Plasma fibrinogen and risk of vascular recurrence after ischaemic stroke: An individual participant and summary-level data meta-analysis of 11 prospective studies.

INTRODUCTION: Inflammation is an emerging target for secondary prevention after stroke and randomised trials of anti-inflammatory therapies are ongoing. Fibrinogen, a putative pro-inflammatory marker, is associated with first stroke, but its association with major adverse cardiovascular events (MACE) after stroke is unclear. MATERIALS AND METHODS: We did a systematic review investigating the association between fibrinogen and post-stroke vascular recurrence. Authors were invited to provide individual-participant data (IPD) and where available we did within-study multivariable analyses with adjustment for cardiovascular risk factors and medications. Adjusted summary-level data was extracted from published reports from studies that did not provide IPD. We pooled risk ratios (RR) by random-effects meta-analysis by comparing supra-median with sub-median fibrinogen levels and performed pre-specified subgroup analysis according to timing of phlebotomy after the index event. RESULTS: Eleven studies were included (14,002 patients, 42,800 follow-up years), of which seven provided IPD. Fibrinogen was associated with recurrent MACE on unadjusted (RR 1.35, 95% CI 1.17-1.57, supra-median vs sub-median) and adjusted models (RR 1.21, 95% CI 1.06-1.38). Fibrinogen was associated with recurrent stroke on univariate analysis (RR 1.19, 95% CI 1.03-1.39), but not after adjustment (RR 1.11, 95% CI 0.94-1.31). The association with recurrent MACE was consistently observed in patients with post-acute (⩾14 days) fibrinogen measures (RR 1.29, 95% CI 1.16-1.45), but not in those with early phlebotomy (<14 days) (RR 0.98, 95% CI 0.82-1.18) (Pinteraction = 0.01). Similar associations were observed for recurrent stroke. DISCUSSION AND CONCLUSION: Fibrinogen was independently associated with recurrence after stroke, but the association was modified by timing of phlebotomy. Fibrinogen measurements might be useful to identify patients who are more likely to derive benefit from anti-inflammatory therapies after stroke.

An exploration of organizational climate in community-based opiate prescribing services; a mixed methods study.

INTRODUCTION: Assessing the internal dynamics of organizations has been shown to provide information that can help planners and policymakers improve service delivery. A good organizational climate, which in this study incorporates mission clarity, team cohesion, staff autonomy, communication, levels of stress, and openness to change has been shown to be of particular importance. Still, there is a dearth of evidence in this area, and while relationships between organizational factors have been identified, little is known about the mechanisms that might underpin these relationships, and there is little understanding of how to address deficits once they are identified. The objective of this study was to identify relationships between program factors that influence organizational climate and to explore which mechanisms might underpin these relationships. METHODS: This paper reports on a cross-sectional, concurrent, mixed-methods study design, across twelve discrete community-based prescribing service providers (organizations) in Ireland. Data was obtained using a staff survey [n = 132] which utilized measurements of organizational readiness to change and one-to-one interviews [n = 12]. Quantitative data was analyzed using multivariate linear regression modeling which assessed relationships between variables, while interviews were analyzed using an abductive approach, both types of data were synthesized at the interpretation stage. RESULTS: A range of interdependent factors were considered to affect the climate of organizations. Surveys identified that specific types of resources, such as physical infrastructure, training, and staffing resources were important for supporting a good organizational climate, while programs with greater needs had a poorer climate. Opportunities for professional growth, the skill sets of staff, and having access to e-communication were also significant. Interviewees reported that rigid organizational hierarchies and bureaucracy, philosophical views of addiction, stress, and staff turnover were influenced by the provision of fewer resources. Interdependent factors such as leadership, supervision, staff relationships, and collective training, also thought to be influenced by resources, were considered to positively influence programs. Resources were not the only challenge identified, and practices within programs and how existing resources are used were also thought to contribute both positively and negatively to the internal dynamics of services. CONCLUSION: Key findings in this study identified that the organization of effective services is influenced by a range of specific factors, some of which can be addressed without additional resources. Overall, staff views of organizations can provide us with valuable information to support service improvement. Using a mixed methods approach can not only identify where relationships between organizational variables exist but can also help us to understand the mechanisms that underpin these relationships and, importantly, how to address deficits once they are identified. In order to improve how substance misuse services work, the need for a long-term systemic approach to program development, which incorporates some of the findings from this study, is required.

An International, Multidisciplinary Consensus Set of Patient-Centered Outcome Measures for Substance-Related and Addictive Disorders.

Background: In 1990, the United States' Institute of Medicine promoted the principles of outcomes monitoring in the alcohol and other drugs treatment field to improve the evidence synthesis and quality of research. While various national outcome measures have been developed and employed, no global consensus on standard measurement has been agreed for addiction. It is thus timely to build an international consensus. Convened by the International Consortium for Health Outcomes Measurement (ICHOM), an international, multi-disciplinary working group reviewed the existing literature and reached consensus for a globally applicable minimum set of outcome measures for people who seek treatment for addiction. Methods: To this end, 26 addiction experts from 11 countries and 5 continents, including people with lived experience (n = 5; 19%), convened over 16 months (December 2018-March 2020) to develop recommendations for a minimum set of outcome measures. A structured, consensus-building, modified Delphi process was employed. Evidence-based proposals for the minimum set of measures were generated and discussed across eight videoconferences and in a subsequent structured online consultation. The resulting set was reviewed by 123 professionals and 34 people with lived experience internationally. Results: The final consensus-based recommendation includes alcohol, substance, and tobacco use disorders, as well as gambling and gaming disorders in people aged 12 years and older. Recommended outcome domains are frequency and quantity of addictive disorders, symptom burden, health-related quality of life, global functioning, psychosocial functioning, and overall physical and mental health and wellbeing. Standard case-mix (moderator) variables and measurement time points are also recommended. Conclusions: Use of consistent and meaningful outcome measurement facilitates carer-patient relations, shared decision-making, service improvement, benchmarking, and evidence synthesis for the evaluation of addiction treatment services and the dissemination of best practices. The consensus set of recommended outcomes is freely available for adoption in healthcare settings globally.

SMART Family and Friends: Feasibility and outcomes of a video-conference delivered intervention for families impacted by another's methamphetamine use.

INTRODUCTION: Families affected by another's substance use, including methamphetamine, experience harms to their mental and physical health. Yet, research has paid little attention to support and service needs of this population. This pilot study examines the feasibility and outcomes of SMART Family and Friends, a video-conference-delivered mutual-support group targeting families affected by another's methamphetamine use. METHODS: Recruitment for this study occurred between March-October 2021 via the SMART Recovery Australia website. Participants were English-speaking Australian residents, ≥18 years, affected by another's methamphetamine use, interested in participating in a manualised eight-module group delivered via video-conferencing. Feasibility was evaluated by attendance rates, participant satisfaction, fidelity ratings, and semi-structured interviews. Measures of distress, quality of life, and family functioning assessed outcomes at baseline and one-month post-treatment conclusion. RESULTS: Forty-three participants commenced SMART Family and Friends groups. 84 % (n = 36) completed ≥4 modules, 67 % (n = 29) completed ≥6, and 42 % (n = 18) completed all 8 modules. Participant satisfaction (M = 4.32, SD = 0.66, out of 5) and facilitator fidelity (>94 % for all modules) were high. A within-group analysis, without comparison condition demonstrated significant improvements in psychological distress (d = 0.38), family impact (d = 0.64), family strain symptoms (d = 0.48), and total family burden (d = 0.69) post-treatment. Qualitative findings illustrated the benefits and challenges of the video-conference-delivered group, as well as recommendations for improvement. CONCLUSIONS: Results provide initial support for the feasibility and positive outcomes of the SMART Family and Friends program. These findings demonstrate the successful provision of a mutual-support group for affected families delivered via video-conferencing, and merit further sufficiently powered randomised-control-trials to evaluate efficacy.

Statin Therapy for Secondary Prevention in Ischemic Stroke Patients With Cerebral Microbleeds.

BACKGROUND AND OBJECTIVES: The association between statin use and the risk of intracranial hemorrhage (ICrH) following ischemic stroke (IS) or transient ischemic attack (TIA) in patients with cerebral microbleeds (CMBs) remains uncertain. This study investigated the risk of recurrent IS and ICrH in patients receiving statins based on the presence of CMBs. METHODS: We conducted a pooled analysis of individual patient data from the Microbleeds International Collaborative Network, comprising 32 hospital-based prospective studies fulfilling the following criteria: adult patients with IS or TIA, availability of appropriate baseline MRI for CMB quantification and distribution, registration of statin use after the index stroke, and collection of stroke event data during a follow-up period of ≥3 months. The primary endpoint was the occurrence of recurrent symptomatic stroke (IS or ICrH), while secondary endpoints included IS alone or ICrH alone. We calculated incidence rates and performed Cox regression analyses adjusting for age, sex, hypertension, atrial fibrillation, previous stroke, and use of antiplatelet or anticoagulant drugs to explore the association between statin use and stroke events during follow-up in patients with CMBs. RESULTS: In total, 16,373 patients were included (mean age 70.5 ± 12.8 years; 42.5% female). Among them, 10,812 received statins at discharge, and 4,668 had 1 or more CMBs. The median follow-up duration was 1.34 years (interquartile range: 0.32-2.44). In patients with CMBs, statin users were compared with nonusers. Compared with nonusers, statin therapy was associated with a reduced risk of any stroke (incidence rate [IR] 53 vs 79 per 1,000 patient-years, adjusted hazard ratio [aHR] 0.68 [95% CI 0.56-0.84]), a reduced risk of IS (IR 39 vs 65 per 1,000 patient-years, aHR 0.65 [95% CI 0.51-0.82]), and no association with the risk of ICrH (IR 11 vs 16 per 1,000 patient-years, aHR 0.73 [95% CI 0.46-1.15]). The results in aHR remained consistent when considering anatomical distribution and high burden (≥5) of CMBs. DISCUSSION: These observational data suggest that secondary stroke prevention with statins in patients with IS or TIA and CMBs is associated with a lower risk of any stroke or IS without an increased risk of ICrH. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that for patients with IS or TIA and CMBs, statins lower the risk of any stroke or IS without increasing the risk of ICrH.

Separation of Lipoproteins for Quantitative Analysis of 14C-Labeled Lipid-Soluble Compounds by Accelerator Mass Spectrometry.

To date, 14C tracer studies using accelerator mass spectrometry (AMS) have not yet resolved lipid-soluble analytes into individual lipoprotein density subclasses. The objective of this work was to develop a reliable method for lipoprotein separation and quantitative recovery for biokinetic modeling purposes. The novel method developed provides the means for use of small volumes (10-200 µL) of frozen plasma as a starting material for continuous isopycnic lipoprotein separation within a carbon- and pH-stable analyte matrix, which, following post-separation fraction clean up, created samples suitable for highly accurate 14C/12C isotope ratio determinations by AMS. Manual aspiration achieved 99.2 ± 0.41% recovery of [5-14CH3]-(2R, 4'R, 8'R)-α-tocopherol contained within 25 µL plasma recovered in triacylglycerol rich lipoproteins (TRL = Chylomicrons + VLDL), LDL, HDL, and infranatant (INF) from each of 10 different sampling times for one male and one female subject, n = 20 total samples. Small sample volumes of previously frozen plasma and high analyte recoveries make this an attractive method for AMS studies using newer, smaller footprint AMS equipment to develop genuine tracer analyses of lipophilic nutrients or compounds in all human age ranges.

'Selling their souls?' Nurses' understanding of addiction and recovery in acute hospital settings.

BACKGROUND: Nursing disciplines do not currently have a shared understanding of addiction or recovery to address their contribution to their patients' needs. Recent developments of addiction nursing models, alongside an international move to standardise language, is slow to be reflected in nurses' perceptions in acute hospital settings. AIM: To explore nurses' understanding of addiction and recovery in acute general hospitals. METHODS: A qualitative study with semi-structured open-ended questions informed by a prior literature review was undertaken with nurses working in an acute general hospital in Dublin, Ireland. RESULTS: The identified themes were the knowledge of addiction, including physical and psychological needs, and the understanding of recovery, patient-centred services and the impact of the individual's environment. CONCLUSION: Standardising language for addiction and recovery and improving addiction education will give nurses a better understanding of the chronic nature of substance use and the importance of this in providing high-quality health care.

Cognitive remediation in residential substance use treatment: A randomized stepped-wedge trial.

ABSTRACTExecutive dysfunction is common in individuals with substance use disorder (SUD) and presents a barrier to treatment engagement. The study aimed to investigate the effectiveness of cognitive remediation (CR) for improving executive functioning and treatment retention in patients with SUD, using a stepped-wedge cluster randomized controlled trial. The sample included 527 adults enrolled across ten residential SUD treatment providers in NSW, Australia. The intervention consisted of 12 hours of CR delivered over six weeks in a group format. The comparator was treatment-as-usual (TAU). Primary outcomes included self-reported executive functioning and proportion of treatment completed (PoTC), measured as the number of days in treatment divided by the planned treatment duration. Intention-to-treat analysis did not find significant differences for self-reported executive functioning (mean difference = -2.49, 95%CI [-5.07, 0.09], p = .059) or PoTC (adjusted mean ratio = 1.09, 95%CI [0.88, 1.36], p = .442). Due to high dropout from the intention-to-treat sample (56%) a post-hoc analysis was conducted using a per-protocol approach, in which CR was associated with improved self-reported executive functioning (mean difference = -3.33, 95%CI [-6.10, -0.57], p = .019) and improved likelihood of treatment graduation (adjusted odds ratio = 2.43, 95%CI [1.43, 4.11], p < .001). More research is required to develop a CR approach that results in service-wide treatment effectiveness.

C-Reactive Protein, Interleukin-6, and Vascular Recurrence According to Stroke Subtype: An Individual Participant Data Meta-Analysis

BACKGROUND AND OBJECTIVES: Anti-inflammatory therapies reduce major adverse cardiovascular events (MACE) in coronary artery disease but remain unproven after stroke. Establishing the subtype-specific association between inflammatory markers and recurrence risk is essential for optimal selection of patients in randomized trials (RCTs) of anti-inflammatory therapies for secondary stroke prevention. METHODS: Using individual participant data (IPD) identified from a systematic review, we analyzed the association between high-sensitivity C-reactive protein, interleukin-6 (IL-6), and vascular recurrence after ischemic stroke or transient ischemic attack. The prespecified coprimary end points were (1) any recurrent MACE (first major coronary event, recurrent stroke, or vascular death) and (2) any recurrent stroke (ischemic, hemorrhagic, or unspecified) after sample measurement. Analyses were performed stratified by stroke mechanism, per quarter and per biomarker unit increase after loge transformation. We then did study-level meta-analysis with comparable published studies not providing IPD. Preferred Reporting Items for Systematic Review and Meta-Analyses IPD guidelines were followed. RESULTS: IPD was obtained from 10 studies (8,420 patients). After adjustment for vascular risk factors and statins/antithrombotic therapy, IL-6 was associated with recurrent MACE in stroke caused by large artery atherosclerosis (LAA) (risk ratio [RR] 2.30, 95% CI 1.21-4.36, p = 0.01), stroke of undetermined cause (UND) (RR 1.78, 1.19-2.66, p = 0.005), and small vessel occlusion (SVO) (RR 1.71, 0.99-2.96, p = 0.053) (quarter 4 [Q4] vs quarter 1 [Q1]). No association was observed for stroke due to cardioembolism or other determined cause. Similar results were seen for recurrent stroke and when analyzed per loge unit increase for MACE (LAA, RR 1.26 [1.06-1.50], p = 0.009; SVO, RR 1.22 [1.01-1.47], p = 0.04; UND, RR 1.18 [1.04-1.34], p = 0.01). High-sensitivity CRP was associated with recurrent MACE in UND stroke only (Q4 vs Q1 RR 1.45 [1.04-2.03], p = 0.03). Findings were consistent on study-level meta-analysis of the IPD results with 2 other comparable studies (20,136 patients). DISCUSSION: Our data provide new evidence for the selection of patients in future RCTs of anti-inflammatory therapy in stroke due to large artery atherosclerosis, small vessel occlusion, and undetermined etiology according to inflammatory marker profile.

Changes in anticoagulation practice in subjects admitted with stroke associated with atrial fibrillation, following introduction of direct oral anticoagulants over 2013-2021.

BACKGROUND: The adoption of direct oral anticoagulants (DOACs) has changed practice in prevention of stroke in atrial fibrillation (AF). We used Irish data national data on stroke and anticoagulation therapy over 9 years to investigate changes in anticoagulation practice and potential consequences on stroke prevalence and thrombolysis. METHODS: AF, anticoagulation, thrombolysis, and stroke data from the Irish National Audit of Stroke (INAS) 2013-2021 were reviewed. The proportion of patients with ischemic stroke (IS) and intracerebral hemorrhage (IH) with known AF admitted on anticoagulation was determined. Effects on age distribution in the population and thrombolysis practice were assessed. RESULTS: AF data were available on 34,630 of 35,241 individuals (98.3%) included in INAS; median age was 74 years and 56% were male. AF was found in 10,016 (28.9%, 9059 IS, 957 IH). 6313 had known AF prior to stroke (63.1%). The proportion all total IS due to AF decreased by 15.3% (31.3%-26.5%, chi-square = 24.6, p < 0.0001). The proportion of IH did not change significantly (21.6%-20.2%, chi-square = 1.8, p = 0.18). Over the 9 years, 3875 (38.6%) of the subjects with AF were recorded as receiving anticoagulants at admission. In 2013, 4.4% of AF-associated strokes were admitted on a DOAC and 21.4% on warfarin; by 2021, 44.1% were receiving a DOAC and 6.2% warfarin. There was a strong inverse correlation between the proportion of anticoagulated stroke patients and the total proportion of AF-associated strokes over time (r = -0.82, p = 0.006). In contrast, no correlation was found between increasing DOAC usage and IH (r = 0.14, p = 0.71). Increased anticoagulation usage correlated with a reduction in patients ⩾ 80 years (r = -0.83, p = 0.006) and also correlated with a relative reduction of 30.1% in subjects thrombolysed <4 h from onset (r = -0.89, p = 0.001). CONCLUSION: DOACs have led to increased use of anticoagulation, but warfarin use fell by two-thirds. There has been a reduction in the proportion of AF-associated IS without a noticeable increase in IH. Increased anticoagulation correlated with reduced numbers of strokes in those >80 years and in the proportion of patients thrombolysed.

'Quitlink': Outcomes of a randomised controlled trial of peer researcher facilitated referral to a tailored quitline tobacco treatment for people receiving mental health services.

OBJECTIVE: The aim of this study was to test the effectiveness of a tailored quitline tobacco treatment ('Quitlink') among people receiving support for mental health conditions. METHODS: We employed a prospective, cluster-randomised, open, blinded endpoint design to compare a control condition to our 'Quitlink' intervention. Both conditions received a brief intervention delivered by a peer researcher. Control participants received no further intervention. Quitlink participants were referred to a tailored 8-week quitline intervention delivered by dedicated Quitline counsellors plus combination nicotine replacement therapy. The primary outcome was self-reported 6 months continuous abstinence from end of treatment (8 months from baseline). Secondary outcomes included additional smoking outcomes, mental health symptoms, substance use and quality of life. A within-trial economic evaluation was conducted. RESULTS: In total, 110 participants were recruited over 26 months and 91 had confirmed outcomes at 8 months post baseline. There was a difference in self-reported prolonged abstinence at 8-month follow-up between Quitlink (16%, n = 6) and control (2%, n = 1) conditions, which was not statistically significant (OR = 8.33 [0.52, 132.09] p = 0.131 available case). There was a significant difference in favour of the Quitlink condition on 7-day point prevalence at 2 months (OR = 8.06 [1.27, 51.00] p = 0.027 available case). Quitlink costs AU$9231 per additional quit achieved. CONCLUSION: The Quitlink intervention did not result in significantly higher rates of prolonged abstinence at 8 months post baseline. However, engagement rates and satisfaction with the 'Quitlink' intervention were high. While underpowered, the Quitlink intervention shows promise. A powered trial to determine its effectiveness for improving long-term cessation is warranted.

Generalisability of the interpersonal theory of suicide to latent profiles of young people attending treatment in a suicide prevention service.

OBJECTIVE: The Interpersonal Theory of Suicide (ITS) could help identify differences in groups of suicidal adolescents and inform treatment. METHOD: Latent Profile Analysis (LPA) using thwarted belongingness (TB), perceived burdensomeness (PB), hopelessness, and capability was conducted on data from an at-risk clinical sample (N = 500). The ITS prediction that changes in TB and PB are associated with changes in suicidal ideation was tested using admission and discharge data. RESULTS: Latent Profile Analysis identified three profiles with increasing complexity and severity on ITS factors. The profiles were labelled low-severity (7.6% of participants), moderate-severity (45.2%), and high-severity (47.2%). ITS predictions were partially supported for the full sample and only for the high-severity and moderate-severity subgroups, whereby changes in TB were significantly associated with changes in suicidal ideation over the course of treatment. However, changes in PB were only significant in the moderate-severity subgroup, and none of the ITS predictions were supported in the low-severity subgroup. Additionally, effect sizes for changes in TB and PB were modest in all analyses. CONCLUSIONS: Our findings highlight the importance reducing low belongingness in youth, which is a component of all supported interventions of youth suicide prevention. However, given the modest association of changes in ITS variables had with changes in suicidal ideation, it may be fruitful to elaborate on the relative importance on types of low belongingness or include other non-ITS variables.

Novel Targets for Molecular Imaging of Inflammatory Processes of Carotid Atherosclerosis: A Systematic Review.

Computed tomography angiography (CTA), magnetic resonance angiography (MRA) and 18F-FDG-PET have proven clinical value when evaluating patients with carotid atherosclerosis. In this systematic review, we will focus on the role of novel molecular imaging tracers in that assessment and their potential strengths to stratify stroke risk. We systematically searched PubMed, Embase, the Web of Science Core Collection, and Cochrane Library for articles reporting on molecular imaging to noninvasively detect or characterize inflammation in carotid atherosclerosis. As our focus was on nonclassical novel targets, we omitted reports solely on 18F-FDG and 18F-NaF. We summarized and mapped the selected studies to provide an overview of the current clinical development in molecular imaging in relation to risk factors, imaging and histological findings, diagnostic and prognostic performance. We identified 20 articles in which the utilized tracers to visualize carotid wall inflammation were somatostatin subtype-2- (SST2-) (n = 5), CXC-motif chemokine receptor 4- (CXCR4-) (n = 3), translocator protein- (TSPO-) (n = 2) and aVß3 integrin-ligands (n = 2) and choline-tracers (n = 2). Tracer uptake correlated with traditional cardiovascular risk factors, that is, age, gender, diabetes, hypercholesterolemia, and hypertension as well as prior cardiovascular disease. We identified discrepancies between tracer uptake and grade of stenosis, plaque calcification, and 18F-FDG uptake, suggesting the importance of alternative characterization of atherosclerosis beyond classical neuroimaging features. Immunohistochemical analysis linked tracer uptake to markers of macrophage infiltration and neovascularization. Symptomatic carotid arteries showed higher uptake compared to asymptomatic (including contralateral, nonculprit) arteries. Some studies demonstrated a potential role of these novel molecular imaging as a specific intermediary (bio)marker for outcome. Several novel tracers show promise for identification of high-risk plaque inflammation. Based on the current evidence we cautiously propose the SST2-ligands and the choline radiotracers as viable candidates for larger prospective longitudinal outcome studies to evaluate their predictive use in clinical practice.

Targeting inflammation to reduce recurrent stroke.

BACKGROUND: Approximately one in four stroke patients suffer from recurrent vascular events, underlying the necessity to improve secondary stroke prevention strategies. Immune mechanisms are causally associated with coronary atherosclerosis. However, stroke is a heterogeneous disease and the relative contribution of inflammation across stroke mechanisms is not well understood. The optimal design of future randomized control trials (RCTs) of anti-inflammatory therapies to prevent recurrence after stroke must be informed by a clear understanding of the prognostic role of inflammation according to stroke subtype and individual patient factors. AIM: In this narrative review, we discuss (1) inflammatory pathways in the etiology of ischemic stroke subtypes; (2) the evidence on inflammatory markers and vascular recurrence after stroke; and (3) review RCT evidence of anti-inflammatory agents for vascular prevention. SUMMARY OF REVIEW: Experimental work, genetic epidemiological data, and plaque-imaging studies all implicate inflammation in atherosclerotic stroke. However, emerging evidence also suggests that inflammatory mechanisms are also important in other stroke mechanisms. Advanced neuroimaging techniques support the role of neuroinflammation in blood-brain barrier dysfunction in cerebral small vessel disease (cSVD). Systemic inflammatory processes also promote atrial cardiopathy, incident and recurrent atrial fibrillation (AF). Although several inflammatory markers have been associated with recurrence after stroke, interleukin-6 (IL-6) and high-sensitivity C-reactive protein (hsCRP) are presently the most promising markers to identify patients at increased vascular risk. Several RCTs have shown that anti-inflammatory therapies reduce vascular risk, including stroke, in coronary artery disease (CAD). Some, but not all of these trials, selected patients on the basis of elevated hsCRP. Although unproven after stroke, targeting inflammation to reduce recurrence is a compelling strategy and several RCTs are ongoing. CONCLUSION: Evidence points toward the importance of inflammation across multiple stroke etiologies and potential benefit of anti-inflammatory targets in secondary stroke prevention. Taking the heterogeneous stroke etiologies into account, the use of serum biomarkers could be useful to identify patients with residual inflammatory risk and perform biomarker-led patient selection for future RCTs.

An Exploration of Organizational Characteristics and Training Adoption in Irish Community Drug Treatment Services.

BACKGROUND: Changes in patterns of drug use and population needs necessitate the adoption of new technologies. Despite high failure rates in adopting new technologies acquired in training, little is known about the process that can support successful change. This study explores the impact that staff and service characteristics have on the process of training adoption in Irish opiate substitution therapy services, with a specific focus on the concept of organizational readiness to change. METHODS: A cross-sectional survey was conducted on a convenience sample of 132 staff members across 12 services in Ireland. The relationship between staff demographics, their perceptions of organizational readiness to change, burnout, and a four-stage process of training adoption were considered. RESULTS: Discipline, job tenure, and educational levels are important predictors of engagement in the adoption process. Staff in services with higher institutional needs, greater pressures for change, and poorer resources were less likely to be exposed to, or adopt, training. Having lower levels of stress and more influence with peers was associated with better adoption of training. CONCLUSIONS: Planners and service managers need to carefully consider the composition or dynamics of services when initiating change. Organizational readiness to change and staff characteristics as measured by instruments used in this study are important determinants of the process of innovation or training adoption and provide a good basis for developing further understanding of how treatment services work. This article expands on results from previous studies conducted in the United States to a European context.

The benefits and challenges of virtual SMART recovery mutual-help groups: Participant and facilitator perspectives.

BACKGROUND: COVID-19 prompted widespread transition of face-to-face mutual-help groups to virtual delivery. Current understanding of the experience of virtual mutual-help groups is limited to 12-step approaches or asynchronous groups (e.g., forums). This paper explores participant and facilitator perspectives regarding the benefits and challenges of accessing SMART Recovery mutual-help groups virtually via videoconference. METHODS: A self-selected convenience sample of participants (n = 29) and facilitators (n = 15) from SMART Recovery mutual-help groups in Australia were enrolled. Participants and facilitators were sampled to reflect experience of virtual groups delivered via videoconference ('online'), face-to-face groups ('face-to-face') or both types of groups ('both'). Telephone qualitative interviews were conducted using a semi-structured interview guide. Interviews were audio-recorded, transcribed, and analysed using iterative categorisation. RESULTS: Participant and facilitators discussed their experience across eight interconnected themes benefits were typically discussed with regard to the (1) availability, (2) ease of access and (3) value add of the chat feature in online groups. Challenges largely pertained to (1) in-group engagement, (2) group size, (3) non-verbal cues, (4) social interaction and (5) technology problems. The impact of these challenges on participant and facilitator experience varied, and neither modality was consistently identified as superior. CONCLUSIONS: SMART Recovery mutual-help groups provided participants with another option for accessing mutual-help and appealed to different people under different circumstances. Depending on the needs and preferences of the individual, online SMART Recovery mutual-help groups may help to mitigate a range of barriers to help seeking and may also engage people otherwise unable or reluctant to engage in treatment. To inform training, practice and policy, improved understanding of the individual and contextual factors that enhance participant engagement, experience and outcomes is needed.

The hospital care and outcomes of long-term care patients treated by paramedics during an emergency call: exploring the potential impact of 'treat-and-refer' pathways and community paramedicine.

INTRODUCTION: Adults living in long-term care (LTC) are at increased risk of harm when transferred to the emergency department (ED), and programs targeting treatment on-site are increasing. We examined characteristics, clinical course, and disposition of LTC patients transported to the ED to examine the potential impact of alternative models of paramedic care for LTC patients. METHODS: We conducted a health records review of paramedic and ED records between April 1, 2016, and March 31, 2017. We included emergency calls originating from LTC centers and patients transported to either ED campus of The Ottawa Hospital. We excluded scheduled or deferrable transfers, and patients with Canadian Triage and Acuity Scale of 1. We categorized patients into groups based on care they received in the ED. We calculated standardized differences to examine differences between groups. RESULTS: We identified four groups: (1) patients requiring no treatment or diagnostics in the ED (7.9%); (2) patients receiving ED treatment within current paramedic directives and no diagnostics (3.2%); (3) patients requiring diagnostics or ED care outside current paramedic directives (54.9%); and (4) patients requiring admission (34.1%). CONCLUSION: This study found 7.9% of LTC patients transported to the ED did not receive diagnostics, medications, or treatment, and overall 11.1% of patients could have been treated by paramedics within current medical directives using 'treat-and-refer' pathways. This group could potentially expand utilizing community paramedics with expanded scopes of practice.

RéSUMé: INTRODUCTION: Les adultes qui vivent dans des établissements de soins de longue durée (SLD) courent un risque accru de subir des préjudices lorsqu'ils sont transférés à l'urgence (SU), et les programmes ciblant le traitement sur place augmentent. Nous avons examiné les caractéristiques, l'évolution clinique et la disposition des patients en SLD transportés à l'urgence afin d'examiner l'impact potentiel des modèles alternatifs de soins paramédicaux pour les patients en SLD. MéTHODES: Nous avons effectué un examen des dossiers médicaux des paramédics et des SU entre le 1er avril 2016 et le 31 mars 2017. Nous avons inclus les appels d'urgence provenant des centres de soins de longue durée et les patients transportés à l'un ou l'autre des campus de l'Hôpital d'Ottawa. Nous avons exclu les transferts planifiés ou reportables et les patients ayant un score d'acuité au triage canadien de 1. Nous avons catégorisé les patients en groupes en fonction des soins reçus à l'urgence. Nous avons calculé des différences normalisées pour examiner les différences entre les groupes. RéSULTATS: Nous avons identifié 4 groupes : 1) les patients qui n'ont pas besoin de traitement ou de diagnostic à l'urgence (7,9 %); 2) les patients qui reçoivent un traitement à l'urgence selon les directives actuelles des ambulanciers et aucun diagnostic (3,2 %); 3) les patients qui ont besoin de diagnostics ou de soins à l'urgence en dehors des directives actuelles des ambulanciers (54,9 %); et 4) patients nécessitant une admission (34,1 %). CONCLUSION: Cette étude a révélé que 7,9 % des patients en SLD transportés à l'urgence n'ont pas reçu de diagnostic, de médicaments ou de traitement et, dans l'ensemble, 11,1 % des patients auraient pu être traités par des ambulanciers paramédicaux selon les directives médicales actuelles en utilisant les voies de traitement et d'aiguillage. Ce groupe pourrait potentiellement prendre de l'expansion en utilisant des ambulanciers paramédicaux communautaires avec des champs de pratique élargis.

The health of people attending residential treatment for alcohol and other drug use: Prevalence of and risks for major lifestyle diseases.

INTRODUCTION: Cardiovascular disease and cancers are the leading cause of mortality amongst people accessing treatment for alcohol and other drug use. The current study aimed to examine risk factors for chronic disease amongst people attending residential alcohol and other drug treatment services. METHODS: Participants (N = 325) were attending residential alcohol and other drug treatment services across Australia. Diabetes and cardiovascular disease risk scores were calculated using established risk estimation algorithms. Differences in existing health conditions, risk factors for chronic diseases and risk algorithms were calculated for males and females. RESULTS: In addition to alcohol and other drug use (including tobacco use), 95% of the sample had at least one other risk factor for chronic disease. Of participants not already diagnosed, 36% were at a high risk of developing type 2 diabetes and 11% had a high risk of developing cardiovascular disease. The heart age of participants was 11 years older than actual age (Mage = 40.63, Mheart age = 52.41). Males had a higher cardiovascular disease risk than females. DISCUSSION AND CONCLUSIONS: A large proportion of people accessing residential alcohol and other drug treatment were at risk of chronic disease. Future research is needed that uses objective indicators of physical health. Such research will help to develop our understanding of prevention and intervention initiatives that could be adopted by treatment providers to improve the physical health of their consumers.

Imaging Carotid Plaque Inflammation Using Positron Emission Tomography: Emerging Role in Clinical Stroke Care, Research Applications, and Future Directions.

Atherosclerosis is a chronic systemic inflammatory condition of the vasculature and a leading cause of stroke. Luminal stenosis severity is an important factor in determining vascular risk. Conventional imaging modalities, such as angiography or duplex ultrasonography, are used to quantify stenosis severity and inform clinical care but provide limited information on plaque biology. Inflammatory processes are central to atherosclerotic plaque progression and destabilization. 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) is a validated technique for quantifying plaque inflammation. In this review, we discuss the evolution of FDG-PET as an imaging modality to quantify plaque vulnerability, challenges in standardization of image acquisition and analysis, its potential application to routine clinical care after stroke, and the possible role it will play in future drug discovery.

Trauma Informed Interventions to Reduce Seclusion, Restraint and Restrictive Practices Amongst Staff Caring for Children and Adolescents with Challenging Behaviours: A Systematic Review.

Engaging with children and adolescents in mental health settings who are exhibiting behaviours that challenge can often result in the use of seclusion, restraint and coercive practices. It is recognised that more therapeutic ways to engage this population are needed, adopting trauma informed interventions may provide a solution. The aim of this systematic review is to synthesize the evidence in relation to the effect of trauma-informed interventions on coercive practices in child and adolescent residential settings. The review is guided by elements of the Cochrane Handbook for Systematic Reviews of Interventions and reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) checklist. Results were synthesized and reported narratively. Nine studies met the eligibility criteria for this review. There was a lack of homogeneity amongst the studies. The trauma-informed interventions used were typically multi-faceted, underpinned by a variety of approaches and sought to bring about changes to clinical practice. Most studies (n = 8) reported significant reductions in the use of restrictive practices following the implementation of a trauma informed approach. The use of a trauma-informed approach, underpinned by an organisational change or implementation strategy, have the potential to reduce coercive practices with children and adolescents. However, the included interventions were insufficiently described to draw strong conclusions.