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Introduction: Statins are effective in preventing vascular disease and are widely recommended and used for the secondary prevention of ischemic stroke. However, there is concern from trials that statins might increase the risk of hemorrhagic stroke, partially reducing their benefit. We sought to systematically review the latest evidence on this question. Methods: Four electronic databases were searched to identify published randomized controlled trials (RCTs) and observational cohort studies (search date December 2020). Two independent reviewers carried out the eligibility assessment based on predefined inclusion criteria. We examined the outcomes of recurrent stroke (after ischemic stroke) of any type, and separately recurrent ischemic stroke and recurrent hemorrhagic stroke. RCTs and observational cohort studies were meta-analyzed separately. Odds ratios (ORs) were used to assess the effect of statin therapy. Meta-analysis was conducted using RevMan 5.4 software. Results: We retrieved 559 papers in searches, of which 11 RCTs and 12 observational cohort studies were included. Both RCTs and observational studies found that statins reduced the odds of stroke of any type in those with an initial ischemic stroke (11 RCTs: OR = 0.87, 95% CI [0.77,0.97]; p = 0.02; 12 cohort studies: OR = 0.80, 95% CI [0.66, 0.96]; p = 0.02). Both RCTs and observational studies found that recurrence of ischemic stroke was reduced by statins (6 RCTs: OR = 0.81, 95% CI [0.70, 0.93]; p = 0.002; 3 observational studies: OR = 0.67, 95% CI [0.61, 0.75]; p < 0.00001). Data from 7 RCTs and 8 cohort studies did not find a significant difference in hemorrhagic stroke but could not rule out a substantial increase or reduction (7 RCTs: OR = 1.15, 95% CI [0.62, 2.13]; p = 0.66; 8 cohort studies: OR = 0.93, 95% CI [0.71, 1.21]; p = 0.59). Conclusions: In people who have experienced an ischemic stroke, statins reduce the risk of recurrent stroke of any type medicated through a reduction of ischemic stroke. We found no increase in the risk of hemorrhagic stroke.

Care home residents with stroke have higher levels of disability and poorer access to health services than those living in their own homes. We undertook observations and semi-structured interviews (n = 28 participants) with managers, staff, residents who had experienced a stroke and their relatives in four homes in London, England, in 2018/2019. Thematic analysis revealed that residents' needs regarding valued activity and stroke-specific care and rehabilitation were not always being met. This resulted from an interplay of factors: staff's lack of recognition of stroke and its effects; gaps in skills; time pressures; and the prioritisation of residents' safety. To improve residential care provision and residents' quality of life, care commissioners, regulators and providers may need to re-examine how care homes balance safety and limits on staff time against residents' valued activity, alongside improving access to specialist healthcare treatment and support.

Background: Limited data are available on sex-related disparities in long-term outcomes after stroke. We estimated sex differences in various stroke long-term outcomes among survivors after stroke in a prospective 25-year follow-up study. Methods: Individuals recruited to the South London Stroke Register, an ongoing multi-ethnic urban-based population stroke register, from 1995 onward were included in the analyses (n=6687). The outcomes were death, subsequent stroke, activity of daily living, instrumental activity of daily living, cognitive impairment, depression, anxiety, and health-related quality of life. Kaplan-Meier curves were generated for mortality, stroke recurrence, and recurrence-free survival by sex and Cox proportional hazards model used to model sex differences up to 25 years. Generalized estimating equation were used to model sex differences in risk of self-reported stroke outcomes over 10 years poststroke outcomes, adjusting for age, preexisting activity of daily living, case-mix, stroke subtypes, and other potential confounding risk factors. Results: There were 49% women (mean age, 72 years; SD, 15.6) and 51% men (mean age, 67 years; SD, 14.3) in 6687 participants. Compared with men, women had 9% (95% CI, 3%–15%) lower covariate-adjusted risk of death and 6% (0%–13%) lower risk of stroke recurrence or death. Generally, women had significantly poorer outcomes in activity of daily living and anxiety than men, and the sex differences persisted to up to 5 years after stroke. Women also had poorer health-related quality of life in physical (β=−2.06 [95% CI, −3.01 to −1.10]) and mental domains (β=−1.48 [95% CI, −2.44 to −0.52]). Although not significant, there was a suggestive trend for poorer outcomes in cognitive impairment and depression in women. No significant difference in stroke recurrence were found between men and women. Conclusions: Female patients with stroke tended to have better covariate-adjusted survival but poorer outcomes among survivors than male patients, with deficits persisting to up to 5 years poststroke.

Background Updatable estimates of COVID-19 onset, progression, and trajectories underpin pandemic mitigation efforts. To identify and characterise disease trajectories, we aimed to define and validate ten COVID-19 phenotypes from nationwide linked electronic health records (EHR) using an extensible framework. Methods In this cohort study, we used eight linked National Health Service (NHS) datasets for people in England alive on Jan 23, 2020. Data on COVID-19 testing, vaccination, primary and secondary care records, and death registrations were collected until Nov 30, 2021. We defined ten COVID-19 phenotypes reflecting clinically relevant stages of disease severity and encompassing five categories: positive SARS-CoV-2 test, primary care diagnosis, hospital admission, ventilation modality (four phenotypes), and death (three phenotypes). We constructed patient trajectories illustrating transition frequency and duration between phenotypes. Analyses were stratified by pandemic waves and vaccination status. Findings Among 57 032 174 individuals included in the cohort, 13 990 423 COVID-19 events were identified in 7 244 925 individuals, equating to an infection rate of 12·7% during the study period. Of 7 244 925 individuals, 460 737 (6·4%) were admitted to hospital and 158 020 (2·2%) died. Of 460 737 individuals who were admitted to hospital, 48 847 (10·6%) were admitted to the intensive care unit (ICU), 69 090 (15·0%) received non-invasive ventilation, and 25 928 (5·6%) received invasive ventilation. Among 384 135 patients who were admitted to hospital but did not require ventilation, mortality was higher in wave 1 (23 485 [30·4%] of 77 202 patients) than wave 2 (44 220 [23·1%] of 191 528 patients), but remained unchanged for patients admitted to the ICU. Mortality was highest among patients who received ventilatory support outside of the ICU in wave 1 (2569 [50·7%] of 5063 patients). 15 486 (9·8%) of 158 020 COVID-19-related deaths occurred within 28 days of the first COVID-19 event without a COVID-19 diagnoses on the death certificate. 10 884 (6·9%) of 158 020 deaths were identified exclusively from mortality data with no previous COVID-19 phenotype recorded. We observed longer patient trajectories in wave 2 than wave 1. Interpretation Our analyses illustrate the wide spectrum of disease trajectories as shown by differences in incidence, survival, and clinical pathways. We have provided a modular analytical framework that can be used to monitor the impact of the pandemic and generate evidence of clinical and policy relevance using multiple EHR sources. Funding British Heart Foundation Data Science Centre, led by Health Data Research UK.

The aim of the Foundation Healthcare Group (FHG) Vanguard model was to develop a sustainable local hospital model between two National Health Service (NHS) Trusts (a London Teaching Hospital Trust and a District General Hospital Trust) that makes best use of scarce resources and can be replicated across the NHS, UK. The aim of this study was to evaluate the provision, use and implementation of the IT infrastructure; based on qualitative interviews and focused mainly on the perspectives of the IT staff and the clinicians' perspectives. In total 24 interview transcripts, along with 'Acute Care Collaboration' questionnaire responses, were analysed using a thematic framework for IT infrastructure, sharing themes across the vascular, paediatric and cardiovascular strands of the FHG programme. Findings indicated that Skype for Business had been an innovative and helpful development widely available to be used between the two Trusts. Clinicians initially reported lack of IT support and infrastructure expected at the outset for a national Vanguard project, but later appreciated that remote access to most clinical applications between the two Trusts became operational. The Local Care Record (LCR), an IT project was perceived to have been delivered successfully in South London. Shared technology reduced patient travelling time by providing locally based shared care. Spreading and scaling-up innovations from the Vanguard sites was the aspiration and challenge for system leaders.

International audience

This chapter describes the epidemiology of stroke, a major cause of disability and premature death worldwide. The accurate classification of strokes is critical in conducting research and guiding clinical management. There are a number of classifications in clinical use, although a precise delineation of stroke subtypes requires the integration of clinical features, findings from diagnostic tests, and knowledge about potential aetiologic factors. Variations in incidence and mortality rates after stroke represent complex interactions between changing population demographics and risk factors, the availability and accessibility of preventative and curative measures, and differences in methods of case ascertainment worldwide. However, the widening gap between low- and high-income countries remains a significant challenge for long-term stroke strategies and this must be addressed before a true worldwide reduction in stroke incidence and mortality can be demonstrated.

Georges Canguilhem's Biophilosophy The eminent French biologist and historian of biology, François Jacob, once notoriously declared «On n’interroge plus la vie dans les laboratoires»: laboratory research no longer inquires into the notion of “Life”. Certain influential French philosophers of science of the mid-century such as Georges Canguilhem would disagree, or at least seek to resist some of Jacob’s diagnosis. Not by imposing a different kind of research program in laboratories, but by an unusual combination of historical and philosophical inquiry into the foundations of the life sciences (particularly medicine, physiology and the cluster of activities that were termed “biology” in the early 1800s). Canguilhem speaks of «defending vitalist biology» and declares that Life cannot be grasped by logic (or at least, «la vie déconcerte la logique»). Is this history and philosophy of biology? Is it vitalism? It definitely is a different project from current philosophy of biology. One short-lived term for it was “biophilosophy”. In this paper I explore the content of this term as it relates to the above questions.

International audience; From its beginnings until the present day, neuroscience has always had a special relationship to philosophy. And philosophy has long puzzled over the relation between mind and brain (and by extension, the relation of cerebral processes to freedom, morals, and justice, but also to perception and art). This volume presents some of the state-of-the-art reflections on philosophical efforts to 'make sense' of neuroscience, as regards issues including neuroaesthetics, neuroethics and neurolaw, but also more critical, evaluative perspectives on topics such as the social neuroscience of race, neurofeminism, embodiment and collaboration, memory and pain, and more directly empirical topics such as neuroconstructivism and embodied robotics. Brain theory as presented here is neither mere commentary on the state of the sciences, nor armchair philosophical reflection on traditional topics. It is more pluralistic than current philosophy of neuroscience (or neurophenomenology), yet more directly engaged with empirical, indeed experimental matters than socio-cultural discussions of 'brainhood' or representations of the brain.

As signaled by its title, Buster Keaton's Go West (1925) borrows as a template for its plot a familiar narrative of national migration and settlement, with the comic protagonist traversing a continent that in nineteenth‐century US culture was often figured as an ever receding ‘frontier’. Drawing on contemporaneous interviews, reviews and press book materials, this paper examines the ways in which Go West reworks elements of a westward migration narrative derived from popular histories and related genre forms. Made at a time when producer Joseph Schenck was touting Keaton's capacity to produce dramatically unified feature‐length films, Go West synthesizes elements of physical comedy with a sentimental story, exposing qualities of estrangement and unsettlement at the tap root of both Western melodrama and urban slapstick. Through the crossing of genres, moreover, Go West reconfigures the cultural map of the western migration plot in ways appropriate to changing conceptions of national geography in the early...

The papers collected in this special issue on Buster Keaton share a commitment to locating the work of the now legendary comic actor and director within historically specific contexts. Drawing on v...

The silent films of Buster Keaton (b. 1895–d. 1966) are among the most critically admired American motion pictures of the pre-sound era. Born to traveling medicine show performers during a stopover in a small town in Kansas, Joseph Frank “Buster” Keaton spent his early years on the road, and as a young child he gained star status as the linchpin of the family’s vaudeville act. He made his debut in motion pictures in 1917 as a member of Roscoe “Fatty” Arbuckle’s company, Comique Films, where he first gained training as comedy filmmaker. From 1920 to 1928 Keaton worked independently and prolifically, supervising and starring in nineteen comedy shorts and ten features, a body of work that remains at the heart of his screen reputation today. Although he never enjoyed the box-office clout of rivals Charlie Chaplin and Harold Lloyd, Keaton’s resilient, sober-faced persona was familiar to movie audiences around the world, and he was second only to Chaplin as the object of critical efforts to define the distinct contributions of slapstick comedy to the nascent art of the screen. Keaton’s career entered a tailspin in the early 1930s—the result of a troubled marriage, struggles with alcoholism, and the loss of control over his films—but he recovered his footing by the end of the decade and worked steadily as a performer and comic consultant in movies, television, and theater until his death. An aging Keaton was occasionally the recipient of nostalgic tributes to the “golden years” of slapstick comedy during these years. A great tide of critical reappraisals of Keaton’s work, however, followed the restoration and revival of his silent films, many of which Keaton himself thought lost, in an effort spearheaded by Raymond Rohauer, who mounted Keaton retrospectives in the 1960s, first in Europe then the United States. Showcasing Keaton’s silent film work as a whole, these screenings were accompanied by a growing critical consensus that an artist of the first rank had been rediscovered. In recent years, video and digital technologies have made Keaton’s films available to an expanding audience of fans, critics, historians, and independent researchers. The annotated bibliography that follows provides a roadmap to Keaton scholarship, including reference guides, biographies, and overviews, and the books and articles through which a critical understanding of Keaton’s cinema has taken shape.

From Hegel to Engels, Sartre and Ruyer (Ruyer, 1933), to name only a few, materialism is viewed as a necropolis, or the metaphysics befitting such an abode; many speak of matter’s crudeness, bruteness, coldness or stupidity. Science or scientism, on this view, reduces the living world to ‘dead matter’, ‘brutish’, ‘mechanical, lifeless matter’, thereby also stripping it of its freedom (Crocker, 1959). Materialism is often wrongly presented as ‘mechanistic materialism’ – with ‘Death of Nature’ echoes of de-humanization and hostility to the Scientific Revolution (which knew nothing of materialism!), also a powerful Christian theme in Cudworth, Clarke and beyond (Overhoff, 2000). Here I challenge this view, building on some aspects of Israel’s Radical Enlightenment concept (Israel, 2001), which has been controversial but for my purposes is a useful claim about the dissemination of a home-grown Spinozism, sometimes reformulated as an ontology of the life sciences, an aspect Israel does not address (compare Secrétan et al., eds., 2007; Citton, 2006). First, I examine some ‘moments’ of radical Enlightenment materialism such as La Mettrie and Diderot (including his Encyclopédie entry “Spinosiste”), but also anonymous, clandestine texts such as L’Âme Matérielle, to emphasize their distinctive focus on the specific existence of organic beings. Second, I show how this ‘embodied’, non-mechanistic character of Enlightenment ‘vital materialism’ makes it different from other episodes, and perhaps more of an ethics than is usually thought (also via the figure of the materialist as ‘laughing philosopher’). Third, I reflect on what this implies for our image of the Enlightenment – no longer a Frankfurt School and/or Foucaldian vision of ‘discipline’, regimentation and order (as in Mayr, 1986) – but ‘vital’, without, conversely, being a kind of holist vitalism “at odds with the universalizing discourse of Encyclopedist materialism, with its insistence on the uniformity of nature and the universality of physical laws” (Williams, 2003): vital materialism is still materialism. Its ethics tends towards hedonism, but its most radical proponents (Diderot, La Mettrie and later Sade) disagree as to what this means.

In a “fireside chat” delivered over national radio on Washington's Birthday, February 23, 1942, President Franklin Delano Roosevelt offered an expansive account of the conflict in which the United States was now engaged, the scope of which extended far beyond Pearl Harbor and the events that had propelled US entry into the war 11 weeks before. The oceans of the world, Roosevelt stressed, were no longer buffers but battlefields and vital thoroughfares for communication and logistical supplies. “It is warfare in terms of every continent, every island, every sea, every air lane in the world,” he explained. “That is the reason why I have asked you to take out and spread before you the map of the whole earth, and to follow with me in the references which I shall make to the world-encircling battle lines of this war.” Referring repeatedly to the listener's map — “I ask you to look at your map again …” — Roosevelt identified various continents, subcontinents, and nations where America's Allies were embattled: China and Russia, the British Isles, Australia and New Zealand, the Dutch Indies, India, the Near East, and Africa. “Look too at North America, Central America, and South America,” he advised, and contemplate the consequences “if all these great reservoirs of power were cut off from each other either by enemy action or self-imposed isolation.” Taking pains to dispel rumors that the US Pacific fleet had been completely destroyed at Pearl Harbor, Roosevelt insisted that topography was of greater consequence than surprise in the success of Japan's attack. Here, too, a world map revealed the true source of the challenge the Allies faced — Japan's complete domination of the islands between Hawaii and the Philippines. Yet the Axis Powers should take no comfort in this advantage, Roosevelt assured his listeners, for “Germany, Italy, and Japan are very close to the maximum output of planes, guns, tanks, and ships.” The task for Americans now was to build up production “so that the United Nations can maintain control of the seas and attain control of the air.” Keywords: animation; Frank Capra; documentary; globalization; George C. Marshall; propaganda; radio; Franklin D. Roosevelt; why we fight; world war ii

Incidence rates for stroke and hypertension are higher in black ethnic groups of African descent in the USA and UK than in white groups, suggesting a need for targeted intervention. We conduct a narrative review of published research evidence on community interventions to manage hypertension among black ethnic groups, and explore the concept of cultural sensitivity in these interventions. Data sources comprised computer-aided searches of published studies over the years 1981 to March 2006, on community strategies for improving hypertension control targeting black groups, and further references from these articles. Twenty-seven relevant studies were identified. Health education was associated with improvements in knowledge about hypertension, while education combined with individualised support for patients to self-manage hypertension, including goal setting and monitoring to enhance patient self-management of hypertension, and family support in managing hypertension were associated with reductions in blood pressure levels and improvements in blood pressure control. Collaboration with black communities, using local or minority ethnic staff, conducting preliminary research with target groups to investigate perceptions and canvass ideas for the intervention design were common methods assumed to achieve cultural sensitivity. Studies, however, provided insufficient robust evidence of the effectiveness of these strategies in terms of quantifiable outcomes, although this criterion is contested, with social justice arguments being offered instead. Implicit assumptions about homogeneity and shared interests within the 'community', and representation of 'community' views have implications for the effectiveness of interventions. These findings highlight areas for the future development of interventions to reduce hypertension rates in black groups, and factors that need to be robustly investigated and explicitly addressed in intervention design.