Effects of a Planned Web-Based Educational Intervention Based on the Health Belief Model for Patients With Ischemic Stroke in Promoting Secondary Prevention During the COVID-19 Lockdown in China: Quasi-Experimental Study.

Background: Some common modified vascular risk factors remain poorly controlled among stroke survivors, and educational programs may help improve these conditions. Objective: This study aimed to evaluate the effect of a planned web-based educational intervention based on the health belief model (HBM) in promoting secondary prevention among patients with ischemic stroke. Methods: An evaluation-blinded quasi-experimental trial with a historical control group was conducted. Patients admitted from March to June 2020 were assigned to the historical control group, and patients admitted from July to October 2020 were assigned to the intervention group. The control group received routine health management. The intervention group received 6 additional sessions based on the HBM via Tencent Meeting, an audio and video conferencing application, within 3 months after discharge. Sessions were held every 2 weeks, with each session lasting approximately 40 minutes. These sessions were conducted in small groups, with about 8 to 10 people in each group. The primary outcomes were changes in blood pressure (BP), low-density lipoprotein cholesterol (LDL-C), hemoglobin A1c (HbA1c), and the proportion of patients achieving the treatment target. The secondary outcomes were medication adherence, assessed with the Morisky Medicine Adherence Scale (MMAS), and disability, assessed with the modified Rankin scale. Results: In total, 315 patients experiencing their first-ever stroke were analyzed. More patients in the intervention group had controlled BP (41.9% vs 28.4%; adjusted odds ratio [aOR] 1.93; P=.01), LDL-C (83.1% vs 67.7%; aOR 2.66; P=.001), and HbA1c (91.9% vs 83.9%; aOR: 3.37; P=.04) levels as well as a significant postintervention decrease in the systolic BP (adjusted ß -3.94; P=.02), LDL-C (adjusted ß -0.21; P=.008), and HbA1c (adjusted ß -0.27; P<.001), compared with control groups. Significant between-group differences were observed in medication adherence (79.4% vs 63.2%; aOR 2.31; P=.002) but not in favorable functional outcomes. Conclusions: A web-based education program based on the HBM may be more effective than current methods used to educate patients having strokes on optimal vascular risk factors and medication adherence.

Understanding treatment-subgroup effect in primary and secondary prevention of cardiovascular disease: An exploration using meta-analyses of individual patient data.

BACKGROUND AND OBJECTIVE: Recommendations for preventing cardiovascular (CV) disease are currently separated into primary and secondary prevention. We hypothesize that relative effects of interventions for CV prevention are not different across primary and secondary prevention cohorts. Our aim was to test for differences in relative effects on CV events in common preventive CV interventions across primary and secondary prevention cohorts. METHODS AND RESULTS: A systematic search was performed to identify individual patient data (IPD) meta-analyses that included both primary and secondary prevention populations. Eligibility assessment, data extraction, and risk of bias assessment were conducted independently and in duplicate. We extracted relative risks (RR) with 95% confidence intervals (95% CI) of the interventions over patient-important outcomes and estimated the ratio of RR for primary and secondary prevention populations. We identified five eligible IPDs representing 524,570 participants. Quality assessment resulted in overall low-to-moderate methodological quality. We found no subgroup effect across prevention categories in any of the outcomes assessed. CONCLUSION: In the absence of significant treatment-subgroup interactions between primary and secondary CV prevention cohorts for common preventive interventions, clinical practice guidelines could offer recommendations tailored to individual estimates of CV risk without regard to membership to primary and secondary prevention cohorts. This would require the development of reliable ASCVD risk estimators that apply across both cohorts.

Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) guidelines for management of dyslipidemia and cardiovascular disease risk reduction: Putting evidence in context.

Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of morbidity and mortality in the United States (U.S.) and incurs significant cost to the healthcare system. Management of cholesterol remains central for ASCVD prevention and has been the focus of multiple national guidelines. In this review, we compare the American Heart Association (AHA)/American College of Cardiology (ACC) and the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) Cholesterol guidelines. We review the evidence base that was used to generate recommendations focusing on 4 distinct themes: 1) the threshold of absolute 10-year ASCVD risk to start a clinician-patient discussion for the initiation of statin therapy in primary prevention patients; 2) the utility of coronary artery calcium score to guide clinician-patient risk discussion pertaining to the initiation of statin therapy for primary ASCVD prevention; 3) the use of moderate versus high-intensity statin therapy in patients with established ASCVD; and 4) the utility of ordering lipid panels after initiation or intensification of lipid lowering therapy to document efficacy and monitor adherence to lipid lowering therapy. We discuss why the VA/DoD and AHA/ACC may have reached different conclusions on these key issues.

Benefits and Risks of Dual Versus Single Antiplatelet Therapy for Secondary Stroke Prevention: A Systematic Review for the 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack.

BACKGROUND: Dual antiplatelet therapy (DAPT) after ischemic stroke or transient ischemic attack may reduce recurrent stroke but also increase severe bleeding compared with single antiplatelet therapy (SAPT). The American Heart Association/American Stroke Association convened an evidence review committee to perform a systematic review and meta-analysis of the benefits and risks of DAPT compared with SAPT for secondary ischemic stroke prevention. METHODS: The Medline, Embase, and Cochrane databases were searched on December 5, 2019, to identify phase III or IV randomized controlled trials (n≥100) from December 1999 to December 2019. We calculated unadjusted relative risks (RRs) and performed meta-analyses of studies based on the duration of treatment (short [≤90 days] versus long [>90 days]). RESULTS: Three short-duration randomized controlled trials were identified that enrolled mostly patients with minor stroke or high risk transient ischemic attack. In these trials, DAPT, compared with SAPT, was associated with a lower 90-day risk of recurrent ischemic stroke (pooled RR, 0.68 [95% CI, 0.55-0.83], I 2=37.1%). There was no significant increase in major bleeding with DAPT in short-duration trials (pooled RR, 1.88 [95% CI, 0.93-3.83], I 2=8.9%). In 2 long-duration treatment randomized controlled trials (mean treatment duration, 18-40 months), DAPT was not associated with a significant reduction in recurrent ischemic stroke (pooled RR, 0.89 [95% CI, 0.79-1.02], I 2=1.4%), but was associated with a higher risk of major bleeding (pooled RR, 2.42 [95% CI, 1.37-4.30], I 2=75.5%). CONCLUSIONS: DAPT was more effective than SAPT for prevention of secondary ischemic stroke when initiated early after the onset of minor stroke/high-risk transient ischemic attack and treatment duration was <90 days. However, when the treatment duration was longer and initiated later after stroke or transient ischemic attack onset, DAPT was not more effective than SAPT for ischemic stroke prevention and it increased the risk of bleeding.

Catheter ablation superiority over the pharmacological treatments in atrial fibrillation: a dedicated review.

Atrial fibrillation globally affects roughly 33.5 million people, making it the most common heart rhythm disorder. It is a crucial arrhythmia, as it is linked with a variety of negative outcomes such as strokes, heart failure and cardiovascular mortality. Atrial fibrillation can reduce quality of life because of the potential symptoms, for instance exercise intolerance, fatigue, and palpitation. There are different types of treatments aiming to prevent atrial fibrillation and improve quality of life. Currently, the primary treatment for atrial fibrillation is pharmacology therapy, however, these still show limited effectiveness, which has led to research on other alternative strategies. Catheter ablation is considered the second line treatment for atrial fibrillation when the standard treatment has failed. Moreover, catheter ablation continues to show significant results when compared to standard therapy. Hence, this review will argue that catheter ablation can show superiority over current pharmacological treatments in different aspects. It will discuss the most influential aspects of the treatment of atrial fibrillation, which are recurrence and burden of atrial fibrillation, quality of life, atrial fibrillation in the setting of heart failure and mortality and whether catheter ablation can be the first line treatment for patients with atrial fibrillation.

Prevention after stroke: A quality assurance study.

OBJECTIVES: In 1997, the Copenhagen Stroke Study revealed that stroke was recurrent in 23% of patients admitted with a stroke. Predictors of recurrence were history of transient ischaemic attack, atrial fibrillation, male gender and hypertension. In 2011, the Danish recurrence rate was 25%. With the aim of preventing recurrent stroke, a preventive clinic was established in 2014 at the Department of Neurology, Herlev Hospital. Data from the preventive clinic are analysed in the present study. MATERIALS AND METHODS: Data from visits to the clinic from October 2014 to October 2016 were collected from electronic medical records. Data on subsequent admissions with stroke were collected from October 2014 to the end of 2017. Data were collected and analyzed as a means of quality assurance. RESULTS: Data from 1083 patients showed that half of the patients were hypertensive at discharge regardless of admission with first ever or recurrent stroke. Nurses at the clinic initiated or intensified antihypertensive medication in 40% of patients. Blood pressure was at target in 64% of patients at last visit to the clinic. Stepwise Cox proportional hazard regression analysis of 1024 patients admitted with ischaemic stroke or transient ischaemic attack showed that tobacco smoking (HR 1.80), admission with a recurrent stroke (HR 1.76) and cholesterol-lowering treatment (HR 1.67) were independent predictors of stroke recurrence. CONCLUSIONS: The recurrence rate in Denmark has remained unchanged for two decades. Risk factors for recurrence seem to change over time. Identification and treatment of actual risk factors may be a way to reduce recurrence.

2021 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in Adults.

The 2021 guidelines primary panel selected clinically relevant questions and produced updated recommendations, on the basis of important new findings that have emerged since the 2016 guidelines. In patients with clinical atherosclerosis, abdominal aortic aneurysm, most patients with diabetes or chronic kidney disease, and those with low-density lipoprotein cholesterol ≥ 5 mmol/L, statin therapy continues to be recommended. We have introduced the concept of lipid/lipoprotein treatment thresholds for intensifying lipid-lowering therapy with nonstatin agents, and have identified the secondary prevention patients who have been shown to derive the largest benefit from intensification of therapy with these agents. For all other patients, we emphasize risk assessment linked to lipid/lipoprotein evaluation to optimize clinical decision-making. Lipoprotein(a) measurement is now recommended once in a patient's lifetime, as part of initial lipid screening to assess cardiovascular risk. For any patient with triglycerides ˃ 1.5 mmol/L, either non-high-density lipoprotein cholesterol or apolipoprotein B are the preferred lipid parameter for screening, rather than low-density lipoprotein cholesterol. We provide updated recommendations regarding the role of coronary artery calcium scoring as a clinical decision tool to aid the decision to initiate statin therapy. There are new recommendations on the preventative care of women with hypertensive disorders of pregnancy. Health behaviour modification, including regular exercise and a heart-healthy diet, remain the cornerstone of cardiovascular disease prevention. These guidelines are intended to provide a platform for meaningful conversation and shared-decision making between patient and care provider, so that individual decisions can be made for risk screening, assessment, and treatment.

Osteoporosis: Recent Recommendations and Positions of the American Society for Bone and Mineral Research and the International Society for Clinical Densitometry.

➤: Osteoporosis is common in orthopaedic patients, not only in those sustaining fragility fractures but also in patients ≥50 years old who are having elective orthopaedic surgery. ➤: The American Society for Bone and Mineral Research (ASBMR) has developed consensus-based recommendations for secondary fracture prevention for all patients who are ≥65 years old with a hip or spine fracture. ➤: The ASBMR encourages orthopaedic surgeons to "Own the Bone," by beginning prevention of a secondary fracture during hospitalization for a fragility fracture, if practicable, and arranging follow-up for continued bone health care after discharge. ➤: The International Society for Clinical Densitometry (ISCD) recognized that many poor outcomes and complications of elective orthopaedic surgery are related to osteoporosis. ➤: The ISCD used an evidence-based approach to create official positions to identify which patients ≥50 years old who are having elective orthopaedic surgery should undergo assessment of bone health and how this should be performed.

Uso de la polipíldora cardiovascular en la prevención secundaria de la enfermedad cerebrovascular / Use of cardiovascular polypills for the secondary prevention of cerebrovascular disease

INTRODUCCIÓN: El control de los factores de riesgo cardiovascular (CV) en la prevención secundaria tras un ictus isquémico es bajo, en parte debido a la falta de adherencia terapéutica. La polipíldora CV puede contribuir a la buena cumplimentación del adecuado tratamiento para la prevención cerebrovascular. El objetivo fue establecer cómo y en qué casos se debería administrar. MÉTODOS: Un grupo de neurólogos redactaron recomendaciones consensuadas mediante una técnica de brainstorming estructurado, basándose en su experiencia y en una revisión bibliográfica. RESULTADOS: Los resultados atienden a la opinión de los expertos. El uso de la polipíldora CV tiene ventajas para pacientes, profesionales sanitarios y para el sistema de salud. Las situaciones clínicas más adecuadas para su uso son el ictus aterotrombótico, el lacunar, el asociado a deterioro cognitivo, el criptogénico con factores de riesgo CV y la enfermedad cerebrovascular silente. Su uso preferente incluye la sospecha de mal cumplimiento, a los pacientes polimedicados, ancianos, polivasculares o con alta carga aterotrombótica, jóvenes activos laboralmente y pacientes con preferencias por la polipíldora CV. Las opciones de administración incluyen el paso de fármacos individuales a la polipíldora CV, el inicio directo desde la fase aguda en casos particulares, a los pacientes con otra estatina o con un antagonista del receptor de la angiotensina ii, o de novo si hubiera sospecha de mala adherencia. No obstante, su uso implica realizar seguimiento del cumplimiento de los objetivos terapéuticos para ajustar la dosis. CONCLUSIONES: Este documento es el primero en establecer recomendaciones de uso de la polipíldora CV en enfermedad cerebrovascular, aparte de sus ventajas sobre la adherencia

INTRODUCTION: There is little control of cardiovascular (CV) risk factors in secondary prevention after an ischaemic stroke, in part due to a lack of adherence to treatment. The CV polypill may contribute to proper treatment adherence, which is necessary for CV disease prevention. This study aimed to establish how and in what cases the CV polypill should be administered. METHODS: A group of 8 neurologists drafted consensus recommendations using structured brainstorming and based on their experience and a literature review. RESULTS: These recommendations are based on the opinion of the participating experts. The use of the CV polypill is beneficial for patients, healthcare professionals, and the health system. Its use is most appropriate for atherothrombotic stroke, lacunar stroke, stroke associated with cognitive impairment, cryptogenic stroke with CV risk factors, and silent cerebrovascular disease. It is the preferred treatment in cases of suspected poor adherence, polymedicated patients, elderly people, patients with polyvascular disease or severe atherothrombosis, young patients in active work, and patients who express a preference for the CV polypill. Administration options include switching from individual drugs to the CV polypill, starting treatment with the CV polypill in the acute phase in particular cases, use in patients receiving another statin or an angiotensin II receptor antagonist, or de novo use if there is suspicion of poor adherence. Nevertheless, use of the CV polypill requires follow-up on the achievement of the therapeutic objectives to make dose adjustments. CONCLUSIONS: This document is the first to establish recommendations for the use of the CV polypill in cerebrovascular disease, beyond its advantages in terms of treatment adherence

Statin Use in Older Adults with Stable Atherosclerotic Cardiovascular Disease.

BACKGROUND/OBJECTIVES: Older adults (>75 years of age) represent two-thirds of atherosclerotic cardiovascular disease (ASCVD) deaths. The 2013 and 2018 American multi-society cholesterol guidelines recommend using at least moderate intensity statins for older adults with ASCVD. We examined annual trends and statin prescribing patterns in a multiethnic population of older adults with ASCVD. DESIGN: Retrospective longitudinal study using electronic health record (EHR) data from 2007 to 2018. SETTING: A large multi-specialty health system in Northern California. PARTICIPANTS: A total of 24,651 adults older than 75 years with ASCVD. MEASUREMENTS: Statin prescriptions for older adults with known ASCVD were trended over time. Multivariable regression models were used to identify predictors of statin prescription (logistic) after controlling for relevant demographic and clinical factors. RESULTS: The study cohort included 24,651 patients older than 75 years; 48% were women. Although prescriptions for moderate/high intensity statins increased over time for adults over 75, fewer than half of the patients (45%) received moderate/high intensity statins in 2018. Women (odds ratio (OR) = 0.77; 95% confidence interval (CI) = 0.74, 0.80), patients who had heart failure (OR = 0.69; 95% CI = 0.65, 0.74), those with dementia (OR = 0.88; 95% CI = 0.82, 0.95) and patients who were underweight (OR = 0.64; 95% CI = 0.57, 0.73) were less likely to receive moderate/high intensity statins. CONCLUSIONS: Despite increasing prescription rates between 2007 and 2018, guideline-recommended statins remained underused in older adults with ASCVD, with more pronounced disparities among women and those with certain comorbidities. Future studies are warranted to examine reasons for statin underuse in older adults with ASCVD.

Consensus statement of the Spanish Society of Internal Medicine and the Spanish Society of Medical Oncology on secondary thromboprophylaxis in patients with cancer.

Up to 20% of cancer patients will develop some manifestation of venous thromboembolic disease (VTD) during their clinical course. VTD greatly impacts morbidity, mortality, quality of life and pharmaceutical expenditure. In addition, both thrombotic relapse and major haemorrhages derived from VTD treatment are more likely in oncological patients. To make the decision to establish secondary thromboprophylaxis as an indefinite treatment in these patients, it is important to review all the risk factors involved, whether related to the disease, the patient or the prior thrombotic event. The objectives of this consensus of the Spanish Society of Internal Medicine (Sociedad Española de Medicina Interna-SEMI) and the Spanish Society of Medical Oncology (Sociedad Española de Oncología Médica-SEOM) are to establish recommendations that help assess the risk of recurrence of VTD and haemorrhagic risk in patients with cancer, as well as to analyse the evidence that exists on the currently available drugs, which will allow the establishment of a protocol for shared decision-making with the informed patient.

Chronic mesenteric ischemia: Clinical practice guidelines from the Society for Vascular Surgery.

BACKGROUND: Chronic mesenteric ischemia (CMI) results from the inability to achieve adequate postprandial intestinal blood flow, usually from atherosclerotic occlusive disease at the origins of the mesenteric vessels. Patients typically present with postprandial pain, food fear, and weight loss, although they can present with acute mesenteric ischemia and bowel infarction. The diagnosis requires a combination of the appropriate clinical symptoms and significant mesenteric artery occlusive disease, although it is often delayed given the spectrum of gastrointestinal disorders associated with abdominal pain and weight loss. The treatment goals include relieving the presenting symptoms, preventing progression to acute mesenteric ischemia, and improving overall quality of life. These practice guidelines were developed to provide the best possible evidence for the diagnosis and treatment of patients with CMI from atherosclerosis. METHODS: The Society for Vascular Surgery established a committee composed of vascular surgeons and individuals experienced with evidence-based reviews. The committee focused on six specific areas, including the diagnostic evaluation, indications for treatment, choice of treatment, perioperative evaluation, endovascular/open revascularization, and surveillance/remediation. A formal systematic review was performed by the evidence team to identify the optimal technique for revascularization. Specific practice recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation system based on review of literature, the strength of the data, and consensus. RESULTS: Patients with symptoms consistent with CMI should undergo an expedited workup, including a computed tomography arteriogram, to exclude other potential causes. The diagnosis is supported by significant arterial occlusive disease in the mesenteric vessels, particularly the superior mesenteric artery. Treatment requires revascularization with the primary target being the superior mesenteric artery. Endovascular revascularization with a balloon-expandable covered intraluminal stent is the recommended initial treatment with open repair reserved for select younger patients and those who are not endovascular candidates. Long-term follow-up and surveillance are recommended after revascularization and for asymptomatic patients with severe mesenteric occlusive disease. Patient with recurrent symptoms after revascularization owing to recurrent stenoses should be treated with an endovascular-first approach, similar to the de novo lesion. CONCLUSIONS: These practice guidelines were developed based on the best available evidence. They should help to optimize the care of patients with CMI. Multiple areas for future research were identified.

Risk stratification and secondary prevention post-myocardial infarction: insights from the EYESHOT Post-MI study.

AIMS: Clinical management of patients more than 1 year after acute myocardial infarction (MI) is challenging. Patient risk stratification may help to establish therapeutic priorities. We aimed to describe the comprehensive risk profile and management of patients with prior MI. METHODS: We analyzed data from the EYESHOT Post-MI study, which evaluated the management of patients 1-3 years after MI. The risk profile of participants was defined according to the qualifying high-risk features of the PEGASUS-TIMI 54 trial (history of diabetes, history of recurrent MI, angiographic evidence of multivessel coronary disease, chronic kidney disease with estimated glomerular filtration rate <60 ml/min, age ≥65 years). Patients were classified into five subgroups according to the presence of zero, one, two, three, or more than three features. RESULTS: Of the 1633 patients in the EYESHOT Post-MI study, 1008 could be stratified according to PEGASUS-TIMI 54 high-risk features. About 22% of patients had no high-risk features, whereas 25% showed at least three features. The prevalence of patients with specific clinical severity indicators was progressively higher with the increasing number of high-risk features. Dual antiplatelet therapy and oral anticoagulation were more frequently used in patients with an increasing number of high-risk features (P for trend <0.0001). Lipid-lowering therapies were less frequently prescribed in patients with a higher number of features (P for trend 0.006 for statins; P for trend 0.007 for ezetimibe). CONCLUSION: Higher-risk post-MI patients, identified by PEGASUS-TIMI 54 high-risk features, showed an increased prevalence of major clinical severity indicators. Secondary prevention therapies were not adequately implemented in higher-risk patients.

["European Commission Initiative on Breast Cancer": Selected Breast Cancer Screening Recommendations from the European Guidelines.] / "European Commission Initiative on Breast Cancer": Recomendaciones seleccionadas de cribado de cáncer de mama de las guías europeas.

OBJECTIVE: The European Commission Initiative on Breast Cancer (ECIBC) has developed new recommendations on breast cancer screening and diagnosis. The objective of this work was to adapt these recommendations to Spanish in order to implement and guarantee the quality and success of breast cancer screening programmes (PCCM) throughout the Spanish territory. METHODS: The new European Guidelines on Screening and Diagnosis of Breast Cancer have been prepared by a multidisciplinary panel of experts and patients (Guidelines Development Group, GDG). The recommendations inclu-ded are supported by systematic reviews of the evidence conducted by a team of researchers from the Ibero-American Cochrane Center. For its preparation, the European Commission's conflict of interest management rules were applied and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used. The GRADE evidence-to-decision (EtD) frameworks were used to minimize potential influence of interests on the recommendations. RESULTS: As a result of the systematic reviews carried out, the GDG published on the ECIBC website a list of recommendations as part of the guidelines for the screening and diagnosis of breast cancer, which were translated into Spanish in this work. CONCLUSIONS: The adaptation to Spanish of the new recommendations helps their implementation and the creation of a uniform PCCM throughout the Spanish territory. All of this improves informed decision making and the success of PCCM.

OBJETIVO: La European Commission Initiative on Breast Cancer (ECIBC) ha desarrollado nuevas recomendaciones sobre cribado y diagnóstico de cáncer de mama. El objetivo de este trabajo fue adaptar dichas recomendaciones al castellano con el fin de implementar y garantizar la calidad y el éxito de los programas de cribado de cáncer de mama (PCCM) en todo el territorio español. METODOS: Las nuevas Guías Europeas sobre Cribado y Diagnóstico de Cáncer de Mama han sido elaboradas por un panel multidisciplinar de expertos y pacientes (Guidelines Development Group, GDG). Las recomendaciones que se incluyen se apoyan en revisiones sistemáticas de la evidencia realizadas por un equipo de investigadores del Centro Cochrane Iberoamericano. Para su elaboración se aplicaron las reglas de manejo de conflicto de intereses de la Comisión Europea y se utilizó la metodología GRADE (Grading of Recommendations Assessment, Development and Evaluation). Se utilizaron los marcos de la evidencia a la decisión (EtD) de GRADE para minimizar posibles influencias de intereses en las recomendaciones. RESULTADOS: Como resultado de las revisiones sistemáticas realizadas, el GDG publicó en la web de la ECIBC una lista de recomendaciones como parte de las guías para el cribado y diagnóstico del cáncer de mama, que fueron traducidas al castellano en este trabajo. CONCLUSIONES: La adaptación al castellano de las nuevas recomendaciones ayuda a su implementación y a crear un PCCM uniforme en todo el territorio español. Todo ello mejora la toma de decisiones informadas y el éxito de los PCCM.

Sunscreen application technique amongst patients with a history of skin cancer.

BACKGROUND: Data on how patients with a history of skin cancer apply sunscreen are lacking. OBJECTIVE: To characterize (1) gender differences in sunscreen application technique (quantity used, anatomic site coverage, and time allocated) and (2) differences in sunscreen application to unaffected skin versus previous skin cancer sites. METHODS: Subjects with a history of skin cancer were asked to apply sunscreen to their head as they normally would. The amount of sunscreen used and application time were recorded. Before and after photos were taken. Using Wood's lamp lighting, an anatomic site coverage score was rated on an ordinal scale (1 = 0-25%, 2 = 26-50%, 3 = 51-75%, 4 = 76-100% coverage). RESULTS: Males used 530 mg more sunscreen (p < 0.001) and applied approximately 5 mg/cm2 of sunscreen versus women, who applied 2 mg/cm2. The average coverage score was 3.27. Males were 7.61 times more likely to adequately apply sunscreen to the ears (p = 0.001). No differences were noted in application times. Coverage scores were similar for unaffected skin and previous skin cancer sites. LIMITATIONS: Observations in a controlled setting may not reflect usual sunscreen application practices. CONCLUSIONS: Overall, skin cancer survivors of both genders effectively applied sunscreen in line with recommended quantity guidelines, but men were significantly better at protecting their ears.

Modification of In-Hospital Recommendation and Prescription of Anticoagulants for Secondary Prevention of Stroke after Launch of Direct Oral Anticoagulants and Change of National Guidelines.

INTRODUCTION: Approximately 1 out of 4 stroke patients suffers ischemic stroke secondary to atrial fibrillation (AF). Although indicated, withholding of anticoagulants for secondary prevention is a widespread phenomenon. OBJECTIVE: We examined the longitudinal change of recommendation and prescription of secondary preventive anticoagulation in AF patients in an acute stroke center setting focusing on the impact of the introduction of direct oral anticoagulants (DOACs) and the change of national stroke prevention guidelines. METHODS: Consecutive patients admitted with an acute cerebrovascular ischemic event underwent regular diagnostic work-up. Pseudonymized clinical data were entered into the institution's stroke registry. In those patients with AF, discharge letters were collected and evaluated for temporal trends and affecting factors of recommended and prescribed antithrombotic secondary medication at the time of discharge from hospital. RESULTS: Of 7,175 patients admitted between January 2009 and December 2018, 1,812 (25.3%) suffered stroke caused by AF. Frequency of patients with recommended anticoagulation increased within the observation period from 66.7 to 95.8% (per year; adjusted odds ratio [OR], 1.309; confidence interval [CI], 1.153-1.486). Independently from this time trend, DOAC approval (adjusted OR, 4.026; CI 1.962-8.265) and guideline change (adjusted OR, 2.184; CI, 1.006-4.743) were associated with an increasing frequency of recommendation for anticoagulation. The rate of patients already receiving recommended anticoagulation for secondary prevention at discharge increased from 42.1 to 62.5%. Introduction of DOACs was not associated with this trend, and guideline change was even associated with decreasing frequency of anticoagulated patients at hospital discharge (adjusted OR, 0.641; CI, 0.414-0.991). Fear of early intracerebral bleeding was the most common reason for withholding anticoagulation (37%) at hospital discharge and stayed stable during the observation period. CONCLUSIONS: Changing national guidelines with discard of contraindications for anticoagulation and the introduction of DOACs led to a broader recommendation of oral anticoagulation. However, both, new guidelines and DOACs, were not found to be associated with an increasing percentage of patients discharged from our hospital already on recommended anticoagulant prevention. This might be explained by the decreasing length of hospital stay during the study period and a missing evidence of early bleeding risk of DOACs in patients with acute brain infarction. Evidence-based data to close this therapeutic gap are needed.