The aim of this updated guideline is to provide comprehensive and timely evidence-based recommendations on the prevention of future stroke among survivors of ischemic stroke or transient ischemic attack. The guideline is addressed to all clinicians who manage secondary prevention for these patients. Evidence-based recommendations are provided for control of risk factors, intervention for vascular obstruction, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke. Recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances, including aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy. Special sections address use of antithrombotic and anticoagulation therapy after an intracranial hemorrhage and implementation of guidelines.

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Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

Theodore G. Ganiats, A. Michael Lincoff, Eric D. Peterson, George J. Philippides, Pierre D. Adams, Charles R. Bridges, Donald E. Casey, Jr, Steven M. Ettinger, Francis M. Fesmire, 2012 Writing Committee Members, Hani Jneid, Jeffrey L. Anderson, R. Scott Wright, Cynthia Foundation/American Heart Association Task Force on Practice Guidelines Cardiology and Replacing the 2011 Focused Update): A Report of the American College of ST-Elevation Myocardial Infarction (Updating the 2007 Guideline − Unstable Angina/Non 2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With

Accf/aha task force members

prevent return to any drinking for acamprosate was 12 (95% CI, 8 to 26; risk difference [RD], −0.09; 95% CI, −0.14 to −0.04) and was 20 (95% CI, 11 to 500; RD, −0.05; 95% CI, −0.10 to −0.002) for oral naltrexone (50 mg/d). The NNT to prevent return to heavy drinking was 12 (95% CI, 8 to 26; RD −0.09; 95% CI, −0.13 to −0.04) for oral naltrexone (50 mg/d). Meta-analyses of trials comparing acamprosate to naltrexone found no statistically significant difference between them for return to any drinking (RD, 0.02; 95% CI, −0.03 to 0.08) or heavy drinking (RD, 0.01; 95% CI, −0.05 to 0.06). For injectable naltrexone, meta-analyses found no association with return to any drinking (RD, −0.04; 95% CI, −0.10 to 0.03) or heavy drinking (RD, −0.01; 95% CI, −0.14 to 0.13) but found an association with reduction in heavy drinking days (weighted mean difference [WMD], −4.6%; 95% CI, −8.5% to −0.56%). Among medications used off-label, moderate evidence supports an association with improvement in some consumption outcomes for nalmefene (heavy drinking days per month: WMD, −2.0; 95% CI, −3.0 to −1.0; drinks per drinking day: WMD, −1.02; 95% CI, −1.77 to −0.28) and topiramate (% heavy drinking days: WMD, −9.0%; 95% CI, −15.3% to −2.7%; drinks per drinking day: WMD, −1.0; 95% CI, −1.6 to −0.48). For naltrexone and nalmefene, NNHs for withdrawal from trials due to adverse events were 48 (95% CI, 30 to 112) and 12 (95% CI, 7 to 50), respectively; risk was not significantly increased for acamprosate or topiramate. CONCLUSIONS AND RELEVANCE Both acamprosate and oral naltrexone were associated with reduction in return to drinking. When directly compared with one another, no significant differences were found between acamprosate and naltrexone for controlling alcohol consumption. Factors such as dosing frequency, potential adverse events, and availability of treatments may guide medication choice.

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Pharmacotherapy for Adults With Alcohol Use Disorders in Outpatient Settings A Systematic Review and Meta-analysis

RESULTS Seventy-eight percent of patients in the buprenorphine group (89 of 114 [95% CI, 70%-85%]) vs 37% in the referral group (38 of 102 [95% CI, 28%-47%]) and 45% in the brief intervention group (50 of 111 [95% CI, 36%-54%]) were engaged in addiction treatment on the 30th day after randomization (P < .001). The buprenorphine group reduced the number of days of illicit opioid use per week from 5.4 days (95% CI, 5.1-5.7) to 0.9 days (95% CI, 0.5-1.3) vs a reduction from 5.4 days (95% CI, 5.1-5.7) to 2.3 days (95% CI, 1.7-3.0) in the referral group and from 5.6 days (95% CI, 5.3-5.9) to 2.4 days (95% CI, 1.8-3.0) in the brief intervention group (P < .001 for both time and intervention effects; P = .02 for the interaction effect). The rates of urine samples that tested negative for opioids did not differ statistically across groups, with 53.8% (95% CI, 42%-65%) in the referral group, 42.9% (95% CI, 31%-55%) in the brief intervention group, and 57.6% (95% CI, 47%-68%) in the buprenorphine group (P = .17). There were no statistically significant differences in HIV risk across groups (P = .66). Eleven percent of patients in the buprenorphine group (95% CI, 6%-19%) used inpatient addiction treatment services, whereas 37% in the referral group (95% CI, 27%-48%) and 35% in the brief intervention group (95% CI, 25%-37%) used inpatient addiction treatment services (P < .001).

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Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial

Aims: The aim of the study was to assess the cumulative evidence on the effectiveness of brief alcohol interventions in primary healthcare in order to highlight key knowledge gaps for further research. Methods: An overview of systematic reviews and meta-analyses of the effectiveness of brief alcohol intervention in primary healthcare published between 2002 and 2012. Findings: Twenty-four systematic reviews met the eligibility criteria (covering a total of 56 randomized controlled trials reported across 80 papers). Across the included studies, it was consistently reported that brief intervention was effective for addressing hazardous and harmful drinking in primary healthcare, particularly in middle-aged, male drinkers. Evidence gaps included: brief intervention effective- ness in key groups (women, older and younger drinkers, minority ethnic groups, dependent/co-morbid drinkers and those living in tran- sitional and developing countries); and the optimum brief intervention length and frequency to maintain longer-term effectiveness. Conclusion: This overview highlights the large volume of primarily positive evidence supporting brief alcohol intervention effects as well as some unanswered questions with regards to the effectiveness of brief alcohol intervention across different cultural settings and in specific population groups, and in respect of the optimum content of brief interventions that might benefit from further research.

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The impact of brief alcohol interventions in primary healthcare: a systematic review of reviews.

This review examined the effectiveness of screening followed by behavioral counseling, with or without referral, for alcohol misuse in primary care settings. Among 23 included trials, brief multico...

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Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the U.S. Preventive Services Task Force

Objectives To assess the effectiveness of screening followed by behavioral counseling for adolescents and adults with alcohol misuse in primary care settings Data Sources MEDLINE®, Embase®, the Cochrane Library, CINAHL®, PsycINFO® Additional studies were identified from reference lists and technical experts Review Methods Two people independently selected, extracted data from, and rated the quality of relevant trials and systematic reviews Quantitative analyses were conducted for outcomes when feasible and used subgroup analyses to explore whether results differed by intensity, sex, country, person delivering the counseling, or setting Two reviewers graded the strength of evidence (SOE) Results A total of 23 trials and six systematic reviews were included The trials generally enrolled subjects with risky/hazardous drinking, usually excluding those with alcohol dependence Among adults receiving interventions, consumption decreased by 36 drinks per week (weighted mean difference [WMD], 36, 95% confidence interval [CI], 24 to 48), 12 percent fewer subjects reported heavy drinking episodes (risk difference 012, 95% CI, 007 to 016), and 11 percent more subjects reported drinking beneath recommended limits (risk difference, 011, 95% CI, 008 to 013) over 12 months compared with controls (moderate SOE) Interventions improved some utilization outcomes (eg, hospital days and costs: low SOE) For most health outcomes, available evidence either demonstrated no difference between interventions and controls (eg, mortality: low SOE) or was insufficient to draw conclusions (eg, accidents, injuries, alcohol-related liver problems: insufficient SOE) The best evidence of effectiveness is for brief (generally, 10 to 15 minutes) multicontact interventions For older adults, trials provided evidence of effectiveness, but effect sizes were smaller than for all adults Trials enrolling college students provided evidence of effectiveness for reducing consumption and heavy drinking episodes (moderate SOE) and some accident, utilization, and academic outcomes (low, low, and moderate SOE, respectively) Studies in adults found benefits lasting several years; for college students, some benefits found at 6 months were no longer significantly different for intervention versus control groups at 12 months The one study enrolling pregnant women did not find a significant difference for reduction in consumption Evidence was insufficient for adolescent populations No studies randomized subjects, practices, or providers to screening and a comparator, and none of the included studies reported followup with referrals as an outcome Conclusions Behavioral counseling interventions improve behavioral outcomes for adults with risky/hazardous drinking For most health outcomes, available evidence either found no difference between interventions and controls or was insufficient to draw conclusions The best evidence of effectiveness is for brief multicontact interventions

Emily M Richmond

Papers

Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the U.S. Preventive Services Task Force

Screening, Behavioral Counseling, and Referral in Primary Care To Reduce Alcohol Misuse