Background and Purpose-Systematic reviews have shown that organized inpatient (stroke unit) care reduces the risk of death after stroke. However, it is unclear how this is achieved. We tested whether stroke unit care could reduce deaths by preventing complications. Methods-We updated a collaborative systematic review of 31 controlled clinical trials (6936 participants) to include reported interventions and complications during early hospital care plus the certified cause of death during follow up. Each secondary analysis used data from between 7 and 17 studies (1652 to 3327 participants). Complications were grouped as physiological, neurological, cardiovascular, complications of immobility, and others. Bayesian hierarchical models were used to estimate odds ratios for features occurring in stroke units versus conventional care. Key Words: complications Ⅲ meta-analysis Ⅲ stroke outcome Ⅲ stroke units I t has been known for many years that organized inpatient (stroke unit) care reduces the risk of death after stroke, 1 but it is not clear how this benefit is achieved. The Stroke Unit Trialists Collaboration carried out an analysis 10 years ago that suggested that stroke units may reduce deaths through preventing complications. 2 However, this analysis had limited statistical power and its conclusions were speculative. Results-BasedIn the most recent update of the stroke unit systematic review, 3 data were available from a larger number of controlled clinical trials. This allowed us to revisit the question "does the prevention of complications explain the survival benefit of stroke unit care?" If this is the case, then we would expect the following observations to be associated with stroke unit care: (1) the more frequent use of interventions designed to prevent complications; (2) a smaller number of recorded serious complications; and (3) fewer deaths attributed to complications.We report a further analysis of the stroke unit review that addresses these questions. Methods Methods of the ReviewThis is a further analysis of a collaborative systematic review carried out by the Stroke Unit Trialists Collaboration. 3 In summary, this involved rigorous searching for clinical trials of organized inpatient (stroke unit) care, the formation of a collaborative group comprising the primary trialists, the collation of extensive descriptive information and outcome data, and the analysis of these data using rigorous meta-analysis methods. For the current analysis, we used a very broad definition of stroke unit care and included any trial that compared organized (stroke unit) care (defined as a multidisciplinary team specializing in stroke care) versus the contemporary conventional care such as a general medical ward or less organized form of stroke care. Stroke unit care could include services based in a discrete ward or provided by a mobile stroke team. In addition to the existing data, we sought information on the following outcomes: Correspondence to Peter Langhorne, PhD, Academic Section of Geriatric Medicine, 3rd Floor, Un...

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Background and Purpose-Stroke severity and dependency are often categorized to allow stratification for randomization or analysis. However, there is uncertainty whether the categorizations used for different stroke scales are equivalent. We investigated the amount of information retained by categorizing severity and dependency, and whether the currently used cut-offs are equivalent across different stroke scales. Methods-Stroke severity and dependency have been categorized as mild, moderate, or severe. We studied 2 acute stroke unit cohorts, measuring Scandinavian Stroke Scale (SSS), modified Rankin Scale (mRS), Barthel Index (BI), and modified National Institutes of Health Stroke Scale (mNIHSS). Receiver operating characteristic (ROC) curves were examined to determine the ability of full and categorized scales to predict death and dependency. A weighted kappa analysis assessed agreement between the categorized scales. Results-When scales are categorized, the area under the ROC curve is significantly reduced; however, the differences are small and may not be practically important. BI, mRS, and SSS all have excellent agreement with each other when categorized, whereas mNIHSS has substantial agreement with mRS and BI. Conclusions-Little

BackgroundGuidelines recommend implementation of multimodal interventions to help prevent recurrent TIA/stroke. We undertook a systematic review to assess the effectiveness of behavioral secondary prevention interventions.StrategySearches were conducted in 14 databases, including MEDLINE (1980-January 2014). We included randomized controlled trials (RCTs) testing multimodal interventions against usual care/modified usual care. All review processes were conducted in accordance with Cochrane guidelines.ResultsTwenty-three papers reporting 20 RCTs (6,373 participants) of a range of multimodal behavioral interventions were included. Methodological quality was generally low. Meta-analyses were possible for physiological, lifestyle, psychosocial and mortality/recurrence outcomes. Note: all reported confidence intervals are 95%. Systolic blood pressure was reduced by 4.21 mmHg (mean) (−6.24 to −2.18, P = 0.01 I2 = 58%, 1,407 participants); diastolic blood pressure by 2.03 mmHg (mean) (−3.19 to −0.87, P = 0.004, I2 = 52%, 1,407 participants). No significant changes were found for HDL, LDL, total cholesterol, fasting blood glucose, high sensitivity-CR, BMI, weight or waist:hip ratio, although there was a significant reduction in waist circumference (−6.69 cm, −11.44 to −1.93, P = 0.006, I2 = 0%, 96 participants). There was no significant difference in smoking continuance, or improved fruit and vegetable consumption. There was a significant difference in compliance with antithrombotic medication (OR 1.45, 1.21 to 1.75, P<0.0001, I2 = 0%, 2,792 participants) and with statins (OR 2.53, 2.15 to 2.97, P< 0.00001, I2 = 0%, 2,636 participants); however, there was no significant difference in compliance with antihypertensives. There was a significant reduction in anxiety (−1.20, −1.77 to −0.63, P<0.0001, I2 = 85%, 143 participants). Although there was no significant difference in odds of death or recurrent TIA/stroke, there was a significant reduction in the odds of cardiac events (OR 0.38, 0.16 to 0.88, P = 0.02, I2 = 0%, 4,053 participants).ConclusionsThere are benefits to be derived from multimodal secondary prevention interventions. However, the findings are complex and should be interpreted with caution. Further, high quality trials providing comprehensive detail of interventions and outcomes, are required.Review RegistrationPROSPERO CRD42012002538.