In Search of a Gold Standard Tool for Assessing Knowledge of Stroke: A Systematic Review.

BACKGROUND: Knowledge of stroke is essential to empower people to reduce their risk of these events. However, valid tools are required for accurate and reliable measurement of stroke knowledge. We aimed to systematically review contemporary stroke knowledge assessment tools and appraise their content validity, feasibility, and measurement properties. METHODS: The protocol was registered in PROSPERO (CRD42023403566). Electronic databases (MEDLINE, PsycInfo, CINAHL, Embase, Scopus, Web of Science) were searched to identify published articles (1 January 2015-1 March 2023), in which stroke knowledge was assessed using a validated tool. Two reviewers independently screened titles and abstracts prior to undertaking full-text review. COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methods guided the appraisal of content validity (relevance, comprehensiveness, comprehensibility), feasibility, and measurement properties. RESULTS: After removing duplicates, the titles and abstracts of 718 articles were screened; 323 reviewed in full; with 42 included (N = 23 unique stroke knowledge tools). For content validity, all tools were relevant, two were comprehensive, and seven were comprehensible. Validation metrics were reported for internal consistency (n = 20 tools), construct validity (n = 17 tools), cross-cultural validity (n = 15 tools), responsiveness (n = 9 tools), reliability (n = 7 tools), structural validity (n = 3 tools), and measurement error (n = 1 tool). The Stroke Knowledge Test met all content validity criteria, with validation data for six measurement properties (n = 3 rated "Sufficient"). CONCLUSION: Assessment of stroke knowledge is not standardised and many tools lacked validated content or measurement properties. The Stroke Knowledge Test was the most comprehensive but requires updating and further validation for endorsement as a gold standard.

A Scoping Review of mHealth Interventions for Secondary Prevention of Stroke: Implications for Policy and Practice.

Secondary prevention is a major priority for those living with stroke and may be improved through the use of mobile Health (mHealth) interventions. While evidence for the effectiveness of mHealth interventions for secondary prevention of stroke is growing, little attention has been given to the translation of these interventions into real-world use. In this review, we aimed to provide an update on the effectiveness of mHealth interventions for secondary prevention of stroke, and investigate their translation into real-world use. Four electronic databases and the gray literature were searched for randomized controlled trials of mHealth interventions for secondary prevention of stroke published between 2010 and 2023. Qualitative and mixed-methods evaluations of the trials were also included. Data were extracted regarding study design, population, mHealth technology involved, the intervention, and outcomes. Principal researchers from these trials were also contacted to obtain further translational information. From 1151 records, 13 randomized controlled trials and 4 evaluations were identified; sample sizes varied widely (median, 56; range, 24-4298). Short message service messages (9/13) and smartphone applications (6/13) were the main technologies used to deliver interventions. Primary outcomes of feasibility of the intervention were achieved in 4 trials, and primary outcomes of changes in risk factors, lifestyle behaviors, and adherence to medication improved in 6 trials. Only 1 trial had a hard end point (ie, stroke recurrence) as a primary outcome, and no significant differences were observed between groups. There was evidence for only 1 intervention being successfully translated into real-world use. Further evidence is required on the clinical effectiveness of mHealth interventions for preventing recurrent stroke, and the associated delivery costs and cost-effectiveness, before adoption into real-world settings.

Socioeconomic status and health-related quality of life after stroke: a systematic review and meta-analysis.

BACKGROUND: Socioeconomic status (SES) is associated with stroke occurrence and survival following stroke but its association with health-related quality of life (HRQoL) following stroke remains uncertain. We performed a systematic review and meta-analysis to examine the association between SES and HRQoL after stroke. METHODS: PubMed, SCOPUS, EMBASE, and Web of Science were searched to identify relevant cohort and case-control studies between January 2000 and May 2022. Two authors screened titles, abstracts and full text articles. One author extracted data from all included studies. Meta-analyses were performed for studies with comparable measurements of SES and HRQoL. Random effects models were used to estimate pooled summary standardised mean differences in HRQoL by SES. RESULTS: Out of 1,876 citations, 39 studies incorporated measurement of overall HRQoL following stroke and were included in the systematic review, with 17 studies included in the meta-analyses. Overall, reports including education, income, occupation and work status effects on HRQoL after stroke were inconsistent among all included 39 studies. In the global meta-analysis of 17 studies, HRQoL among survivors of stroke was lower in the low SES group than in the high SES group (standardised mean difference (SMD) -0.36, 95% CI -0.52, -0.20, p < 0.0001). When using education and income indicators separately, summary effects were similar to those of the global analysis (low versus high education SMD -0.38, 95% CI -0.57, -0.18, p < 0.0001; low versus high income SMD -0.39, 95% CI -0.59, -0.19, p < 0.0001). CONCLUSIONS: Across all SES indicators, people with stroke who have lower SES have poorer overall HRQoL than those with higher SES. Accessibility and affordability of poststroke support services should be taken into consideration when planning and delivering services to people with low SES.

trips4health: a single-blinded randomised controlled trial incentivising adult public transport use for physical activity gain.

BACKGROUND: Public transport users tend to accumulate more physical activity than non-users; however, whether physical activity is increased by financially incentivising public transport use is unknown. The trips4health study aimed to determine the impact of an incentive-based public transport intervention on physical activity. METHODS: A single-blinded randomised control trial of a 16-week incentive-based intervention involved Australian adults who were infrequent bus users (≥ 18 years; used bus ≤ 2 times/week) split equally into intervention and control groups. The intervention group were sent weekly motivational text messages and awarded smartcard bus credit when targets were met. The intervention group and control group received physical activity guidelines. Accelerometer-measured steps/day (primary outcome), self-reported transport-related physical activity (walking and cycling for transport) and total physical activity (min/week and MET-min/week) outcomes were assessed at baseline and follow-up. RESULTS: Due to the COVID pandemic, the trial was abandoned prior to target sample size achievement and completion of all assessments (N = 110). Steps/day declined in both groups, but by less in the intervention group [-557.9 steps (-7.9%) vs.-1018.3 steps/week (-13.8%)]. In the intervention group, transport-related physical activity increased [80.0 min/week (133.3%); 264.0 MET-min/week (133.3%)] while total physical activity levels saw little change [35.0 min/week (5.5%); 25.5 MET-min/week (1.0%)]. Control group transport-related physical activity decreased [-20.0 min/week (-27.6%); -41.3 MET-min/week (-17.3%)], but total physical activity increased [260.0 min/week (54.5%); 734.3 MET-min/week (37.4%)]. CONCLUSION: This study found evidence that financial incentive-based intervention to increase public transport use is effective in increasing transport-related physical activity These results warrant future examination of physical activity incentives programs in a fully powered study with longer-term follow-up. TRIAL REGISTRATION: This trial was registered with the Australian and New Zealand Clinical Trials Registry August 14th, 2019: ACTRN12619001136190; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377914&isReview=true.

Antihypertensive Medication Adherence and the Risk of Vascular Events and Falls After Stroke: A Real-World Effectiveness Study Using Linked Registry Data.

BACKGROUND: Real-world evidence is limited on whether antihypertensive medications help avert major adverse cardiovascular events (MACE) after stroke without increasing the risk of falls. We investigated the association of adherence to antihypertensive medications on the incidence of MACE and falls requiring hospitalization after stroke. METHODS: A retrospective cohort study of adults who were newly dispensed antihypertensive medications after an acute stroke (Australian Stroke Clinical Registry 2012-2016; Queensland and Victoria). Pharmaceutical dispensing records were used to determine medication adherence according to the proportion of days covered in the first 6 months poststroke. Outcomes between 6 and 18 months postdischarge included: (i) MACE, a composite outcome of all-cause death, recurrent stroke or acute coronary syndrome; and (ii) falls requiring hospitalization. Estimates were derived using Cox models, adjusted for >30 confounders using inverse probability treatment weights. RESULTS: Among 4076 eligible participants (median age 68 years; 37% women), 55% had a proportion of days covered ≥80% within 6 months postdischarge. In the subsequent 12 months, 360 (9%) participants experienced a MACE and 337 (8%) experienced a fall requiring hospitalization. After achieving balance between groups, participants with a proportion of days covered ≥80% had a reduced risk of MACE (hazard ratio: 0.68; 95% CI: 0.54-0.84) and falls requiring hospitalization (subdistribution hazard ratio: 0.78; 95% CI: 0.62-0.98) than those with a proportion of days covered <80%. CONCLUSIONS: High adherence to antihypertensive medications within 6 months poststroke was associated with reduced risks of both MACE and falls requiring hospitalization. Patients should be encouraged to adhere to their antihypertensive medications to maximize poststroke outcomes.

Personalized knowledge to reduce the risk of stroke (PERKS-International): Protocol for a randomized controlled trial.

RATIONALE: Theoretically, most strokes could be prevented through the management of modifiable risk factors. The Stroke Riskometer™ mobile phone application (hereon "The App") uses an individual's data to provide personalized information and advice to reduce their risk of stroke. AIMS: To determine the effect of The App on a combined cardiovascular risk score (Life's Simple 7®, LS7) of modifiable risk factors at 6 months post-randomization. METHODS AND DESIGN: PERKS-International is a Phase III, multicentre, prospective, pragmatic, open-label, single-blinded endpoint, two-arm randomized controlled trial (RCT). Inclusion criteria are as follows: age ⩾ 35 and ⩽75 years; ⩾2 LS7 risk factors; smartphone ownership; no history of stroke/myocardial infarction/cognitive impairment/terminal illness. The intervention group (IG) will be provided with The App, and the usual care group (UCG) is provided with generic online information about risk factors, but not be informed about The App. Face-to-face assessments will be conducted at baseline and 6 months, and online at 3 and 12 months. The RCT includes a process and economic evaluation. STUDY OUTCOMES AND SAMPLE SIZE: The primary outcome is a difference in the mean change in LS7 (seven individual items: blood pressure, cholesterol, glucose, body mass index (BMI), smoking, physical activity, and diet) from baseline to 6 months post-randomization with intention-to-treat analysis. Secondary outcomes include: change in individual LS7 items, quality of life; stroke awareness, adverse events; health service use; and costs. Based on pilot data, 790 participants (395 IG, 395 UCG) will be required to provide 80% power (two-sided α = 0.05) to detect a mean difference in the LS7 of ⩾0.40 (SD 1.61) in IG compared to 0.01 (SD 1.44) in the UCG at 6 months post-randomization. DISCUSSION: Stroke is largely preventable. This study will provide evidence of the effectiveness of a mobile app to reduce stroke risk. TRIAL REGISTRATION: ACTRN12621000211864.

Longitudinal associations of childhood fitness and obesity profiles with midlife cognitive function: an Australian cohort study.

OBJECTIVES: Clusters of low fitness and high obesity in childhood are associated with poorer health outcomes in later life, however their relationship with cognition is unknown. Identifying such profiles may inform strategies to reduce risk of cognitive decline. This study examined whether specific profiles of childhood fitness and obesity were associated with midlife cognition. DESIGN: Prospective study. METHODS: In 1985, participants aged 7-15 years from the Australian Childhood Determinants of Adult Health study were assessed for fitness (cardiorespiratory, muscular power, muscular endurance) and anthropometry (waist-to-hip ratio). Participants were followed up between 2017 and 2019 (aged 39-50). Composites of psychomotor speed-attention, learning-working memory and global cognition were assessed using CogState computerised battery. Latent profile analysis was used to derive mutually exclusive profiles based on fitness and anthropometry. Linear regression analyses examined associations between childhood profile membership and midlife cognition adjusting for age, sex and education level. RESULTS: 1244 participants were included [age: 44.4 ±â€¯2.6 (mean ±â€¯SD) years, 53% female]. Compared to those with the highest levels of fitness and lowest waist-to-hip ratio, three different profiles characterised by combinations of poorer cardiorespiratory fitness, muscular endurance and power were associated with lower midlife psychomotor-attention [up to -1.09 (-1.92, -0.26) SD], and lower global cognition [up to -0.71 (-1.41, -0.01) SD]. No associations were detected with learning-working memory. CONCLUSIONS: Strategies that improve low fitness and decrease obesity levels in childhood could contribute to improvements in cognitive performance in midlife.

"Factors influencing sedentary time and physical activity early after stroke: a qualitative study".

PURPOSE: We aimed to understand from the perspective of stroke survivors and their carers (1) factors contributing to sedentary time and physical activity during inpatient rehabilitation and the transition home, and (2) actual and perceived opportunities to reduce sedentary time and increase physical activity. MATERIAL AND METHODS: Qualitative study with 7 stroke survivor/carer dyads and 8 stroke survivors. Semi-structured interviews were conducted 2-4 weeks after hospital discharge, audio recorded and transcribed prior to thematic analysis. RESULTS: Stroke survivors were mean age 69 [SD15] years (53% male). Carers were mean age 62 [SD15] years (86% were female). Five themes were identified: (1) Education and guidance about physical activity and sedentary behaviour after stroke is important to build understanding of recovery and secondary prevention, (2) Stroke survivors need clear communication about safety and risk, (3) Return to life participation supports motivation for and engagement in physical activity, 4) Social and professional influences and 5) Opportunities to be physically active. CONCLUSION: Stroke survivors and their carers need a clearer understanding of the role of physical activity and risks of sedentary time during stroke recovery. Physical activity enablers included consistent communication, building confidence and skills to self-manage activity before discharge.Implications for RehabilitationInpatient rehabilitation and early after discharge may be an important time-point to support stroke survivors to establish long term physical activity behaviours before contact with healthcare professionals reduces.To reduce sedentary behaviour, people need to understand the health benefits of breaking up sedentary time and people who need physical support to stand up will need greater support from health professionals.Being able to imagine a future post-stroke self is important motivation to get up and move. Rehabilitation should help develop a person's vision of their post-stroke self.Managing potential risks in hospital without overly restricting physical activity is important and requires consistent communication from the multi-disciplinary team.Building a person's confidence and skills to self-manage physical activity in the community prior to discharge home may be another key enabler for activity.

Associations between childhood to adulthood socio-economic mobility and adult diet quality.

The impact of change in socio-economic status (SES) from childhood to adulthood (SES mobility) on adult diet is not well understood. This study examined associations between three SES mobility variables (area disadvantage, education, occupation) and adult diet quality. 1482 Australian participants reported childhood area-level SES in 1985 (aged 10-15 years) and retrospectively reported highest parental education and main occupation (until participant age 12) and own area-level SES, education, occupation and dietary intake in 2004-2006 (aged 26-36 years). A Dietary Guidelines Index (DGI) was calculated from food frequency and habit questionnaires. A higher score (range 0-100) indicated better diet quality. Sex-stratified linear regression models adjusted for confounders. Area-level SES mobility was not associated with diet quality. Compared with stable high (university) education, stable low (school only) was associated with lower DGI scores (males: ß = -5·5, 95 % CI: -8·9, -2·1; females: ß = -6·3, 95 % CI: -9·3, -3·4), as was downward educational mobility (participant's education lower than their parents) (males: ß = -5·3, 95 % CI: -8·5, -2·0; females: ß = -4·5, 95 % CI: -7·2, -1·7) and stable intermediate (vocational) education among males (ß = -3·9, 95 % CI: -7·0, -0·7). Compared with stable high (professional/managerial) occupation, stable low (manual/out of workforce) males (ß = -4·9, 95 % CI: -7·6, -2·2), and participants with downward occupation mobility (males: ß = -3·2, 95 % CI: -5·3, -1·1; females: ß = -2·8, 95 % CI: -4·8, -0·8) had lower DGI scores. In this cohort, intergenerational low education and occupation, and downward educational and occupational mobility, were associated with poor adult diet quality.

Associations between diet quality and DSM-IV mood disorders during young- to mid-adulthood among an Australian cohort.

PURPOSE: Many studies have reported associations between diet and depression, but few have used formal diagnoses of mood disorder as the outcome measure. We examined if overall diet quality was associated cross-sectionally or longitudinally with DSM-IV mood disorders among an adult cohort. METHODS: Participants from the Australian Childhood Determinants of Adult Health study were followed up during 2004-06 (n = 1974, age 26-36 years), 2009-11 (n = 1480, 31-41 years), and 2014-19 (n = 1191, 36-49 years). Dietary Guidelines Index (DGI) scores were calculated from food frequency questionnaires at each time-point (higher DGI reflects better diet quality). DSM-IV mood disorders (dysthymia or depression) during the periods between, and 12 months prior to each follow-up were determined using the Composite International Diagnostic Interview. Sex-stratified risk and prevalence ratios (PR) and 95% confidence intervals (CI) were estimated using log-binomial regression. Covariates included age, self-perceived social support index score, marital status, parenting status, education, occupation, physical activity, BMI, and usual sleep duration. RESULTS: A 10-point higher DGI was cross-sectionally associated with lower prevalence of mood disorders at the third follow-up only (females PR = 0.73, 95% CI = 0.56, 0.95; males PR = 0.72, 95% CI = 0.53, 0.97), but was attenuated after covariate adjustment (females PR = 0.92, 95% CI = 0.73, 1.16; males PR = 0.92, 95% CI = 0.69, 1.22). Adjustment for social support in the final model had attenuated the association for both sexes from 18% reduced prevalence to 8%. DGI scores were not longitudinally associated with mood disorder risk. CONCLUSIONS: Crude cross-sectional associations between diet quality and mood disorders at ages 36-49 years were explained by sociodemographic and lifestyle factors, particularly social support.

Primary stroke prevention worldwide: translating evidence into action.

Stroke is the second leading cause of death and the third leading cause of disability worldwide and its burden is increasing rapidly in low-income and middle-income countries, many of which are unable to face the challenges it imposes. In this Health Policy paper on primary stroke prevention, we provide an overview of the current situation regarding primary prevention services, estimate the cost of stroke and stroke prevention, and identify deficiencies in existing guidelines and gaps in primary prevention. We also offer a set of pragmatic solutions for implementation of primary stroke prevention, with an emphasis on the role of governments and population-wide strategies, including task-shifting and sharing and health system re-engineering. Implementation of primary stroke prevention involves patients, health professionals, funders, policy makers, implementation partners, and the entire population along the life course.

The state of stroke services across the globe: Report of World Stroke Organization-World Health Organization surveys.

BACKGROUND: Improving stroke services is critical for reducing the global stroke burden. The World Stroke Organization-World Health Organization-Lancet Neurology Commission on Stroke conducted a survey of the status of stroke services in low and middle-income countries (LMICs) compared to high-income countries. METHODS: Using a validated World Stroke Organization comprehensive questionnaire, we collected and compared data on stroke services along four pillars of the stroke quadrangle (surveillance, prevention, acute stroke, and rehabilitation) in 84 countries across World Health Organization regions and economic strata. The World Health Organization also conducted a survey of non-communicable diseases in 194 countries in 2019. RESULTS: Fewer surveillance activities (including presence of registries, presence of recent risk factors surveys, and participation in research) were reported in low-income countries than high-income countries. The overall global score for prevention was 40.2%. Stroke units were present in 91% of high-income countries in contrast to 18% of low-income countries (p < 0.001). Acute stroke treatments were offered in ∼ 60% of high-income countries compared to 26% of low-income countries (p = 0.009). Compared to high-income countries, LMICs provided less rehabilitation services including in-patient rehabilitation, home assessment, community rehabilitation, education, early hospital discharge program, and presence of rehabilitation protocol. CONCLUSIONS: There is an urgent need to improve access to stroke units and services globally especially in LMICs. Countries with less stroke services can adapt strategies from those with better services. This could include establishment of a framework for regular monitoring of stroke burden and services, implementation of integrated prevention activities and essential acute stroke care services, and provision of interdisciplinary care for stroke rehabilitation.

A Meta-Analysis of Rupture Risk for Intracranial Aneurysms 10 mm or Less in Size Selected for Conservative Management Without Repair.

BACKGROUND: Small unruptured intracranial aneurysms (UIAs) are considered to have low risk of rupture. The proportion of UIAs measuring 10 mm or less in size that rupture when selected for conservative management without repair is not well known. The aim of this study is to determine the proportion of UIAs that rupture by size threshold from ≤10 to ≤3 mm when selected for management without repair and to determine the level of precision and sources of heterogeneity in the rupture risk estimate. METHODS: This study was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42019121522). The Ovid MEDLINE, EMBASE, Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials were searched (inception to August 2020). Studies with longitudinal follow-up of patients with UIAs ( ≤10 mm to ≤3 mm) without endovascular or neurosurgical repair were eligible. We included studies, which provided details of aneurysm size and in which UIA rupture was reported as an outcome. The primary outcome of the pooled proportion of UIA rupture during follow-up was synthesized with random-effects meta-analysis; heterogeneity was explored using meta-regression. RESULTS: A total of 31 studies that included 13,800 UIAs ≤10 mm in size were eligible for data synthesis. The pooled proportion of ≤10 mm UIAs that ruptured when managed without repair was 1.1% (95% CI 0.8-1.5; I 2 = 52.9%) over 3.7 years. Findings were consistent in sensitivity analyses at all the size stratified thresholds including ≤5 and ≤3 mm; rupture occurred in 1.0% (95% CI 0.8-1.3; I 2 = 0%) of 7,280 ≤5 mm UIAs and 0.8% (95% CI 0.4-1.5; I 2 = 0%) of 1,228 ≤3 mm UIAs managed without repair. In higher quality studies with lower risk of bias, rupture occurred in 1.8% (95% CI 1.5-2.0; I 2 = 0%) over 3.9 years. In meta-regression, aneurysm size, shape, anatomical location, and exposure to prior subarachnoid hemorrhage were not identified as sources of heterogeneity. CONCLUSION: For every 1,000 UIAs that are 10 mm or less in size and selected for conservative management without repair, between 8 and 15 UIAs are estimated to rupture over 3.7 years. When stratified by size, these pooled rupture risk estimates are consistent and clinically applicable for ≤5 mm UIAs selected for management without repair. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/prospero/, identifier: CRD42019121522.

Sedentary time and activity behaviors after stroke rehabilitation: Changes in the first 3 months home.

BACKGROUND: Sedentary time is prevalent following stroke, limiting functional improvement, and increasing cardiovascular risk. At discharge we examined: 1) change in sedentary time and activity over the following 3 months' and 2) physical, psychological or cognitive factors predicting any change. A secondary aim examined cross-sectional associations between factors and activity at 3 months. METHODS: People with stroke (n = 34) were recruited from two rehabilitation units. An activity monitor (ActivPAL3) was worn for 7 days during the first week home and 3 months later. Factors examined included physical, psychological, and cognitive function. Linear mixed models (adjusted for waking hours) were used to examine changes in sedentary time, walking, and step count over time. Interaction terms between time and each factor were added to the model to determine if they modified change over time. Linear regression was performed to determine factors cross-sectionally associated with 3-month activity. RESULTS: ActivPAL data were available at both time points for 28 (82%) participants (mean age 69 [SD 12] years). At 3 months, participants spent 39 fewer minutes sedentary (95%CI -70,-8 p = .01), 21 minutes more walking (95%CI 2,22 p = .02) and completed 1112 additional steps/day (95%CI 268,1956 p = .01), compared to the first week home. No factors predicted change in activity. At 3 months, greater depression (ß 22 mins (95%CI 8,36) p = .004) and slower gait speed (ß - 43 mins 95%CI -59,-27 p ≤ 0.001) were associated with more sedentary time and less walking activity, respectively. CONCLUSIONS: Sedentary time reduced and walking activity increased between discharge home and 3 months later. Interventions targeting mood and physical function may warrant testing to reduce sedentary behavior 3 months following discharge.

SiPP (Stroke in Pregnancy and Postpartum): A prospective, observational, international, multicentre study on pathophysiological mechanisms, clinical profile, management and outcome of cerebrovascular diseases in pregnant and postpartum women.

RATIONALE: Cerebrovascular diseases associated with pregnancy and postpartum period are uncommon; however, they can have an important impact on health of both women and foetus or newborn. AIMS: To evaluate the frequency, characteristics and management of cerebrovascular events in pregnant/postpartum women, to clarify pathophysiological mechanisms underlying the occurrence of these events including biomolecular aspects, and to assess the short- and long-term cerebrovascular and global cardiovascular outcome of these patients, their predictors and infant outcome. METHODS AND DESIGN: This is an observational, prospective, multicentre, international case-control study. The study will include patients with cerebrovascular events during pregnancy and/or within six months after delivery. For each included case, two controls will be prospectively recruited: one pregnant or puerperal subject without any history of cerebrovascular event and one non-pregnant or non-puerperal subject with a recent cerebrovascular event. All controls will be matched by age, ethnicity and type of cerebrovascular event with their assigned cases. The pregnant controls will be matched also by pregnancy weeks/trimester. Follow-up will last 24 months for the mother and 12 months for the infant. SUMMARY: To better understand causes and outcomes of uncommon conditions like pregnancy/postpartum-related cerebrovascular events, the development of multisite, multidisciplinary registry-based studies, such as the Stroke in Pregnancy and Postpartum study, is needed in order to collect an adequate number of patients, draw reliable conclusions and give definite recommendations on their management.

Childhood/Adolescent Smoking and Adult Smoking and Cessation: The International Childhood Cardiovascular Cohort (i3C) Consortium.

Background Despite declining US adolescent smoking prevalence from 40% among 12th graders in 1995 to around 10% in 2018, adolescent smoking is still a significant problem. Using the International Childhood Cardiovascular Cohort (i3C) Consortium, which includes 7 international cohorts recruited in childhood and followed into adulthood, the present study was designed to confirm the important relation between adolescent smoking and daily adult smoking and present new data on adult smoking into the forties and comparison of smoking in the United States, Finland, and Australia. Methods and Results Childhood smoking experience during ages 6 to 19 in the 1970s and 1980s was classifiable in 6687 i3C participants who also provided smoking status in their twenties and forties through 2011-2018. Prevalence of daily smoking in their twenties was directly related to degree of smoking during adolescence and inversely related to the age at which that smoking experience occurred (P trend, <0.001). Similar patterns were observed for prediction of smoking during age forties. Among the 2465 smokers in their twenties, cessation by their forties was generally inverse to degree of smoking in ages 6 to 19 (P trend, <0.001). Prevalence of smoking during adolescence and adulthood was similar among US, Finnish, and Australian participants. Conclusions These long-term follow-up data show that smoking intensity increased throughout adolescence. Prevalence of adult smoking and cessation by the forties were both correlated with levels of childhood smoking intensity. These data lend support to preventive strategies designed to reduce, delay, or eliminate any youth access to cigarettes.

Factors Associated with Persistently High Muscular Power from Childhood to Adulthood.

PURPOSE: Child and adult muscular power have been shown to associate with contemporary cardiometabolic health. Muscular power typically persists (tracks) between childhood and adulthood. Few studies span childhood to adulthood, so we aimed to identify modifiable and environmental factors associated with the persistence or change in muscular power across the life course. METHODS: Prospective study examining 1938 participants who had their muscular power (standing long jump distance) measured in 1985 as children 7-15 yr old and again 20 yr later in adulthood (26-36 yr old). A selection of objectively measured anthropometric characteristics (adiposity and fat-free mass), cardiorespiratory fitness (CRF), self-reported physical activity, dietary (quality and fruit, vegetable, and protein intake), and sociodemographic data were available at both time points. Muscular power was separated into thirds, and participants were reported as having persistently low, decreasing, persistently moderate, increasing, or persistently high muscular power. RESULTS: Higher adiposity, lower physical activity, diet quality and socioeconomic status (SES) across the life course, and lower adult CRF were associated with persistently low muscular power. Lower adult protein intake and an increase in adiposity over time were associated with decreasing muscular power. An increase in fat-free mass was associated with a reduced probability of decreasing or persistently high muscular power and an increased probability of increasing muscular power. Higher adult fruit intake was associated with increasing muscular power. Lower adiposity across the life course, higher adult CRF and SES, and higher child protein intake were associated with persistently high muscular power. CONCLUSION: Healthy weight, good CRF, greater protein intake, and high SES are important correlates of high muscular power maintained from childhood to adulthood.

Cluster patterns of behavioural risk factors among children: Longitudinal associations with adult cardio-metabolic risk factors.

Much of what is known about childhood clusters of cardiovascular disease behavioural risk factors (RFs) comes from cross-sectional studies, providing little insight into the long-term health impacts of different behavioural cluster profiles. This study aimed to establish the longitudinal relationship between cluster patterns of childhood behavioural RFs and adult cardio-metabolic RFs. Data were from an Australian prospective cohort study of 1265 participants measured in 1985 (ages 9-15 yrs), and in 2004-06 (ages 26-36 yrs). At baseline, children self-reported smoking status, alcohol consumption, physical activity (PA), dietary behaviour and psychological well-being. At follow-up, participants completed questionnaires and attended study clinics where the following component indicators of the metabolic syndrome (MetS) score were measured: waist circumference, blood pressure, fasting blood glucose and lipids. TwoStep cluster analyses were carried out to identify clusters in childhood. Linear regression was used to examine the longitudinal associations between cluster patterns of childhood behavioural RFs and adult cardio-metabolic RFs. Four childhood cluster patterns of behavioural RFs labelled 'most healthy', 'high PA', 'most unhealthy', and 'breakfast skippers' were identified. The unhealthier childhood clusters predicted a significantly higher adult MetS score ('most unhealthy': ß = 0.10, 95%CI = 0.01, 0.19) and adult waist circumference ('most unhealthy': ß = 2.29, 95%CI = 0.90, 6.67; 'breakfast skippers': ß = 2.15, 95%CI = 0.30, 4.00). These associations were independent of adult behavioural RFs and socio-economic position. These findings emphasise the impact of multiple childhood behavioural RFs on important adult health outcomes and may be useful for the development of early intervention strategies, where identification of children at higher risk of poorer adult cardio-metabolic health is vital.

"Connecting patients and therapists remotely using technology is feasible and facilitates exercise adherence after stroke".

Purpose: Repetitive task practice after stroke is important to improve function, yet adherence to exercise is low. The aim of this study was to determine whether using the internet, a tablet application, and a chair sensor that connected to a therapist was feasible in monitoring adherence and progressing a functional exercise at home.Methods: Ten participants with stroke completed a 4-week sit-to-stand exercise using the technology at home (ACTRN12616000051448). A therapist remotely monitored exercise adherence, progressed goals, and provided feedback via the app. Measures of feasibility (design, recruitment/withdrawals, adherence, safety, participant satisfaction and estimates of effect on function) were collected.Results: Participants' mean age was 73.6 years [SD 9.9 years]. The system was feasible to deliver and monitor exercise remotely. All participants completed the study performing a mean 125% of prescribed sessions and 104% of prescribed repetitions. Participants rated the system usability (78%), enjoyment (70%) and system benefit (80%) as high. No adverse events were reported. The mean pre- and post-intervention difference in the total short performance physical battery score was 1.4 (95% CI 0.79, 2.00).Conclusions: It was feasible and safe to prescribe and monitor exercises using an app and sensor-based system. A definitive trial will determine whether such technology could facilitate greater exercise participation after stroke.