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Stroke continues to plague the United States, affecting 795,000 people annually. Although stroke mortality has decreased, the overall incidence of stroke appears essentially unchanged. With a population that is projected to increase in age and stroke risk over the next 10-15 years, this is concerning. Current stroke prevention education may not be adequately tailored to community learning needs. Analyzing existing demographic data within electronic medical records may allow healthcare systems to identify high-risk neighborhoods by geocoding stroke diagnoses and then completing a qualitative analysis within the target community of specific stroke knowledge deficits. That information may then inform stroke prevention education for that neighborhood. A descriptive, exploratory approach was used to identify a community with a high incidence of stroke using geocoded demographic data from patients coding out with a stroke diagnosis. Qualitative interviews conducted within the community yielded the following themes: fragmented knowledge of stroke causes and risk factors, unawareness of hypertension and diabetes as significant risk factors for stroke, knowing but experiencing challenges to engaging in healthy practices—specifically, diet and exercise, and financial barriers to healthcare resources. While most of the participants had adequate healthcare coverage and reported regular interactions with a primary healthcare provider, this community continued to experience a higher incidence of stroke than surrounding neighborhoods. The findings of this study highlighted specific challenges to stroke prevention that may inform future stroke prevention initiatives. Future research in other communities using this approach may provide additional insights into the specific knowledge deficits unique to communities, as well as revealing patterns and trends in stroke prevention knowledge. Approaching stroke prevention education using only data obtained from large registries may provide a broad overview of knowledge deficits, but lack the specificity necessary to effectively address stroke knowledge needs at the community level. Recognizing the challenges inherent with behavior modification for implementing lifestyle changes should also be considered when designing future stroke education. Harnessing technology in the form of web applications, text messaging, and email for maintaining communication with patients may improve effectiveness of stroke prevention interventions. Implementing a comprehensive health promotion program that addresses specific community needs with tailored health education and behavioral support may lead to decreased incidence of cerebrovascular disease in this community and provide a model for managing other preventable diseases. / Includes bibliography. / Dissertation (Ph.D.)--Florida Atlantic University, 2019. / FAU Electronic Theses and Dissertations Collection

The purpose of this study was to investigate how patients who had undergone Hallberg's  TIA-school at Enköpings Lasarett rate their physical and mental health 18 months after participation. Another purpose was to examine whether they re-diagnosed with a TIA or suffered a stroke. The design of the quantitative study was longitudinal and descriptive. In the study 16 patients participated and to measure their mental and physical health the questionnaire SF36 was used. The results showed that none of the participants suffered a new TIA or stroke since participation in the TIA-school. The participants' self-rated health measured with SF36 showed the highest values ​​in the areas of social function, emotional role function and physical role function. Which indicates a good self-rated health in these areas. Participants were asked how their physical and mental health limited them in everyday life. The majority of participants was not limited at all during the day, either physically (50%) or psychologically (62.5%). Our results demonstrate that a TIA-school like the one at Enköpings Lasarett may have long-term effects on an individual basis, but this effect can not be demonstrated in all off the patients.

Stroke is the second most common cause of death worldwide and the leading cause of long-term neurological disability. In the UK, stroke accounts for approximately 6% of total National Health Service and Social Services expenditure. The burden of stroke is predicted to increase because of the ageing population. Whilst effective primary prevention is important, about 30% of strokes occur in individuals with a previous transient ischaemic attack (TIA) or minor stroke. Recent prospective studies have shown a high early risk of recurrent stroke in the days after TIA or minor stroke. The prompt use of preventative strategies has been shown to be highly effective in reducing this early risk of recurrence and there is now a consensus in favour of rapid access services and urgent secondary prevention after TIA. However, there are several areas where clinical practice still needs to be improved, including delays in seeking medical attention, the reliability of clinical diagnosis of TIA in the acute phase, prediction of stroke recurrence risk and the control of risk factors, particularly blood pressure (BP), in longer-term secondary prevention. My thesis will focus on these clinically important areas. I have used data from a population-based study; the Oxford Vascular Study (OXVASC). OXVASC is a prospective, population-based incidence study of vascular disease in all territories in Oxfordshire, UK, which started in 2002 and is ongoing. The study population comprises approximately 91 000 individuals registered with nine general practices and uses multiple overlapping methods of “hot” and “cold” pursuit to identify all patients with acute vascular events. The research described in this thesis has several clinically useful findings which address areas for improvement during the patient journey after TIA and minor ischaemic stroke. First, I have highlighted that despite public education campaigns, about 70% of patients still fail to correctly recognise TIA or minor stroke symptoms and about 30% delay seeking medical attention for over 24 hours. Second, I have shown that recurrent TIA within 7-days is not associated with a greater stroke risk than after a single TIA, other than in the capsular warning syndrome. Third, in patients with definite posterior circulation TIA or stroke, preceding transient isolated “brainstem” symptoms occur in 26%, which has implications for the current diagnostic criteria for TIA. Fourth, I have shown that the Face Arm and Speech Test does not reliably identify patients at high early risk of recurrent stroke after TIA and minor stroke and has limited potential to improve access to care. Fifth, I have shown that outpatient management of clinic-referred minor stroke is feasible and may be as safe as inpatient care. Sixth, that stroke recurrence risk after minor stroke is delayed compared with TIA, and is high during the subacute phase despite current best medical treatment. Seventh, I have assessed Bluetooth- based home BP monitoring after TIA or minor stroke as a way of achieving better BP control and shown that this method is feasible, irrespective of age, and patient satisfaction is high. Finally, I have studied the late outcomes after TIA and stroke in OXVASC in comparison with a similar cohort from the 1980’s. I have shown that the age and sex specific later risk of recurrent stroke after TIA and stroke in Oxfordshire has fallen. However, the risk of fatal recurrent stroke remains high in contrast with the risk of fatal cardiac events which is low.

In Saskatchewan, stroke is the third leading cause of death as well was the major cause of adult disability. Once a person suffers a stroke or transient ischemic attack (TIA), they are at high risk for having a secondary (or recurrent) stroke. Despite this knowledge, secondary stroke prevention is often overlooked in the care of stroke/TIA patients. With the vision of decreasing the incidence and impact of stroke in Saskatchewan, the Saskatchewan Integrated Stroke Strategy (SISS) was recently implemented. The purpose of this study is to begin the development of an evaluation measurement system for the SISS based on the guidelines and measures from the Canadian Stroke Strategy (CSS) specifically pertaining to secondary stroke prevention.<p> This multi-year cross-sectional study is an analysis of de-identified health data derived from linkage of administrative and laboratory data. Select indicators from the CSS Performance Measurement Manual involving medications use for secondary stroke prevention (antihypertensives, antilipidemics, anticoagulants) and intermediate health outcomes (serum LDL cholesterol, INR) are calculated. Regression is used to quantify the association of patient demographic and socioeconomic characteristics and geographic location of care with receipt of guideline-recommended secondary stroke prevention. The target population is Saskatchewan residents who have been hospitalized for a stroke or TIA between April 1, 2001 and March 31, 2008.<p> The results of this study indicated that secondary stroke prevention in Saskatchewan is sub-optimal in the management of hypertension, dyslipidemia, and atrial fibrillation. Although there has been some improvement over the time period, a significant number of patients are not taking the recommended medications at discharge from acute care. Similarly, a considerable number of patients are not receiving the appropriate laboratory tests within the year following their stroke event. Through regression analysis it was revealed that a number of correlates (ie. age, income, on medication before the stroke event) were significantly associated with receiving these specific elements of secondary stroke prevention, suggesting potential differences in provision of care. Finally, regional differences in secondary stroke prevention were found for a number of the outcomes, which may indicate differences in care throughout the province.<p> The findings of this study serve as a baseline for evaluation of the impact of the Saskatchewan Integrated Stroke Strategy in the area of secondary stroke prevention. The results make apparent the fact that secondary stroke prevention in Saskatchewan can be improved, and that there is much opportunity for future research in this area.

In Saskatchewan, stroke is the third leading cause of death as well was the major cause of adult disability. Once a person suffers a stroke or transient ischemic attack (TIA), they are at high risk for having a secondary (or recurrent) stroke. Despite this knowledge, secondary stroke prevention is often overlooked in the care of stroke/TIA patients. With the vision of decreasing the incidence and impact of stroke in Saskatchewan, the Saskatchewan Integrated Stroke Strategy (SISS) was recently implemented. The purpose of this study is to begin the development of an evaluation measurement system for the SISS based on the guidelines and measures from the Canadian Stroke Strategy (CSS) specifically pertaining to secondary stroke prevention.<p> This multi-year cross-sectional study is an analysis of de-identified health data derived from linkage of administrative and laboratory data. Select indicators from the CSS Performance Measurement Manual involving medications use for secondary stroke prevention (antihypertensives, antilipidemics, anticoagulants) and intermediate health outcomes (serum LDL cholesterol, INR) are calculated. Regression is used to quantify the association of patient demographic and socioeconomic characteristics and geographic location of care with receipt of guideline-recommended secondary stroke prevention. The target population is Saskatchewan residents who have been hospitalized for a stroke or TIA between April 1, 2001 and March 31, 2008.<p> The results of this study indicated that secondary stroke prevention in Saskatchewan is sub-optimal in the management of hypertension, dyslipidemia, and atrial fibrillation. Although there has been some improvement over the time period, a significant number of patients are not taking the recommended medications at discharge from acute care. Similarly, a considerable number of patients are not receiving the appropriate laboratory tests within the year following their stroke event. Through regression analysis it was revealed that a number of correlates (ie. age, income, on medication before the stroke event) were significantly associated with receiving these specific elements of secondary stroke prevention, suggesting potential differences in provision of care. Finally, regional differences in secondary stroke prevention were found for a number of the outcomes, which may indicate differences in care throughout the province.<p> The findings of this study serve as a baseline for evaluation of the impact of the Saskatchewan Integrated Stroke Strategy in the area of secondary stroke prevention. The results make apparent the fact that secondary stroke prevention in Saskatchewan can be improved, and that there is much opportunity for future research in this area.

Balali_Pargol_MSc thesis_Neuroscience department_2023Sep / Background: Cerebral microbleeds are asymptomatic neuroimaging markers of small vessel disease (SVD), visualized as small hypointensities on blood-sensitive magnetic resonance imaging (MRI) sequences. Patients with ischemic stroke and microbleeds are at a higher risk of future ischemic stroke and intracranial hemorrhage. Antithrombotic therapies, the mainstay treatment of secondary stroke prevention, are associated with an increased risk of bleeding. This raises concerns surrounding the net benefit of antithrombotic therapies in these hemorrhage-prone patients. The overarching aim of this thesis is to determine the safety of antithrombotic treatments in patients with hemorrhage-prone SVD marked by microbleeds on MRI or prior intracerebral hemorrhage (ICH). I aimed to characterize the association between baseline microbleeds and the risk of future clinical outcomes in patients with ischemic stroke and whether there exists treatment effect modification of different anticoagulants on clinical outcomes according to microbleeds presence, location, and number. Methods: We performed post hoc analyses on two multicenter previously conducted randomized trials in patients with non-cardioembolic ischemic stroke. For the PACIFIC-STROKE trial, we used multivariable regression models to determine the contribution of microbleeds to the risk of new microbleeds, hemorrhagic transformation (HT), ischemic stroke, intracranial hemorrhage, and death. We assessed the treatment effect of asundexian, a factor XIa inhibitor, vs. placebo on these clinical outcomes, stratified by microbleeds presence, location, and number. I was trained on standardized rating of microbleeds on MRI, achieved excellent interrater reliability, and rated all DATAS-II participant MRIs. I used multivariable logistic regression models to identify the association between microbleeds and HT and 90-day excellent functional outcome. I assessed the interaction between treatment with dabigatran, a direct thrombin inhibitor, vs. aspirin and microbleeds for these outcomes. Separately, I performed a review of the literature and wrote an editorial discussing the optimum timing of antiplatelet re-initiation after ICH. Results: The PACIFIC-STROKE post hoc analyses showed that microbleeds are associated with a 1.6-fold and 4.4-fold higher risk of HT and new microbleeds, respectively. The DATAS-II exploratory analyses demonstrated no association between the risk of outcomes and microbleeds presence. We found no interaction between treatment assignment and microbleed presence for any of the clinical outcomes investigated in either of these studies. Based on the totality of evidence, we concluded that early resumption of antiplatelets in ICH survivors is likely to be safe. Conclusion: Our findings do not support existing concerns surrounding the use of anticoagulants in patients with acute ischemic stroke and microbleeds on MRI, nor for the early resumption of antiplatelets in ICH survivors. / Thesis / Master of Science (MSc) / Diseases of small brain blood vessels can lead to strokes due to blockage or bleeding. Small, asymptomatic brain bleeds on MRIs (microbleeds) are common among affected patients. Patients with clot-induced stroke and microbleeds have a higher risk of both types of strokes. Blood thinners are standard treatments to prevent future clotting events after clot-induced stroke. However, their potential to increase the risk of brain bleeding has raised concerns regarding their use in patients with microbleeds or bleeding-induced stroke. We assessed information from two large, previously completed randomized trials to evaluate the safety of strong blood thinners (anticoagulants) in patients with clot-induced stroke and microbleeds. Additionally, we evaluated the risk vs. benefit of restarting milder blood thinners (antiplatelets) early after bleeding-induced stroke. Bleeding was more prevalent in patients with microbleeds; however, the effect of the anticoagulants tested on bleeding outcomes was not modified by microbleed presence. Overall, our findings suggest that blood thinners are safe in patients with clot-induced stroke and microbleeds, and that early resumption of antiplatelets seems safe in patients with bleeding-induced stroke.

Yes / Objective: To better understand the factors influencing the uptake of direct oral anticoagulants (DOACs) across different health economies in National Health Service England from the perspective of health professionals and other health economy stakeholders. Design: Qualitative interview study using a critical realism perspective and informed by the Diffusion of Innovations in Service Organisations model. Setting: Three health economies in the North of England, United Kingdom. Participants: Healthcare professionals involved in the management of patients requiring oral anticoagulants, stakeholders involved in the implementation of DOACs and representatives of pharmaceutical industry companies and patient support groups. Intervention: Semistructured interviews (face-to-face or telephone) were conducted with 46 participants. Interviews were analysed using the Framework method. Results: Identified factors having an impact on the uptake of DOACs were grouped into four themes: perceived value of the innovation, clinician practice environment, local health economy readiness for change, and the external health service context. Together, these factors influenced what therapy options were offered and prescribed to patients with atrial fibrillation. The interviews also highlighted strategies used to improve or restrict the uptake of DOACs and tensions between providing patient-centred care and managing financial implications for commissioners. Conclusions: The findings contribute to the wider literature by providing a new and in-depth understanding on the uptake of DOACs. The findings may be applicable to other new medicines used in chronic health conditions. / This work presents research funded by the Pharmacy Research UK (grant number: PRUK-2018-GA-1-KM) and Leeds Teaching Hospitals NHS Trust (grant number: N/A).

Yes / Warfarin and direct oral anticoagulants (DOACs) have been shown to reduce the risk of stroke in patients with atrial fibrillation, yet many patients are still not being anticoagulated. This article discusses the barriers to the initiation of oral anticoagulants, in particular DOACs, and how these can be overcome.

Yes / Patients with non-valvular atrial fibrillation (AF) requiring oral anticoagulants (OAC) for stroke prevention currently have a choice of five OACs. A systematic review was undertaken to explore if patients with AF requiring an OAC for stroke prevention are involved in decision-making.