Background: Small trials have suggested that fluoxetine may improve neurological recovery from stroke. FOCUS, AFFINITY and EFFECTS are a family of investigator-led, multicentre, parallel group, randomised, placebo-controlled trials which aim to determine whether the routine administration of fluoxetine (20 mg daily) for six months after an acute stroke improves patients’ functional outcome. Methods/Design: The core protocol for the three trials has been published (Mead et al., Trials 20:369, 2015). The trials include patients aged 18 years and older with a clinical diagnosis of stroke and persisting focal neurological deficits at randomisation 2–15 days after stroke onset. Patients are randomised centrally via each trials’ web-based randomisation system using a common minimisation algorithm. Patients are allocated fluoxetine 20 mg once daily or matching placebo capsules for six months. The primary outcome measure is the modified Rankin scale (mRS) at six months. Secondary outcomes include: living circumstances; the Stroke Impact Scale; EuroQol (EQ5D-5 L); the vitality subscale of the 36-Item Short Form Health Survey (SF36); diagnosis of depression; adherence to medication; serious adverse events including death and recurrent stroke; and resource use at six and 12 months and the mRS at 12 months. Discussion: Minor variations have been tailored to the national setting in the UK (FOCUS), Australia, New Zealand and Vietnam (AFFINITY) and Sweden (EFFECTS). Each trial is run and funded independently and will report its own results. A prospectively planned individual patient data meta-analysis of all three trials will provide the most precise estimate of the overall effect and establish whether any effects differ between trials or subgroups. This statistical analysis plan describes the core analyses for all three trials and that for the individual patient data meta-analysis. Recruitment and follow-up in the FOCUS trial is expected to be completed by the end of 2018. AFFINITY and EFFECTS are likely to complete follow-up in 2020. Trial registration: FOCUS: ISRCTN, ISRCTN83290762. Registered on 23 May 2012. EudraCT, 2011-005616-29. Registered on 3 February 2012. AFFINITY: Australian New Zealand Clinical Trials Registry, ACTRN12611000774921. Registered on 22 July 2011. EFFECTS: ISRCTN, ISRCTN13020412. Registered on 19 December 2014. Clinicaltrials.gov, NCT02683213. Registered on 2 February 2016. EudraCT, 2011-006130-16. Registered on 8 August 2014.

Background: An essential strategy to reduce mortality and disability after stroke is to ensure access to evidence-based care. In developed countries, it has been shown that if hospitals improve the quality of care, the impact of stroke is attenuated. However, in developing countries, data on the processes of care and associated patient outcomes are scarce. We examined the care processes and outcomes among patients with acute stroke from a stroke unit in a major public hospital in Vietnam whereby there are approximately 15,000 hospital admissions for stroke per year. Methods: We included first-ever strokes admitted to the 115 People’s Hospital (June 2017-March 2018). Data were collected in the Registry of Stroke Care Quality which is used in >50 countries. Baseline characteristics, stroke-related factors (e.g., type and severity), processes of care (e.g., thrombolysis), and outcomes at discharge were examined including mortality and functional outcome, assessed as the walking ability without assistance. Results: Data were available for 6601 patients with first-ever stroke (44% women, 80% ischemic stroke [IS], median age: 62 years, interquartile range [IQR]: 53-72) who received stroke unit care. The median time from stroke onset to hospital arrival was 15.7 hours (IQR: 5.6-37.5). At admission, the median National Institute of Health Stroke Scale score indicating stroke severity was 7 (IQR: 4-12). Among those with IS, 9% received intravenous thrombolysis. Over 90% of the participants received recommended process of care including dysphasia screening (99%), antihypertensive agents (92%), cholesterol-lowering medication (IS = 99%), and antithrombotic medication (IS = 98%). At discharge (median length of stay: 4 days, IQR: 3-6), 3% of all cases died and 46% were able to walk independently. Advanced age, stroke severity, and not receiving antihypertensive agent(s) were contributing factors to mortality and poorer functional outcome. Conclusion: There was a considerable delay in the time from stroke onset to hospital arrival. Evidence-based care at the stroke unit was consistently provided. It remains unclear whether other hospitals in Vietnam and other developing countries perform as well. Greater public awareness of stroke to reduce onset to arrival times and more stroke units are warranted to achieve the excellent outcomes in the major public hospital.

The COVID-19 pandemic has impacted the health system worldwide. Stroke is one of the leading causes of death and disability in the world. Asia has a diverse health system and more than two-thirds of strokes occur in this region. The Asian Stroke Advisory Panel (ASAP) conducted a survey among the member countries to explore the impact of COVID-19 on stroke care. The stroke admission numbers have fallen, as have the number of patients who received thrombolysis and mechanical thrombectomy. The stroke unit and rehabilitation beds have been reallocated for COVID-19 care. ASAP recommends emergency department screening of stroke patients for COVID-19 and protected stroke code to be activated for COVID-19 suspect stroke patients. Noncontrast computed tomography (CT), CT angiography, and CT chest are the imaging modalities of choice. All health care professionals involved in triaging, imaging, and stroke care should wear appropriate personal protective equipment. All eligible stroke patients (COVID suspect/positive/non-COVID) should receive intravenous thrombolysis/mechanical thrombectomy. Mobile stroke units and robots can be used wherever available for evaluation and triaging. All stroke patients should receive standard stroke unit care. Limited rehabilitation should be offered to patients and training of caregivers if needed. Telemedicine/telestroke should be used for rehabilitation and follow-up. The ASAP consensus statement can be adapted to suit local and national health care systems.

Background: Stroke globally impacts mortality and disability. Compliance with international standards and evidence-based practices for acute stroke management would improve patient outcomes. Objectives: We aimed to present a descriptive analysis of the quality of acute stroke care across different countries using the Registry of Stroke Care Quality (RES-Q). Method: In a cross-sectional study, data from key quality indicators such as Emergency Medical Services (EMS) deployment rates, hospital arrival to imaging time (door-to-imaging: DIT), hospital arrival to thrombolysis time (door-to-needle: DNT), and Stroke Unit Care/Intensive Care Unit (SU/ICU) admission frequencies were examined. The analysis employed descriptive statistics and Spearman correlation tests. Results: Of 334,184 patients from 1130 hospitals in 70 countries, 218,832 patients (65.5%) from 47 countries were diagnosed with acute ischemic stroke after exclusions. The number of patients per country ranged from 226 to 62,080. International variability in care quality was observed: EMS (7–97%); SU/ICU (12–100%); and median DIT (7–41 min); and DNT (20–75 min). IVT rates varied markedly across countries, ranging from <1% to 52%. Higher patient volumes were positively correlated with SU/ICU admission and negatively with DIT and DNT (ρ = 0.10, –0.22, –0.42, respectively). Conclusion: This study demonstrates substantial international variation in the use of quality monitoring in clinical practice as well as in key indicators of acute ischemic stroke care, including intravenous thrombolysis rates and treatment timelines. The extent of variability highlights opportunities for benchmarking and targeted quality improvement efforts across diverse healthcare systems.

In Asia, especially Vietnam, AF is a common arrhythmia and is linked to a higher risk of stroke and systemic embolism. Anticoagulation therapy for stroke prevention in AF patients can result in bleeding complications. To effectively manage AF, adopting appropriate anticoagulation and addressing modifiable risk factors are crucial. Vietnamese clinicians are particularly interested in non-vitamin K antagonist oral anticoagulants (NOACs), a recent development in AF treatment. However, the lack of head-to-head trials comparing NOACs makes selecting a specific NOAC challenging. This review aims to provide a comprehensive overview of the available clinical evidence on NOACs for stroke prevention in AF to assist clinicians in making informed decisions and improving treatment outcomes in patients with AF. The first part of this review will present the current landscape of AF in Vietnam, focusing on AF prevalence and highlighting gaps in clinical practice. Furthermore, this part extensively discusses the anticoagulation strategy for both primary and secondary stroke prevention in AF.