Hypertension, or high blood pressure, is a key modifiable risk factor for heart disease and stroke. International guidelines have highlighted ‘poor adherence to treatment’ and ‘physician inertia’ as major barriers to effective blood pressure management. The Maximising Adherence, Minimising Inertia (MIAMI) intervention, a theory-based complex intervention, supports General Practitioners (GPs) and people with hypertension in maximising medication use to manage blood pressure. This pilot cluster randomised control trial (RCT) aimed to collect and analyse feasibility data to refine the MIAMI intervention and assess the feasibility of a definitive RCT. A pilot cluster RCT with a MIAMI intervention arm and usual care control arm was conducted. Quantitative data collection consisting of clinical measures and a self-report questionnaire took place at baseline and twelve week follow up. Semi-structured interviews with GP and patient participants were conducted. Fidelity (as measured by a protocol checklist and through qualitative interviews) and health economics costings were assessed. Six GP practices (intervention arm n = 3, control arm n = 3) and 52 patients (intervention arm n = 25, control arm n = 27) took part. All six GP practices and 92

Abstract Background Large-artery ischaemic stroke is associated with a high-risk of recurrence. Inflammation is important in the development and rupture of carotid plaque. It remains unknown if blood-biomarkers can reliably quantify vascular inflammation. We investigated whether blood-biomarkers were associated with recurrent ipsilateral Ischaemic Stroke (IS). Methods hsCRP and IL-6 were measured in blood-samples using immunochemiluminescence immunoassays from three cohort studies. Median follow-up was 3.9 years (IQR 1.6–5.8). The primary outcome was recurrent ipsilateral IS. Results Of 269 participants, 130 (48.3%) had severe CS (median age, 71 (IQR 64–78)). There were 19 ipsilateral recurrent IS in 1,046-patient-years follow-up. hsCRP was dichotomised at 2 mg/L and IL-6 at 7 pg/ml (expected-normal value for assay). 187 (69.5%) had hsCRP<2 mg/L and 170 (63.2%) had IL-6 ≥ 7 pg/ml. 146 (54.3%) participants had combined-raised hsCRP≥2 mg/L and IL-6 ≥ 7 pg/ml. On unadjusted Cox analysis, hsCRP≥2 mg/L was associated with increased risk of ipsilateral recurrent IS (HR 9.25, CI 1.24–69.2, p = 0.03) while IL-6 ≥ 7 pg/ml trended towards increased risk (HR 2.36, CI 0.79–7.1, p = 0.1.) However, combined raised-hsCRP/IL-6 was associated with an increased risk of recurrent ipsilateral IS (HR 3.58, CI 1.2–10.7, p = 0.02.) However, after adjustment for age, sex, smoking and time-to-phlebotomy, these associations attenuated. When patients were divided into three risk categories defined by levels of hsCRP and IL-6 (low [both markers low], intermediate [discordant markers], high [both markers raised]0, the rate of recurrent stroke increased across the categories, p = 0.013 for trend. The c-statistic for combined-raised hsCRP/IL-6 was 0.66 (CI 0.57–0.75) indicating prognostication better than chance to predict recurrent-ipsilateral IS. Conclusion Using blood inflammatory proteins in combination may add value in risk prediction in patients with carotid atherosclerosis, although this concept requires independent replication and validation in larger cohorts.

Background Inflammation driven by pro-inflammatory cytokines is a new therapeutic target in coronary disease. Few data exist on the association of key upstream cytokines and post-stroke recurrence. In a prospective cohort study, we investigated the association between pivotal cytokines, high-sensitivity C-reactive protein (hsCRP) and one-year outcomes. Methods BIO-STROKETIA is a multi-center prospective cohort study of non-severe ischemic stroke (modified Rankin score <= 3) and transient ischemic attack. Controls were patients with transient symptoms attending transient ischemic attack clinics with non-ischemic final diagnosis. Exclusion criteria were severe stroke, infection, and other pro-inflammatory disease; hsCRP and cytokines (interleukin (IL) 6, IL-1 beta, IL-8, IL-10, IL-12, interferon-gamma (IFN-gamma), tumor-necrosis factor-alpha (TNF-alpha)) were measured. The primary outcome was one-year recurrent stroke/coronary events (fatal and non-fatal). Results In this study, 680 patients (439 stroke, 241 transient ischemic attack) and 68 controls were included. IL-6, IL-1 beta, IL-8, IFN-gamma, TNF-alpha, and hsCRP were higher in stroke/transient ischemic attack cases (p <= 0.01 for all). On multivariable Cox regression, IL-6, IL-8, and hsCRP independently predicted one-year recurrent vascular events (adjusted hazard ratios (aHR) per-quartile increase IL-6 1.31, confidence interval (CI) 1.02-1.68, p = 0.03; IL-8 1.47, CI 1.15-1.89, p = 0.002; hsCRP 1.28, CI 1.01-1.62, p = 0.04). IL-6 (aHR 1.98, CI 1.26-3.14, p = 0.003) and hsCRP (aHR 1.81, CI 1.20-2.74, p = 0.005) independently predicted one-year fatality. IL-6 and hsCRP (adjusted odds ratio per-unit increase 1.02, CI 1.01-1.04) predicted poor functional outcome, with a trend for IL-1 beta (p = 0.054). Conclusion Baseline inflammatory cytokines independently predicted late recurrence, supporting a rationale for randomized trials of anti-inflammatory agents for prevention after stroke and suggesting that targeted therapy to high-risk patients with high baseline inflammation may be beneficial.

Abstract Background A bubble study is performed routinely on patients under the age of 65 years of age with a confirmed diagnosis of either acute ischaemic stroke or TIA in order to assist with the presence of a Patent Foramen Ovale(PFO)/Atrial Septal Defect(ASD) as an aetiology for the stroke event. Historically, a referral letter would be written to a hospital who specialises in cardiac structural surgeries, requesting a review of a patient with a positive bubble study and acute stroke. Closure would typically exceed 9 months. Methods The Stroke RANP led out on the project as she performs all bubble studies in stroke survivors. A designated Cardiologist, who also works in a hospital where PFO closures takes place, is notified by the RANP or team about a positive bubble study and the images are reviewed. It is then decided if the patients requires a TOE or not. A 2-page PFO referral form was created which contains all relevant information. Results Stroke RANP performed 92 bubble studies between January 2021 and May 2022. There were 18 positive studies (20% positivity rate): 7 positive studies from January to August 2021 (pre-pathway) and 11 positive studies from September 2021 to May 2022 (post-pathway). 72% (5/7) of patients had a TOE performed following a positive bubble study result pre-pathway, whereas only 1 TOE was performed out of 11 cases (9%) post-pathway. The time from positive bubble study to closure time reduced from 9months on average to 3 months. Conclusion There was a 63% reduction in the number of TOEs being performed for patients with a positive bubble study with the introduction of this PFO pathway. Additionally, there was a 6-month reduction time from the positive bubble study result to closure. This pathway has improved patient outcomes for this young group of stroke survivors and assists with the reduction of further stroke events in the future.

Abstract Background Recent studies have demonstrated the variability of aetiology, clinical presentation and overall mortality between different ethnic groups presenting with acute stroke. The non-native Irish population accounts for almost 13% of the total population and is predicted to grow over the next decade. Recording and analysis of acute stroke patients based on their ethnicity and population demographics is an important step in planning for the future of stroke care in Ireland. In this study, we aimed to evaluate key differences between the Irish and non-Irish population presenting with acute stroke to an Irish hospital. Methods We reviewed our hospital stroke registry over a 12-month period (January-December 2021). Key parameters including country of birth, ethnicity, other patient demographics, clinical presentation, aetiology and subtype of stroke, stroke management and clinical outcomes. Results Of the 245 acute strokes admitted to our hospital in 2021, non-ethically Irish patients made up 12.2% (n = 30). The average age of non-ethnically Irish stroke presentations was younger than Irish stroke presentations (59 versus 71 years). Haemorrhagic strokes were more common in the non-Irish population (13.3% in non-Irish cohort vs 9.8% in Irish cohort). Median time of symptom onset to presentation to hospital was 3 hours and 58 minutes in the Irish patients and 6 hours and 10 minutes in the non-Irish patients. The overall length of stay in hospital post stroke was similar between the two population groups at an average of 19 days duration. Conclusion This study identifies disparities in acute stroke presentation between the Irish and non-Irish population presenting to an Irish hospital. This study demonstrated the importance of further research on a national scale to record the variability of strokes in different ethnic groups in order to adequately plan primary and secondary stroke care and provide targeted public health campaigns to remain inclusive to Ireland’s growing and increasingly diverse population.

Objective The presence of atherosclerotic plaque components such as lipid rich necrotic core and intraplaque haemorrhage is associated with increased plaque vulnerability, and may be used to stratify the risk of future cerebrovascular events. Our aim was to investigate the relationship between selected carotid plaque components imaged with CTA, patient characteristics, and clinical outcomes. Methods Symptomatic patients underwent carotid CTA as part of the BIOVASC study. Images were analysed for plaque volume composition with a semi-automatic Hounsfield Unit (HU)-based algorithm. Plaque components were classified based on their attenuation values: lipids <61 HU, fibrous tissue 61-129 HU and calcium >131 HU. Parametric and non-parametric tests were performed to compare plaque measurements to clinical characteristics and outcomes. Results One-hundred and two symptomatic carotids were analysed (avg. age 69y, 54.9% Male, 29.4% severe stenosis). Mean plaque volume was 480±230 mm3, and the mean LRNC volume was 170±100 mm3. A difference in LRNC volume was identified between moderate and severe stenosis (190–150 mm3, p=0.012). Regression analysis showed that age and gender may predict increased plaque volume (p<0.001). A trend for reduced mean plaque LRNC was identified in patients receiving statins (130-210 mm3, p=0.08). Intra-reader reliability showed good agreement (0.62-0.78, p<0.001) between CTA plaque measurements. Conclusions In-vivo CTA plaque volume composition assessment is feasible with good intra-reader reliability. Our findings suggest that CTA-HU measurements may be used to provide improved mechanistic and diagnostic insights into atherosclerotic disease, and facilitate the quantification of selected plaque components whose presence may be associated with increased plaque vulnerability. Key Points ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was partially supported by the Health Research Board (Ireland). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study has been granted full institutional, ethical approval by the Mater Misericordiae University Hospital Ethics Committee on the 2 April 2014 as part of the larger BIOVASC study (Reference number: 1/378/1131). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors * BIOVASC : Biomarkers Imaging Vulnerable Atherosclerosis in Symptomatic Carotid disease CPR : Curved-planar reformation DSA : Digital subtraction angiography ECST : European Carotid Surgery Trial FC : Fibrous cap ICA : Internal carotid artery ICC : Intraclass correlation IPH : Intraplaque haemorrhage LRNC : Lipid rich necrotic core MRS : Modified Rankin scale NASCET : North American Symptomatic Carotid Endarterectomy Trial TIA : Transient ischaemic attack

Abstract Background Early supported discharge (ESD) facilitates people with a stroke to be discharged from the hospital environment earlier than conventional care to continue their rehabilitation within the home with a multi-disciplinary team. Known benefits of ESD from Randomised Controlled Trials conducted include reducing the length of a hospital stay, long term dependency, and cost savings. There is limited qualitative evidence available on ESD. This systematic review and qualitative synthesis explored the experiences of those involved in ESD including people with stroke, family members, caregivers as well as healthcare professionals. Method A literature search was completed in 11 databases which generated 3,425 articles. Qualitative or mixed Method studies that included qualitative data on the experiences of people with stroke, family members, caregivers and healthcare professionals of an ESD service were included. The Critical Appraisal Skills Programme checklist was used to appraise the methodological quality of the papers. The findings were synthesised using the three step process for thematic synthesis. Results A total of fourteen studies were included with the methodological quality of the studies deemed good overall. Four key themes emerged: 1) ESD is experienced by people with stroke as a goal-focused and supportive process leading to positive outcomes, 2) ESD eases the transition from the hospital to the home environment but the transition from ESD to social and community services is often problematic, 3) Organisational, logistical and inter-professional factors are critical to the success of ESD and 4) The home environment enhances rehabilitation. Conclusion The findings of this qualitative evidence synthesis highlight the importance of the home environment in the rehabilitation process post stroke. Key practice implications point to the need for increased attention to periods where care transitions occur from ESD to community services.

Early supported discharge (ESD) facilitates people with a stroke to be discharged from the hospital environment earlier than conventional care to continue their rehabilitation within the home with a multi-disciplinary team. Known benefits of ESD from Randomised Controlled Trials conducted include reducing the length of a hospital stay, long term dependency, and cost savings. There is limited qualitative evidence available on ESD. This systematic review and qualitative synthesis explored the experiences of those involved in ESD including people with stroke, family members, caregivers as well as healthcare professionals. A literature search was completed in 11 databases which generated 3,425 articles. Qualitative or mixed studies that included qualitative data on the experiences of people with stroke, family members, caregivers and healthcare professionals of an ESD service were included. The Critical Appraisal Skills Programme checklist was used to appraise the methodological quality of the papers. The findings were synthesised using the three step process for thematic synthesis. A total of fourteen studies were included with the methodological quality of the studies deemed good overall. Four key themes emerged: 1) ESD is experienced by people with stroke as a goal-focused and supportive process leading to positive outcomes, 2) ESD eases the transition from the hospital to the home environment but the transition from ESD to social and community services is often problematic, 3) Organisational, logistical and inter-professional factors are critical to the success of ESD and 4) The home environment enhances rehabilitation. The findings of this qualitative evidence synthesis highlight the importance of the home environment in the rehabilitation process post stroke. Key practice implications point to the need for increased attention to periods where care transitions occur from ESD to community services.

Background and importance Intensive clinical pharmacy input from admission to discharge has been shown to improve patient outcomes. The clinical pharmacy service in our institution has historically been under-resourced. Aim and objectives The study aim was to develop a ward based clinical pharmacy service and to evaluate its impact using a number of clinical, safety and financial metrics. Material and methods A clinical pharmacist was assigned to provide pharmaceutical care to patients on a medicine for the older person ward. Over an 8 week period, the pharmacist prospectively recorded her interventions/activities. To assess impact on patient care, interventions were graded according to the Eadon criteria. The potential cost avoidance associated with interventions was estimated using two methods identified in the literature. Both define costs related to medication errors and calculate cost avoidance associated with clinical interventions based on prevention of harm. Medication incident reporting was analysed to assess the impact on patient safety. Results Eighty–four patients received a pharmacist review. Across a spectrum of activities, a total of 267 pharmacist interventions were recorded: 87% of patients had at least one pharmacist intervention. A total of 90% of interventions requiring follow–up with the medical team were accepted and resulted in a change to patient care. Eadon grading of interventions deemed that 81% of interventions improved the standard of patient care. Two different methods were used to estimate potential cost avoidance: one estimated annual savings of €154 103–€344 926; the other estimated these at €174 373. Given current pharmacist salary costs, this equates to a cost–benefit ratio of 2.8:1 to 6.3:1. (This does not include the 27% reduction in drug spend observed during the study period. However, more longitudinal data are required to confirm and characterise this phenomenon.) In the third quarter of 2018, 21 medication incidents were reported from the study ward compared with an average of 4 incident reports from the first and second quarters of 2018. This represents a fivefold increase in medication incident reporting, suggestive of an enhanced culture of patient safety. Conclusion and relevance This study assessed and quantified a wide spectrum of pharmacist contributions to medication management and safety. Costing of these contributions estimated the cost–benefit ratio of the clinical pharmacy service, providing compelling support for the extension of this service throughout the hospital. References and/or acknowledgements No conflict of interest.

Decreased life expectancy (LE) has historically been found among people with intellectual disability (ID) compared to the general population. Several recent studies have looked into ageing and cause of death in ID. Results of many of these studies suggest that, although LE in ID remains lower than the general population, it has increased across many Western societies in recent decades. Increases in LE in the general and ID populations appear to follow similar trends. Some major causes of mortality in ID are similar to the general population, and therefore may be amenable to similar preventative healthcare interventions. In this article, we have outlined possible reasons for improved LE in ID, and potential areas that may require further intervention. However, more detailed studies on mortality in ID may provide more accurate insight into areas requiring intervention in ID populations.

Background: Home care services are pivotal for the timely and successful discharge of frail older adults.I n Ireland they are largely provided by private companies.Home Care Services accounted for €376 m of Irish health expenditure in 2017.19,807 people were in receipt of a home care package (HCP) and 46,243 of home help hours.We conducted a survey to illuminate the patient experience of home care and specific issues arising in practice.Methods: We circulated a questionnaire to patients attending our Day Hospital, collecting information on demographics, level of dependence, specific home & community

Objective: Elevated blood pressure (BP), or hypertension, is a growing burden worldwide, leading to over 10 million deaths each year. May Measurement Month (MMM) is a global initiative aimed at raising awareness of high BP and acting as a stimulus to improving screening programs worldwide. In the United Kingdom (UK) nearly 1 in 5 people, and in the Republic of Ireland (RoI) 3 out of 10, have hypertension, of which a large proportion remains undiagnosed. Design and method: An opportunistic cross-sectional survey of volunteers aged ≥18 years was carried out in May 2017 and 2018. BP measurement, definition of hypertension and statistical analysis followed a standardized protocol. Screenings sites in hospitals, universities, shopping centres, workplaces, sports clubs, community centres, GP practices, and pharmacies were set up across the UK and RoI as part of this initiative. Results: 12,714 individuals were screened during MMM17&18. After multiple imputation, 4,815 (37.9%) had hypertension. Of individuals not receiving antihypertensive medication, 2,388 (23.3%) were hypertensive. Of individuals receiving antihypertensive medication, 1,038 (42.9%) had uncontrolled BP. Conclusions: MMM17&18 were the largest BP screening campaigns ever undertaken in the UK and RoI. These data prove for the first time that a relatively inexpensive, volunteer based, convenience sampling of screening blood pressure in the community identified 2 out of 5 individuals as hypertensive, with 1 in 4 not receiving treatment. Of major concern is that these data demonstrate that of those individuals receiving treatment, 2 out of 5 still did not have controlled BP.