and increased heart rate at day 1 and reduced between-visit systolic BP variability. Conclusions-Increased between-visit BP variability was associated with poor functional and cognitive outcomes and increased death 90 days after acute stroke. In addition to lowering BP and rate-pressure product, GTN reduced betweenvisit systolic BP variability. Agents that lower BP variability in acute stroke require further study., British United Provident Association UK Foundation; National Institute for Health Research TARDIS [10/104/24]; British Heart Foundation RIGHT-2 (Rapid Intervention With Glyceryl Trinitrate in Hypertensive Stroke Trial 2) [CS/14/4/30972]; Medical Research CouncilMedical Research Council UK (MRC) [G0501797], ENOS (Efficacy of Nitric Oxide in Stroke) was funded by the British United Provident Association UK Foundation and Medical Research Council (G0501797). J.P. Appleton is funded by National Institute for Health Research TARDIS (10/104/24) trial (Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke) and British Heart Foundation RIGHT-2 (Rapid Intervention With Glyceryl Trinitrate in Hypertensive Stroke Trial 2; CS/14/4/30972).

Background: Central adjudication of stroke type is commonly implemented in large multicentre clinical trials. We investigated the effect of central adjudication of diagnosis of stroke type at trial entry in the Efficacy of Nitric Oxide in Stroke (ENOS) trial. Methods: ENOS recruited patients with acute ischaemic or haemorrhagic stroke, and diagnostic adjudication was carried out using cranial scans. For this study, diagnoses made by local site clinicians were compared with those by central, masked adjudicators using kappa statistics. The trial primary analysis and subgroup analysis by stroke type were re-analysed using stroke diagnosis made by local clinicians, and simulations were used to assess the impact of increased non-differential misclassification and subgroup effects. Results: Agreement on stroke type (Ischaemic, Intracerebral Haemorrhage, Unknown stroke type, No-stroke) was high (κ = 0.92). Adjudication of stroke type had no impact on the primary outcome or subgroup analysis by stroke type. With misclassification increased to 10 times the level observed in ENOS and a simulated subgroup effect present, adjudication would have affected trial conclusions. Conclusions: Stroke type at trial entry was diagnosed accurately by local clinicians in ENOS. Adjudication of stroke type by central adjudicators had no measurable effect on trial conclusions. Diagnostic adjudication may be important if diagnosis is complex and a treatment-diagnosis interaction is expected. Keywords: Adjudication, Diagnosis, Clinical trial, Stroke

Introduction Recent advances in stroke management and care have resulted in improved survival and outcomes. However, providing equitable access to acute care, rehabilitation and longer-term stroke care is challenging. Recent Irish evidence indicates variation in stroke outcomes across hospitals, and a need for continuous audit of stroke care to support quality improvement. The aim of this project is to develop a core minimum dataset for use in the new Irish National Audit of Stroke (INAS), which aims to improve the standard of stroke care in Ireland. This paper outlines the protocol for conducting a scoping review of international practice and guidelines in auditing acute and non-acute stroke care. Objective Identify data items that are currently collected by stroke audits internationally, and identify audit guidelines that exist for recommending inclusion of content in stroke audit datasets. Methods and analysis This scoping review will be conducted in accordance with the Preferred Reporting Items for Systematic Reviews extension for Scoping Reviews (PRISMA-ScR). We will search the following databases: Medline Ovid; Embase; CINAHL EBSCOHost. Grey literature will also be searched for relevant materials, as will relevant websites. Study selection and review will be carried out independently by two researchers, with discrepancies resolved by a third. Data charting and synthesis will involve sub-dividing relevant sources of evidence, and synthesising data into three categories: i) acute stroke care; ii) non-acute stroke care; and iii) audit data collection procedures and resourcing. Data will be charted using a standardised form specific to each category. Consultation with knowledge users will be conducted at all stages of the scoping review. Discussion This scoping review will contribute to a larger project aimed at developing an internationally benchmarked stroke audit tool that will be used prospectively to collect data on all stroke admissions in Ireland, encompassing both acute and non-acute data items.

The relationship between plaque morphology, cerebral micro-embolic signals (MES) and platelet biomarkers in carotid stenosis patients warrants investigation. We combined data from two prospective, observational studies to assess carotid plaque morphology and relationship with cerebral MES and platelet biomarkers in patients with recently symptomatic (≤4 weeks of transient ischaemic attack (TIA)/ischaemic stroke) versus asymptomatic carotid stenosis. Plaque morphology on ultrasound was graded with Grey-Scale Median (GSM) and Gray–Weale (GW) scoring. Bilateral transcranial Doppler ultrasound classified patients as ‘MES+ve’ or ‘MES-ve’. Full blood counts were analysed and flow cytometry quantified CD62P and CD63 expression, leucocyte-platelet complexes and reticulated platelets. Data from 42 recently symptomatic carotid stenosis patients were compared with those from 36 asymptomatic patients. There were no differences in median GSM scores between symptomatic and asymptomatic patients (25 vs. 30; P = 0.31) or between MES+ve vs. MES-ve symptomatic patients (36 vs. 25; P = 0.09). Symptomatic patients with GSM-echodense plaques (GSM ≥25) had higher platelet counts (228 vs. 191 × 109/L), neutrophil–platelet (3.3 vs. 2.7%), monocyte–platelet (6.3 vs. 4.55%) and lymphocyte–platelet complexes (2.91 vs. 2.53%) than ‘ asymptomatic patients with GSM-echodense plaques’ ( P ≤ 0.03). Recently, symptomatic carotid stenosis patients with ‘GSM-echodense plaques’ have enhanced platelet production/secretion/activation compared with their asymptomatic counterparts. Simultaneous assessment with neurovascular imaging and platelet biomarkers may aid risk-stratification in carotid stenosis.

Introduction Falls are common post-stroke events but their relationship with healthcare costs is unclear. The aim of this study was to examine the relationship between healthcare costs in the first year after stroke and falls among survivors discharged to the community. Patients and methods Survivors of acute stroke with planned home discharges from five large hospitals in Ireland were recruited. Falls and healthcare utilisation data were recorded using inpatient records, monthly calendars and post-discharge interviews. Cost of stroke was estimated for each participant from hospital admission for one year. The association of fall-status with overall cost was tested with multivariable linear regression analysis adjusting for pre-stroke function, stroke severity, age and living situation. Results A total of 109 stroke survivors with complete follow-up data (mean age = 68.5 years (SD = 13.5 years)) were included. Fifty-three participants (49%) fell following stroke, of whom 28 (26%) had recurrent falls. Estimated mean total healthcare cost was €20,244 (SD=€23,456). The experience of one fall and recurrent falls was independently associated with higher costs of care (p = 0.02 and p Discussion The observed relationship between falls and cost is likely to be underestimated as aids and adaptions, productivity losses, and nursing home care were not included. Conclusion This study points at differences across fall-status in several healthcare costs categories, namely the index admission, secondary/tertiary care (including inpatient re-admissions) and allied healthcare. Future research could compare the cost-effectiveness of inpatient versus community-based fall-prevention after stroke. Further studies are also required to inform post-stroke bone-health management and fracture-risk reduction.

Introduction In ischaemic stroke care, fast reperfusion is essential for disability free survival. It is unknown if bypassing thrombolysis centres in favour of endovascular thrombectomy (mothership) outweighs transport to the nearest thrombolysis centre for alteplase and then transfer for endovascular thrombectomy (drip-and-ship). We use conditional probability modelling to determine the impact of treatment times on transport decision-making for acute ischaemic stroke. Materials and methods Probability of good outcome was modelled using a previously published framework, data from the Irish National Stroke Register, and an endovascular thrombectomy registry at a tertiary referral centre in Ireland. Ireland was divided into 139 regions, transport times between each region and hospital were estimated using Google’s Distance Matrix Application Program Interface. Results were mapped using ArcGIS 10.3. Results Using current treatment times, drip-and-ship rarely predicts best outcomes. However, if door to needle times are reduced to 30 min, drip-and-ship becomes more favourable; even more so if turnaround time (time from thrombolysis to departure for the endovascular thrombectomy centre) is also reduced. Reducing door to groin puncture times predicts better outcomes with the mothership model. Discussion This is the first case study modelling pre-hospital transport for ischaemic stroke utilising real treatment times in a defined geographic area. A moderate improvement in treatment times results in significant predicted changes to the optimisation of a national acute stroke patient transport strategy. Conclusions Modelling patient transport for system-level planning is sensitive to treatment times at both thrombolysis and thrombectomy centres and has important implications for the future planning of thrombectomy services.

Background Greater numbers of older patients are accessing hospital services. Specialist geriatric input at presentation may improve outcomes for at-risk patients. The Survey of Health, Ageing and Retirement in Europe Frailty Instrument (SHARE-FI) frailty measure, developed for use in the community, has also been used in the emergency department (ED). Aim To measure frailty, review its prevalence in older patients presenting to ED and compare characteristics and outcomes of frail patients with their non-frail counterparts. Design Patient characteristics were recorded using symphony® electronic data systems. SHARE-FI assessed frailty. Cognition, delirium and 6 and 12 months outcomes were reviewed. Methods A prospective cohort study was completed of those aged ≥70 presenting to ED over 24 h, 7 days a week. Results Almost half of 198 participants (46.7%, 93/198) were classified as frail, but this was not associated with a significant difference in mortality rates (OR 0.89, 95% CI 0.58-1.38, P = 0.614) or being alive at home at 12 months (OR 1.07, 95% CI 0.72-1.57, P = 0.745). Older patients were more likely to die (OR 2.34, 95% CI 1.30-4.21, P = 0.004) and less likely to be alive at home at 12 months (OR 0.49, 95% CI 0.23-0.83, P = 0.009). Patients with dementia (OR 0.24, P = 0.005) and on ≥5 medications (OR 0.37, 95% CI 0.16-0.87, P = 0.022) had a lower likelihood of being alive at home at 12 months. Conclusions Almost half of the sample cohort was frail. Older age was a better predictor of adverse outcomes than frailty as categorized by the SHARE-FI. SHARE-FI has limited predictability when used as a frailty screening instrument in the ED.

Understanding the experiences of fallers after stroke could inform falls-prevention interventions, which have not yet shown effectiveness in this population. The aim of this study was to explore the experience of recurrent fallers post-stroke in relation to recovery and living with falls.Participants who had more than one fall in the first year after stroke were identified from a prospective cohort study. The methods of grounded theory informed data collection and analysis. Semi-structured interviews were conducted, audio-recorded and transcribed. Coding was conducted and categories were developed inductively.Nine stroke survivors aged 53-85 were interviewed 18-22 months post-discharge. Participants had experienced between 2 and 9 falls and one participant suffered a fracture. Three inter-linked categories were identified: (i) Judging the importance of falls by exploring cause and consequence, (ii) getting back up, and (iii) being careful.Stroke survivors' assessment of their own falls-risk and their individual priorities contribute to their decisions around activity participation. "Being careful" could be described as a form of self-managing falls-risk. The inclusion of self-management principles, peer-educators, and education to rise from the floor in falls-management programmes warrants investigation. Not all falls were considered equally important by participants. This could be considered when defining falls-related outcomes. Implications for Rehabilitation Healthcare professionals may be able to offer an increased sense of control to stroke survivors through education about how to avoid particular causes and consequences of falls. Falls-related advice should be specific, relevant to the individual, and respectful of their sense of identity. Being able to rise from the floor appears to be important for coping with falls and falls-risk. Professionals should be cognisant of the potential differences of opinion between stroke survivors and their families around management of falls-risk.

Background: GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation) is a prospective, global registry program describing antithrombotic t...

WOS: 000367136500008, PubMed: 26645254, Background and Purpose The Efficacy of Nitric Oxide in Stroke (ENOS) trial found that transdermal glyceryl trinitrate (GTN, a nitric oxide donor) lowered blood pressure but did not improve functional outcome in patients with acute stroke. However, GTN was associated with improved outcome if patients were randomized within 6 hours of stroke onset. Methods In this prespecified subgroup analysis, the effect of GTN (5 mg/d for 7 days) versus no GTN was studied in 629 patients with intracerebral hemorrhage presenting within 48 hours and with systolic blood pressure 140 mm Hg. The primary outcome was the modified Rankin Scale at 90 days. Results Mean blood pressure at baseline was 172/93 mm Hg and significantly lower (difference -7.5/-4.2 mm Hg; both P0.05) on day 1 in 310 patients allocated to GTN when compared with 319 randomized to no GTN. No difference in the modified Rankin Scale was observed between those receiving GTN versus no GTN (adjusted odds ratio for worse outcome with GTN, 1.04; 95% confidence interval, 0.78-1.37; P=0.84). In the subgroup of 61 patients randomized within 6 hours, GTN improved functional outcome with a shift in the modified Rankin Scale (odds ratio, 0.22; 95% confidence interval, 0.07-0.69; P=0.001). There was no significant difference in the rates of serious adverse events between GTN and no GTN. Conclusions In patients with intracerebral hemorrhage within 48 hours of onset, GTN lowered blood pressure was safe but did not improve functional outcome. Very early treatment might be beneficial but needs assessment in further studies., Bupa UK Foundation; Medical Research CouncilMedical Research Council UK (MRC) [G0501797]; Agency for Science, Technology and Research (Singapore)Agency for Science Technology & Research (ASTAR); Hypertension Trust (United Kingdom); Queen Elizabeth II Health Sciences Centre Research Fund (Canada); Reichstadt family (United Kingdom); Medical Research CouncilMedical Research Council UK (MRC) [MR/K026992/1]; National Institute for Health ResearchNational Institute for Health Research (NIHR) [NF-SI-0611-10003], Efficacy of Nitric Oxide in Stroke (ENOS) was funded by the Bupa UK Foundation and Medical Research Council (G0501797). Other funders, who supported the trial, were the Agency for Science, Technology and Research (Singapore), Hypertension Trust (United Kingdom), Queen Elizabeth II Health Sciences Centre Research Fund (Canada), and Reichstadt family (United Kingdom).

It has been found that many organisations still fail to meet the basic rights of those in their care, in terms of access to food, drink and support when they need it. In acknowledgment that food service in hospitals must be given a higher priority, and be recognised as an integral part of the patient's treatment and care, Irish hospitals must now have a system to evaluate the nutritional and hydrational care for patients admitted to hospital. The purpose of this audit was to examine the level of mealtime support available to patients during the main mealtime service in our hospital. As the audit highlighted the need to alter ward processes around the mealtime service, quality improvement initiatives were introduced. These initiatives had a positive impact, enabling ward staff to improve adequacy of mealtime support to patients, leading to better patient quality care at this time.

Background and purposeHealthcare systems are challenged to provide access to thrombectomy in acute stroke patients. Either the “drip and ship” or “mothership” models result in increased numbers of patients in the endovascular stroke centre (ESC). We describe our approach for a “drip, ship, retrieve and leave” model repatriating patients immediately or within 24 hours of thrombectomy.MethodsWe included consecutive patients who underwent thrombectomy from January 2016 to June 2018. Patients from local region primary stroke centres (PSC) are immediately repatriated and those from remote region PSCs are admitted for 24 hours before repatriation. Key parameters recorded included clinical, radiological and timeline data as well as 90-day modified Rankin Scale (mRS). Patients who stayed beyond the intended time period in the ESC were analysed.ResultsFrom January 2016 to June 2018, 435 patients were transferred, with 352 patients in the local region group and 83 in the remote region group. The median NIHSS was 16 with a median ASPECTS of 9. Good functional outcome was seen in 47% of patients with a mortality rate of 19%. The local region group that were repatriated at the intended time period had a 90-day mRS 0–2 of 47% compared with 20% of those admitted to the ESC (P=0.006). Mortality rates were 20% and 27% respectively (P=0.377). The remote region group, repatriated at 24 hours' post-emergency endovascular thrombectomy had 90-day mRS 0–2 of 65% compared with 41% in the group admitted (P=0.042). Mortality rates were 4% and 22% respectively (P=0.007).ConclusionThis model enables the treatment of large numbers of patients with large vessel occlusion acute ischaemic stroke with thrombectomy within a national stroke service and system of care which would not otherwise be facilitated.

Background Falls are a serious problem among stroke survivors due to subsequent injuries, recovery setbacks, dependence, and mortality. A growing body of dual-task (DT) studies suggests a role of executive functions in gait control and falls, particularly in subacute stroke. However, few studies have compared distinct executive and non-executive tasks, nor their effects on chronic stroke gait. Research question: The purpose of this cross-sectional study was to compare the effects of distinct working memory (2-back) and inhibition (Stroop) tasks on walking gait performance in chronic stroke survivors. Methods A pilot sample of chronic stroke survivors (n = 11, 8 males, mean age = 70.91, 6-12months post-stroke event) and age-matched healthy controls (n = 13, 4 male; mean age = 68.46) were tested. Gait performance (speed, stride time, stride time variability, stride length and stride length variability) was measured using 2 wireless inertial measurement sensors under 4 walking conditions: 1) preferred walking (single-task: ST), 2) walking with a 2-back DT, 3) walking with a Stroop DT, and 4) walking with a non-executive motor response DT. The secondary tasks were also carried out in both ST (seated) and DT conditions, to examine bidirectional effects. Results While the stroke survivor sample had a slower gait speed across conditions and tasks, there were no significant differences between the groups [F(1, 22) = 1.13, p =.299, η2p = .049] on the spatial or temporal gait characteristics recorded: gait performance was maintained during executive and non-executive DTs. In addition, we did not find a significant effect of group on cognitive task performance (all p > .052). However, we observed a cost in accuracy on the 2-back DT for both groups, suggesting resource overlap and greater cognitive load (all t > 19.72, all p Significance Our gait data contradict previous studies evidencing impaired gait post-stroke, suggesting functional recovery in this chronic stroke sample.

The current manuscript is the second update of the original Practical Guide, published in 2013 [Heidbuchel et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-651; Heidbuchel et at Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015;17:1467-1507]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with atrial fibrillation (AF) and have emerged as the preferred choice, particularly in patients newly started on anticoagulation. Both physicians and patients are becoming more accustomed to the use of these drugs in clinical practice. However, many unresolved questions on how to optimally use these agents in specific clinical situations remain. The European Heart Rhythm Association (EHRA) set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group identified 20 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 20 topics are as follows i.e., (1) Eligibility for NOACs; (2) Practical start-up and follow-up scheme for patients on NOACs; (3) Ensuring adherence to prescribed oral anticoagulant intake; (4) Switching between anticoagulant regimens; (5) Pharmacokinetics and drug-drug interactions of NOACs; (6) NOACs in patients with chronic kidney or advanced liver disease; (7) How to measure the anticoagulant effect of NOACs; (8) NOAC plasma level measurement rare indications, precautions, and potential pitfalls; (9) How to deal with dosing errors; (10) What to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a potential risk of bleeding; (11) Management of bleeding under NOAC therapy; (12) Patients undergoing a planned invasive procedure, surgery or ablation; (13) Patients requiring an urgent surgical intervention; (14) Patients with AF and coronary artery disease; (15) Avoiding confusion with NOAC dosing across indications; (16) Cardioversion in a NOAC-treated patient; (17) AF patients presenting with acute stroke while on NOACs; (18) NOACs in special situations; (19) Anticoagulation in AF patients with a malignancy; and (20) Optimizing dose adjustments of VKA. Additional information and downloads of the text and anticoagulation cards in different languages can be found on an EHRA website (www.NOACforAF.eu).

Introduction: The mechanisms responsible for the disparity in stroke risk between asymptomatic and symptomatic carotid stenosis are not fully understood. Profiles of ‘reticulated platelets’ and red cell reticulocytes in carotid stenosis patients are poorly understood. Methods: This prospective, multi-centre, observational analytical study compared full blood count parameters and platelet production/turnover biomarkers in early-phase (≤4 weeks after TIA/stroke) and late-phase (≥3 months) symptomatic versus asymptomatic moderate-severe (≥50-99%) carotid stenosis patients. Reticulated platelets were quantified by whole-blood flow cytometry and by an ‘automated assay’ (Sysmex XE-2100™). Multiple linear regression analysis controlled for the potential influence of independent variables on observed differences between groups. Results: Data from 43 early-phase symptomatic and 37 late-phase symptomatic patients were compared with 34 asymptomatic patients. The mean platelet count in citrate-anticoagulated blood was higher in early-phase (P=0.040) and late-phase symptomatic (P=0.045) than asymptomatic patients. Mean platelet volume was higher in early symptomatic than asymptomatic patients (10.8 vs . 10.45fl; P=0.04). There were no differences in % reticulated platelets between groups using flow cytometry. However, the ‘automated assay’ revealed a higher ‘unadjusted’ reticulated-platelet fraction (%RPF) in early-phase (5.78%; Pvs . asymptomatic patients (3.48%). The % red cell reticulocytes was lower in early (0.92%; P=0.035) and late symptomatic (0.93%; P=0.036) than asymptomatic patients (1.07%). Discussion: There is an ongoing stimulus to increased platelet production/secretion/reduced clearance, and an increased population of immature, potentially ‘more-reactive’ reticulated platelets in symptomatic carotid stenosis patients which may contribute to the higher risk of stroke in symptomatic vs . asymptomatic carotid stenosis.

Introduction: Cerebral microembolic signals (MES) predict increased stroke risk in carotid stenosis however micro-emboli negative symptomatic patients also demonstrate increased risk compared to asymptomatic patients. Enhanced platelet activation may contribute to this risk disparity. Methods: We performed a prospective, observational analytical study assessing platelet counts, platelet activation status, and the relationship between platelet activation and MES in asymptomatic versus symptomatic moderate (≥50-69%) or severe (≥70-99%) carotid stenosis. Full blood count measurements were performed, and whole-blood flow cytometry used to quantify platelet surface activation marker expression (CD62P and CD63) and circulating leucocyte-platelet complexes. Bilateral simultaneous Transcranial Doppler (TCD) ultrasound monitoring of the middle cerebral arteries was performed to classify patients’ MES status. Results: Complete TCD data from 28 asymptomatic patients were compared with 35 symptomatic patients in the ‘early phase’ (≤4 weeks) and 30 of these patients in the ‘late phase’ (≥3 months) after TIA/ischaemic stroke. The %MES positive patients were higher in early symptomatic (31.4%; P = 0.027), but not in late symptomatic (6.7%; P = 0.996) vs. asymptomatic patients (7.1%). There were no significant differences in platelet counts, mean platelet volume, %CD62P or %CD63 expression between early/late symptomatic and asymptomatic MES negative patients (P>0.05). There were however, a significantly higher %circulating lymphocyte-platelet complexes in early symptomatic vs. asymptomatic patients (2.7% vs. 2.17%;P=0.02) Discussion: Increased lymphocyte-platelet complex formation in recently symptomatic vs. asymptomatic MES-negative patients indicates enhanced platelet activation in this early symptomatic subgroup. Platelet biomarkers, in combination with TCD, have the potential to aid risk-stratification in carotid stenosis.

Background: People with dementia are among the most frequent service users in the acute hospital. Despite this, the acute hospital is not organized in a manner that best addresses their needs. Methods: We examined acute dementia care over a 3-year period from 2010 to 2012 in a 600-bed university hospital, to clarify the service activity and costs attributable to acute dementia care. Results: Nine hundred and twenty-nine patients with dementia were admitted during the study period, accounting for 1433/69 718 (2%) of all inpatient episodes, comprising 44 449/454 169 (10%) of total bed days. The average length of stay was 31.0 days in the dementia group and 14.1 days in those >65 years without dementia. The average hospital care cost was almost three times more (€13 832) per patient with dementia, compared with (€5404) non-dementia patients, accounting for 5% (almost €20 000 000) of the total hospital casemix budget for the period. Discussion: Service activity attributable to dementia care in the acute hospital is considerable. Moreover, given the fact that a significant minority of cognitive impairment goes unrecognized after acute admissions, it is likely that this is under-representative of the full impact of dementia in acute care. Although the money currently being spent on acute dementia care is considerable, it is being used to provide a service that does not meet its user needs adequately. It is clear that acute hospitals need to provide a more ‘dementia friendly’ service for acutely unwell older persons.

Objectives The Beers (2012) criteria and the screening tool of older persons' potentially inappropriate prescriptions (STOPP) criteria are often used to identify potentially inappropriate medication (PIM) use in elderly patients. The aim of this study is to determine the prevalence of PIM use in nursing home residents (NHRs) aged ≥65 years presenting to the Emergency Department (ED); to compare the Beers and STOPP criteria and to identify the potential role of PIMs in ED attendances. Setting The ED of an urban tertiary referral hospital. Participants Acutely unwell long-term care NHRs seeking medical assistance at the ED. Design and Measurements This is a retrospective cohort study. Demographic and clinical data were retrieved from the ED electronic record system, from the clinical records, and transfer letters for all NHRs who attended the ED in 2011. Beers 2012 and STOPP criteria were used to identify PIMs. Results Of 195 NHRs identified, 165 were included. The mean age (±standard deviation) was 82.5 (±7.7) years; 110 (66.7%) were female and 157 (95.2%) were prescribed at least 1 PIM by either criterion. One hundred forty patients (84.8%) received a PIM according to STOPP criteria and 147 (89.1%) according to the Beers criteria. In the majority of patients (148; 89.7%), there was a difference in the medications Beers and STOPP identified as inappropriate. Fifty patients (30.3%) were considered to have a link between their attendance at ED and the PIM prescribed when assessed subjectively. Objective assessment using the WHO-UMC criteria found 7 (4.2%) had a ‘probable’ link and 45 (27.3%) a ‘possible’ link. Conclusions These results show a high rate of PIM prescribing in this cohort. The use of criteria such as Beers and STOPP may be a useful guide for physicians coordinating the long-term care of NHRs and may have the potential to reduce attendances at ED.

Non-vitamin K antagonist oral anticoagulants (NOACs) are a major advance for stroke prevention in atrial fibrillation (AF). Use of the vitamin K antagonist (VKA), warfarin, has dropped 40% since 2010 in our institution. There is limited Irish hospital data on NOAC prescribing for stroke prevention. Single centre, retrospective observational cohort study of consecutive AF patients at increased risk of stroke and/or awaiting electrical cardioversion. Data on prescribed NOACs from February 2010 till July 2015 was collected from the electronic inpatient record. Appropriateness of prescriptions was based on CHA2DS2–VASC score and accuracy on individual NOAC SPCs. Potential drug interactions and bleeding risk were also quantified. A total of 348 patients AF and increased risk of stroke (CHA2DS2–VASC score > 1 for men and > 2 for women) were studied. Forty-eight percent were female with a mean age 71 ± 18.6 years, 52% of whom were > 75. Mean CHA2DS2-Vasc and HAS-BLED scores were 4.1 ± 1.8 and 1.4 ± 0.8, respectively. Rivaroxaban, dabigatran and apixaban were prescribed to 154 (54.2%), 106 (34.3%) and 41 (13.2%) patients, respectively. 20.4% had inaccurate prescriptions; 92.9% (n = 65) underdosed and 7.1% (n = 5) on inappropriately higher doses. Neither choice of NOAC, age, history of anaemia, previous bleeding or co-prescribed antiplatelets influenced the accuracy of prescription (p = NS), but decreased renal function appeared to do so (p = 0.05). Our study highlights significant inaccuracies in NOAC prescribing. Patients commenced on NOACs should be assessed and followed up in a multidisciplinary AF clinic to ensure safe and effective prescribing and stroke prevention.

Contains fulltext : 176888.pdf (Publisher’s version ) (Closed access) BACKGROUND: Age appropriateness of anticoagulants for stroke prevention in atrial fibrillation is uncertain. OBJECTIVE: To review oral anticoagulants for the treatment of atrial fibrillation in older (age >65 years) people and to classify appropriate and inappropriate drugs based on efficacy, safety and tolerability using the Fit-fOR-The-Aged (FORTA) classification. METHODS: We performed a structured comprehensive review of controlled clinical trials and summaries of individual product characteristics to assess study and total patient numbers, quality of major outcome data and data of geriatric relevance. The resulting evidence was discussed in a round table with an interdisciplinary panel of ten European experts. Decisions on age appropriateness were made using a Delphi process. RESULTS: For the eight drugs included, 380 citations were identified. The primary outcome results were reported in 32 clinical trials with explicit and relevant data on older people. Though over 24,000 patients aged >75/80 years were studied for warfarin, data on geriatric syndromes were rare (two studies reporting on frailty/falls/mental status) and missing for all other compounds. Apixaban was rated FORTA-A (highly beneficial). Other non-vitamin K antagonist oral anticoagulants (including low/high-intensity dabigatran and high-intensity edoxaban) and warfarin were assigned to FORTA-B (beneficial). Phenprocoumon, acenocoumarol and fluindione were rated FORTA-C (questionable), mainly reflecting the absence of data. CONCLUSIONS: All non-vitamin K antagonist oral anticoagulants and warfarin were classified as beneficial or very beneficial in older persons (FORTA-A or -B), underlining the overall positive assessment of the risk/benefit ratio for these drugs. For other vitamin-K antagonists regionally used in Europe, the lack of evidence should challenge current practice.

Stroke among adults of working age is increasing. We aimed to explore the experience of stroke among young women in Ireland. In total, 12 women (aged between 18 and 50 years) participated in semi-structured interviews. Data were analysed using interpretative phenomenological analysis. Four super-ordinate themes were identified: stroke as an illness of later life (‘obviously it’s for older people’), post-stroke selves, a desire for peer support and the impact of stroke on relationships. Findings indicate the importance of addressing the specific needs of younger stroke patients from admission to recovery through provision of inclusive all-age acute stroke services with tailored rehabilitation.

Purpose of the study Although cognitive impairment and delirium are highly prevalent in older patients who present to the emergency department, multiple studies have highlighted inadequate detection by doctors. This study investigated potential reasons underlying this. Study Design A 14-item self-administered questionnaire was distributed to all medical, surgical and emergency department physicians involved in the care of older patients in the emergency department of an urban university teaching hospital between January and March 2012. Results The questionnaire was completed by 76/97 (78%) of eligible respondents. Respondents reported screening an average of one in four older patients that they reviewed. Almost one-third (22/76, 29%) felt they lacked the relevant expertise to perform cognitive screening: those with training in geriatrics were less likely to cite lack of expertise as a factor. While the majority felt screening for cognition in the emergency department-setting was important (59/76, 78%), several limiting factors were identified: lack of a screening tool; lack of privacy; too much noise; and time constraints. There was no consensus on who should perform screening. Conclusions Doctors reviewing patients in the emergency department-setting reported several important factors limiting their ability to screen older patients for cognitive impairment. Respondents to this questionnaire did not feel the emergency department environment was conducive towards the assessment of cognition in older patients. Clarification of each discipline's responsibility in the detection, assessment and management of delirium and/or dementia, and the implementation of emergency department cognitive screening instruments more suited to this setting would likely improve detection and management.

peer-reviewed Background: Several multivariable models have been derived to predict post-stroke falls. These require validation before integration into clinical practice. The aim of this study was to externally validate two prediction models for recurrent falls in the first year post-stroke using an Irish prospective cohort study. Methodology: Stroke patients with planned home-discharges from five hospitals were recruited. Falls were recorded with monthly diaries and interviews six and 12 months post-discharge. Predictors for falls included in two risk-prediction models were assessed at discharge. Participants were classified into risk-groups using these models. Model 1, incorporating inpatient falls-history and balance, had a six-month outcome. Model 2, incorporating inpatient near-falls history and upper limb function, had a twelve-month outcome. Measures of calibration, discrimination (area under the curve (AUC)) and clinical utility (sensitivity/ specificity) were calculated. Results: 128 participants (mean age=68.6 years, SD=13.3) were recruited. The fall status of 117 and 110 participants was available at six and 12 months respectively. Seventeen and 28 participants experienced recurrent falls by these respective timepoints. Model 1 achieved an AUC=0.56 (95% CI 0.46–0.67), sensitivity=18.8% and specificity=93.6%. Model 2 achieved AUC=0.55 (95% CI 0.44–0.66), sensitivity=51.9% and specificity=58.7%. Model 1 showed no significant difference between predicted and observed events (Risk Ratio (RR)=0.87, 95% CI 0.16–4.62). In contrast, model 2 significantly over-predicted fall events in the validation cohort (RR=1.61, 95% CI 1.04–2.48). Conclusions: Both models showed poor discrimination for predicting recurrent falls. A further large prospective cohort study would be required to derive a clinicallyuseful falls-risk prediction model for a similar population. ACCEPTED peer-reviewed

Rationale Outcome after intracerebral hemorrhage remains poor. Tranexamic acid is easy to administer, readily available, inexpensive, and effective in other hemorrhagic conditions. Aim This randomized trial aims to test the hypothesis that intravenous tranexamic acid given within 8 h of spontaneous intracerebral hemorrhage reduces death or dependency. Design Phase III prospective double-blind randomized placebo-controlled trial. Participants within 8 h of spontaneous intracerebral hemorrhage are randomized to receive either intravenous tranexamic acid 1 g 10 min bolus followed by 1 g 8 h infusion, or placebo. Sample size estimates A trial of 2000 participants (300 from start-up phase and 1700 from main phase) will have 90% power to detect an ordinal shift of the modified Rankin Scale with odds ratio 0.79. Study outcomes The primary outcome is death or dependency measured by ordinal shift analysis of the 7 level mRS at day 90. Secondary outcomes are neurological impairment at day 7 and disability, quality of life, cognition, and mood at day 90. Safety outcomes are death, serious adverse events, thromboembolic events, and seizures. Cost outcomes are length of stay in hospital, readmission, and institutionalization. Discussion This pragmatic trial is assessing efficacy of tranexamic acid after spontaneous intracerebral hemorrhage. Recruitment started in 2013; as of 15th January 2016 1355 participants have been enrolled, from 95 centers in seven countries. Recruitment is due to end in 2017. TICH-2 Trial is registered as ISRCTN93732214.

The Irish Health Information and Quality Authority (HIQA) published National Quality Standards for Residential Care Settings for Older People in 2009. We reported on experiences of general practitioners (GPs) in Dublin caring for nursing home patients (NHPs) in 2006. We revisit these experiences following publication of HIQA's standards. 400 GPs received an anonymous postal survey. Of 204 respondents, 145 (71%) felt NHPs required more contact time and 124 (61%) reported more complex consultations compared to other patients. Only 131 (64%) felt adequately trained in gerontology. 143 (70%) reported access to specialist advice, but only 6 (3%) reported a change in this following HIOA standards. 65 (32%) had witnessed substandard care in a NH, of which 16 (25%) made no report, similar figures to 2006. There remains similar levels of concern regarding patient complexity, substandard care, access to specialist support and training in the care of NHPs. Many GPs expressed uncertainty regarding their role in implementing HIQA standards.