Ethnic differences in stroke incidence and case fatality in Auckland, New Zealand

BACKGROUND AND PURPOSE

This study compares stroke incidence, 28-day case fatality, and hospital management for Maori, Pacific Islands people ("Pacific people"), and others (mostly Europeans) living in Auckland, New Zealand.

METHODS

Data come from the Auckland Stroke Study, a population-based study that registered all stroke events occurring among Auckland residents aged 15 years or more during a 1-year period ending February 29, 1992.

RESULTS

During the study year, 1803 stroke events were registered, including 82 (4.5%) in Maori, 113 (6.3%) in Pacific people, 1572 (87.2%) in Europeans, and 36 (2.0%) in others of Indian or Chinese origin. The mean +/- SD age of stroke patients was 55.0 +/- 16.0 years in Maori, 59.7 +/- 14.9 years in Pacific people, and 73.3 +/- 12.1 years in Europeans. Maori and Pacific people have significantly higher estimated relative risks of stroke compared with Europeans (OR, 1.34; 95% confidence interval [CI], 1.05 to 1.67 in Maori; and OR, 1.63; 95% CI, 1.33 to 1.98 in Pacific people). Maori and Pacific people also have higher estimated relative risks of death within 28 days of stroke compared with Europeans, especially men.

CONCLUSIONS

This study indicates that there are important differences in stroke incidence rates and case fatality among the major ethnic groups in Auckland. The reasons for the higher incidence rates in Maori and Pacific people may be related to levels of risk factors, but this requires further investigation. Ongoing monitoring of stroke incidence and outcome should include separate reporting by ethnicity.

A cross-cultural study on impaired self-awareness in Japanese patients with brain dysfunction

Japanese patients with brain dysfunction (21 with severe traumatic brain injury [TBI], 21 with right, and 21 with left cerebral vascular accidents [CVA]) were asked to make behavioral ratings regarding their competencies in several areas. Relatives of patients and physical therapists who treated them also rated each patient's behavioral competency. Japanese patients with TBI overestimated their behavioral competencies compared with therapists ratings, but not relatives' ratings. Japanese patients with TBI overstimated self-care skills but not their ability to interact in socioemotional situations. Patients who had right and left CVA did not differ in their mean ratings of behavioral competency. Among all patient groups, there was no correlation between self-reported competencies and performance on a neuropsychological test. Family ratings of patients' behavioral competencies correlated with the patients' neuropsychological test performance. Post hoc analyses of patients with TBI suggest that speed of finger tapping related to an impaired self-awareness. Whereas cultural factors may influence self-reports of behavioral competency, patients across cultures with brain dysfunction seem to have reduced insight into their actual level of neuropsychological functioning.

Socioeconomic deprivation, ethnicity, and stroke mortality in Greater London and south east England

OBJECTIVE AND SETTING

To examine geographical variation in stroke mortality in Greater London compared with the surrounding South East Region of England.

DESIGN

Cross sectional, ecological analysis based on electoral wards.

SUBJECTS

Resident population aged 45 years or more.

MAIN OUTCOME MEASURE

Age specific stroke mortality rates in five age bands, 1986-92.

MAIN OUTCOME MEASURE

Age specific stroke mortality rates in five age bands, 1986-92.

MAIN RESULTS

In the 45-54 years age band, stroke mortality rate ratios (95% confidence intervals) relative to the surrounding south east were 2.09 (1.81, 2.4) for Inner London and 1.31 (1.15, 1.5) for Outer London for men and 1.64 (1.4, 1.93) and 1.13 (0.98, 1.31) respectively for women. This gradient diminished and reversed with increasing age. In the 85+ age band, rate ratios were 0.82 (0.76, 0.89) for Inner London and 0.89 (0.84, 0.94) for Outer London for men and 0.8 (0.75, 0.85) and 0.88 (0.84, 0.92) respectively for women. Carstairs deprivation index and the percentages of Afro-Caribbean men and women and Irish born men were significantly and positively correlated with stroke mortality at the ward level. The Carstairs effect diminished with increasing age. Adjustment for these variables diminished or abolished the higher stroke mortality risks in London for younger people but had little effect on the lower risks for older Londoners.

CONCLUSIONS

Higher rates of stroke mortality among middle aged adults in Greater London, compared with the surrounding South East Region, are associated with socioeconomic deprivation and ethnicity. These factors do not explain the relatively lower stroke mortality among older Londoners.

Apolipoprotein E epsilon4 and the risk of dementia with stroke. A population-based investigation

OBJECTIVE

To investigate the association between the apolipoprotein E (APOE) genotypes and dementia in patients with stroke, defined as either vascular dementia (VaD) or Alzheimer disease with cerebrovascular disease (AD with CVD).

DESIGN AND SETTING

Population-based, case-control study from Rotterdam, the Netherlands, and New York City.

PARTICIPANTS

A total of 187 patients with dementia and stroke were compared with 507 controls similar in age and ethnic group.

MAIN OUTCOME MEASURES

The APOE allele frequencies in patients and controls; the odds ratio of dementia with stroke, VaD, and AD with CVD, adjusted for age, sex, residency, and education; and the percent attributable risk related to the APOE epsilon4 allele.

RESULTS

Overall, patients with dementia and stroke had a higher APOE epsilon4 allele frequency than controls. Compared with APOE epsilon3 homozygote individuals, APOE epsilon4 homozygotes had a 7-fold increased risk of dementia with stroke (OR=6.9; 95% CI, 1.6-29.4), while APOE epsilon4 heterozygotes had nearly a 2-fold increase in risk (OR=1.8; 95% CI, 1.2-2.7). Risks associated with APOE epsilon4 were elevated regardless of the subtype of dementia with stroke or age or sex. The percent attributable risk related to the APOE epsilon4 allele among demented patients with stroke was 41% overall, 33% among those with VaD, and 44% among those with AD with CVD.

CONCLUSION

The APOE epsilon4 allele is a genetic risk factor for dementia with stroke, including VaD and AD with CVD. This may imply shared genetic susceptibility to dementia associated with stroke and AD. Alternatively, the category of patients with dementia and stroke, including VaD as currently defined, may include patients with AD.

Social class and race disparities in premature stroke mortality among men in North Carolina

The purpose of this work was to examine the association between social class and premature stroke mortality among blacks and whites. For black men and white men in North Carolina, aged 35-54 years, mortality data from vital statistics files and population data from Census Public Use Microdata Sample files were matched according to social class for the years 1984-1993. Four categories of social class were defined based upon a two-dimensional classification scheme of occupations. For each category of social class, race-specific age-adjusted stroke mortality rates were calculated, and race-specific prevalences of income, wealth, education, unemployment, and disability were estimated. Women were excluded because comparable information on social class was not available from the mortality and population data sources. For both black men and white men, the highest rates of premature stroke mortality were observed among the lowest social classes. The rate ratios (RR) between the lowest and highest social class were 2.8 for black men and 2.3 for white men. Within each social class, black men had substantially higher rates of premature stroke mortality than white men (black-to-white RR ranged from 4.0 to 4.9). Among both black men and white men, the highest social class consistently had the most favorable levels of income, wealth, education, and employment. The inverse association between social class and stroke mortality for both black men and white men supports the need for stroke prevention efforts that address the structural inequalities in economic and social conditions.

Body height, cardiovascular risk factors, and risk of stroke in middle-aged men and women. A 14-year follow-up of the Finnmark Study

BACKGROUND

Geographical differences in stroke mortality are not fully explained by population variations in blood pressure and antihypertensive treatment. Some studies have suggested that factors connected with health and nutrition in early life may be related to stroke morbidity and mortality. Body height is a sensitive marker for socioeconomic conditions, but results are conflicting as to whether height is associated with stroke.

METHODS AND RESULTS

In a population-based study, we investigated stroke incidence in relation to height and classic cardiovascular risk factors. A total of 13,266 men and women 35 to 52 years of age were followed for 14 years, and 241 first events of stroke were registered. Stroke incidence was 36% higher in men. Height was inversely related to stroke in a dose-response manner. Per 5-cm increase in height, the age-adjusted risk of stroke was 25% lower in women (P < .0001) and 18% lower in men (P = .0007). Systolic blood pressure and daily smoking were positively associated with stroke in both sexes, while serum triglyceride level was a significant risk factor in women only (relative risk per 1 mmol/L, 1.3; 95% CI, 1.1 to 1.5). The associations remained after adjustment for possible confounders and were also observed in certain subtypes of stroke.

CONCLUSIONS

The results are consistent with the theory that factors influencing early growth as well as adult lifestyle factors contribute to cerebrovascular disease in adult age.

Racial variation in predicted and observed in-hospital death. A regional analysis

OBJECTIVE

To compare observed, predicted, and risk-adjusted hospital mortality rates in white and African-American patients and to determine whether, as prior studies suggest, African-American patients would have higher predicted risks of death and similar or higher risk-adjusted mortality.

DESIGN

Retrospective cohort study.

SETTING

Thirty hospitals in northeast Ohio.

PATIENTS

A total of 88205 eligible patients consecutively discharged in the years 1991 through 1993 with the following 6 diagnoses: acute myocardial infarction, congestive heart failure, obstructive airways disease, gastrointestinal hemorrhage, pneumonia, and stroke.

METHODS

We measured predicted risks of death at admission for each diagnosis using validated multivariable models based on standard clinical data abstracted from patients' medical records. We then adjusted in-hospital mortality rates in white and African-American patients for predicted risk of death and other covariates using logistic regression analysis.

MAIN OUTCOME MEASURES

Predicted risk of death at admission and observed hospital mortality in white and African-American patients.

RESULTS

Predicted risks of death were lower (P<.001) in African Americans for 4 of the 6 diagnoses. Adjusted odds of hospital death were lower (P<.01) in African Americans for 2 of the 6 diagnoses (congestive heart failure and obstructive airways disease) and similar for the other 4 diagnoses. For all diagnoses, in aggregate, the adjusted odds of hospital death were 13% lower in African-American compared with white patients (multivariable odds ratio, 0.87; 95% confidence interval, 0.80-0.94). Findings were similar if further adjustments were made for differences in length of stay, site of hospitalization, or discharge triage practices.

CONCLUSION

Contrary to our a priori hypotheses, predicted risks of death and risk-adjusted mortality rates were generally lower in African-American patients. Our finding of lower predicted risk may reflect racial differences in hospital admission practices or in access to outpatient care. However, our findings suggest that, once hospitalized, African-American patients attained similar or better outcomes, as measured by an important measure--hospital mortality.

Association of transient ischemic attack/stroke symptoms assessed by standardized questionnaire and algorithm with cerebrovascular risk factors and carotid artery wall thickness. The ARIC Study, 1987-1989

The baseline examination (1987-1989) for the Atherosclerosis Risk in Communities (ARIC) Study was conducted in 15,792 free-living residents aged 45-64 years in four geographically dispersed US communities. A questionnaire on symptoms of transient ischemic attack (TIA) and stroke was evaluated by computer algorithm for 12,205 of these participants. Data were also collected on lipoprotein levels, hemostasis, hematology, anthropometry, blood pressure, medical history, lifestyle, socioeconomic status, and medication use. Noninvasive high resolution B-mode ultrasonographic imaging was used to determine carotid arterial intimal-medial wall thickness (IMT). The cross-sectional relation between the prevalence of TIA/stroke symptoms and putative risk factors was assessed by logistic regression, controlling for age and community. Odds ratios for TIA/stroke symptoms were significantly elevated (p < or = 0.01) for diabetes mellitus, current smoking, hypertension, lower levels of education, income, and work activity, and higher levels of lipoprotein(a), IMT, hemostasis factor VIII, and von Willebrand factor. However, the relations with education and carotid IMT were not present for black Americans. In whites, the relations of TIA/stroke symptoms to IMT were nonlinear. Only at extreme levels of IMT were symptoms substantially more frequent: For example, men with an IMT greater than 1.17 mm or women with an IMT greater than 0.85 mm had approximately twice the odds of having positive TIA/stroke symptoms as those with lower IMTs. The authors plan in future analyses to address the issue prospectively, as well as to examine the relation with magnetic resonance imaging-defined outcomes and clinically defined incident stroke.

Cerebrovascular disease in the Afro-American population

The types of stroke which are unique to Afro-American patients are reviewed. The major risk factors which contribute to the higher incidence of stroke in this population are analyzed.

The Tel Aviv Stroke Registry. 3600 consecutive patients

BACKGROUND AND PURPOSE

We undertook to estimate the frequency of various risk factors and the type and severity of stroke in different ethnic groups documented in a large hospital-based stroke registry. Tel Aviv is a metropolis with about 400000 inhabitants and about 600000 daily visitors and workers. The Tel Aviv Medical Center (TAMC) is the only tertiary medical care facility to which all patients with acute stroke are referred. Israel is a country with a heterogeneous population, of which a significant proportion was born abroad. The people differ in their genetic background, as well as in their early environmental conditions, lifelong diet, and other habits. This variety has proved to be a fertile ground for the study of different neurological diseases, including stroke.

METHODS

A prospective hospital-based registry using systematic computer coding of data of all consecutive stroke patients admitted to the TAMC has been conducted since May 1988. Different aspects of the amassed data were analyzed statistically.

RESULTS

From May 1988 until April 1994, 3600 stroke patients were admitted to the TAMC. The mean age was 73.2 years, and 58.2% were males. Cerebral infarctions were diagnosed in 80.9%, primary intracerebral hemorrhages in 8.0%, and transient ischemic attacks in 11.1%. There were 861 patients (24%) who were admitted with recurrent strokes. Past medical history of hypertension was the major risk factor (occurring in 52.2% of the patients), followed by ischemic heart disease (29.7%), diabetes mellitus (25.2%), smoking (17.0%), atrial fibrillation (14.3%), and hyperlipidemia (8.4%). Ischemic heart disease and atrial fibrillation were more frequent in patients from Europe and America (Ashkenazi group), whereas diabetes mellitus and smoking were more prominent in the other groups. The in-hospital mortality rate was 13.8% and was similar in both ethnic groups.

CONCLUSIONS

This registry allows the study of the risk factors, natural history, and clinical manifestations of stroke in different ethnic groups.

Diagnosis and treatment of concomitant hypertension and stroke

There remains nearly a twofold increase in blacks compared with whites for stroke mortality. The death rate from cerebral hemorrhage in blacks approximates twice that of whites. Subarachnoid hemorrhage is a frequent cause of mortality and morbidity in stroke and is also about twice as frequent in blacks. Lacunar strokes occur more in blacks reflecting increased incidence of hypertension and are leading causes of multi-infarct encephalopathy and dementia. Therefore, the concomitant occurrence of hypertension and stroke is most common in African Americans and requires diagnosis of the type of stroke, which then defines the rationale of blood pressure control. Cerebral vascular changes associated with acute, chronic, and reactive hypertension are operative. When to treat, when not to treat, and the appropriateness of specific antihypertensive agents in acute stroke are relevant. A common misconception is that the increased blood pressure is the cause of the stroke when it is likely the result of the stroke. Lowering the blood pressure in all acute stroke patients with elevated blood pressure may worsen the neurologic deficit. Thus, the judicious control of blood pressure is to be stressed in the concomitant occurrence of hypertension and stroke.

Ethnicity and cardiovascular disease: The Evans County heart study

A long term study of diversity between two ethnic groups was developed in Evans County, Georgia. The findings are predicated on the genotypic-phenotypic interactions, with the multitude of environmental factors. The genetic-environmental interaction ultimately determines the individual's state of health or disease. For example, coronary heart disease prevalence and incidence rates were extremely low for blacks in Africa and four times lower than whites in rural South Georgia in the 1960s. Excessive hypertension and diabetes mellitus, and greater cerebrovascular disease mortality in black men, is now well known. Blood pressure levels studied in rural Africa were normal and did not rise with age, whereas blacks, conversely, demonstrated twice as much hypertension in South Georgia as whites and demonstrated an inverse relation between education and blood pressure (ie, the lower the education the higher the blood pressure). Cultural adaptation has accelerated hypertensive disease and strokes in blacks, while there remains an excess of atherosclerotic coronary heart disease in white men. Secular trends suggest that coronary heart disease is decreasing among white men but may be increasing in black men. Studies of ethnicity and biracial populations provide important cardiovascular disease associations with clinical risk factor studies.

Epidemiology of hypertension in African American women

To describe the epidemiology of hypertension in U.S. African American women and to highlight priority areas for future research, data from the nationwide surveys of the U.S. National Center for Health Statistics, from selected multicenter studies of the U.S. National Heart, Lung, and Blood Institute, as well as from selected other population-based studies, were reviewed. In 1988 through 1991, an estimated 3 million African American women aged 18 and older had hypertension. Compared with that in U.S. whites, hypertension in black women is characterized by higher incidence, earlier onset, longer duration, higher prevalence, and higher rates of hypertension-related mortality and morbidity. Risk factors for hypertension incidence in black women include obesity and weight gain. The effectiveness of drug therapy of hypertension has been established in black women, and important gains in rates of treatment and control have been accomplished. Nevertheless, rates of hypertension-related mortality for black women remain among the highest in the industrialized nations. Further research on causes and prevention of hypertension in black women is needed. Goals related to prevention and control of hypertension in African Americans for the year 2000 have been established and must be vigorously pursued.

[Behçet disease with primary involvement of the cerebral vessels]

HISTORY AND CLINICAL FINDINGS

Two months after the onset of mainly frontal headaches a 25-year-old man of Turkish descent additionally developed double vision. Fundoscopy revealed bilateral choked discs and right trochlear paralysis. Computed tomography and digital subtraction angiography demonstrated thrombosis of the superior sagittal sinus. On admission to hospital the patient was fully conscious but had marked meningism, bilaterally positive Lasègue's sign (painful straight leg raising) at a 50 degree angle, and multiple oral aphthous ulcers. The sinus thrombosis suggested a chronic inflammatory process, while the oral ulcers pointed to Behçet's syndrome.

INVESTIGATIONS

Inflammatory parameters (erythrocyte sedimentation rate, C-reactive protein and white blood cell count) were increased and the HLA-B27 test was positive. Other laboratory tests, cerebrospinal fluid, chest radiogram and ECG were unremarkable.

TREATMENT AND COURSE

Despite intravenous administration of heparin nad cefuroxim for one week the sagittal sinus thrombosis spread to the straight sinus. In the third week scrotal ulcerations were noted and taken to confirm Behçet's syndrome. Immunosuppressive treatment with methylprednisolone (initially 80 mg daily) and 2 weeks later together with chlorambucil (0.1 mg/kg daily) was started. Four weeks later the patient was free of symptoms and discharged.

CONCLUSION

Neurological signs are not adequately stressed by the International Study Group for Behçet's Disease among its listed diagnostic criteria.

Diabetes mellitus, race, and socioeconomic status. A population-based study

To identify factors associated with diabetes mellitus and to determine whether racial differences in these factors, especially socioeconomic status, explain the high prevalence of diabetes among African-Americans, we performed a cross-sectional study using a population-based, representative sample from three US communities. The participants comprised 975 white and 418 African-American adults, aged 35 to 54 years. The main outcome variable was the presence of diabetes defined by either self-report or abnormal results on the oral glucose tolerance test (serum glucose level > 10.0 mmol/L (180 mg/dL) 1 hour after 50-g oral glucose dose). Compared to their white counterparts, African-American participants were more overweight, displayed greater central adiposity, and had lower socioeconomic status. Diabetes was over twice as prevalent among African-Americans (10.3%) as compared to whites (4.6%; odds ratio (OR) = 2.38; 95% confidence interval (95% CI): 1.50, 3.75; P = 0.0001). After adjustments for racial differences in age, socioeconomic status, overweight, and central adiposity, African-Americans remained over twice as likely to have diabetes compared to whites (OR = 2.35; 95% CI: 1.49, 3.73; P = 0.0003). The excess prevalence of diabetes in African-Americans was greatest in individuals of low socioeconomic status (OR = 4.09) and least among individuals of high socioeconomic status (OR = 1.90; P < 0.001 for trend). Racial differences in obesity and socioeconomic status do not appear to explain fully the higher prevalence of diabetes among African-Americans. African-American race seems to be a strong, independent risk factor for diabetes, especially among individuals of low socioeconomic status.

Mortality from coronary heart disease and stroke for six ethnic groups in California, 1985 to 1990

Coronary heart disease and stroke death rates were compared for six ethnic groups (non-Hispanic white, Hispanic, African-American, Chinese, Japanese, and Asian Indian) by sex and age (25 to 44, 45 to 64, 65 to 84, and 25 to 84 years old) using California census and 1985 to 1990 death data. African-American men and women in all age groups had the highest rates of death from coronary heart disease, stroke, and all causes (except for coronary heart disease in the oldest men). Hispanics, Chinese, and Japanese in all age-sex groups had comparatively low death rates for coronary heart disease and stroke, although stroke was proportionally an important cause of death for Chinese and Japanese groups. Coronary heart disease was an important cause of death for Asian Indians although death rates were generally not higher than those for other ethnic groups. Ethnic differences were most marked for women and younger age groups.

Stroke in young black patients. Risk factors, subtypes, and prognosis

BACKGROUND AND PURPOSE

Stroke subtypes and prognosis differ among older black patients compared with whites; however, few data are available regarding stroke among young black patients.

METHODS

To determine the risk factors for stroke, stroke subtype, and prognosis among young black patients, we retrospectively reviewed the medical records of all 15- to 44-year-old patients admitted with stroke to a university-affiliated public hospital from January 1990 through June 1994.

RESULTS

Of the 248 eligible patients admitted with stroke, 219 were blacks. Hypertension was more frequently associated with stroke in young black than in non-black patients (55% versus 24%, P = .003). Cocaine abuse was frequent among both black and non-black patients (27% versus 38%, P = NS). Hypertensive intracerebral hemorrhage (64%) was the most common subtype of intracerebral hemorrhage (n = 67), and lacunar infarction (21%) was the most common subtype of cerebral infarction (n = 112) in young black patients. Outcome in black patients with stroke at discharge was 69% independent, 8% dependent, and 23% dead.

CONCLUSIONS

The high frequency of hypertension, hypertensive intracerebral hemorrhage, and lacunar infarction among young black patients with stroke suggests accelerated hypertensive arteriolar damage, possibly due to poor control of hypertension.

Epidemiology of stroke in Hispanic Americans

BACKGROUND AND PURPOSE

In 1990 cerebrovascular disease was the fourth leading cause of death in Hispanics in the United States. However, little information has been published about the epidemiology of stroke in US Hispanic populations.

METHODS

Data from the National Center for Health Statistics were examined to characterize the pattern of stroke occurrence and risk factors among Hispanics in the United States.

RESULTS

In 1989 through 1991, stroke death rates were similar in Hispanics and whites aged 45 to 64 years; at ages 65 and over, Hispanics had rates that were substantially lower than those of whites. Data from national surveys suggest that the ethic differences in stroke mortality may be due in part to lower blood pressure in Hispanics than non-Hispanics.

CONCLUSIONS

Cohort studies, well-designed case-control studies, and continued oversampling of Hispanics in national surveys are needed to further define the epidemiological patterns of stroke in US Hispanics and to guide stroke prevention efforts.

Patients', relatives', and nurses' experience of stroke in northern Vietnam

Transcriptions were made of interviews held in Vietnam with five nurses, five people affected by stroke (aged 28-60), and with one relative each. Their stories were analysed as texts by means of a phenomenological hermeneutic method. The role of the nurses in Vietnam appeared to differ from that usually ascribed to nurses in Western institutionalized care. In the former a relative was expected to carry out basic care during the acute stage and to assist socioeconomically thereafter. The interviewees spoke of family bonds in the past, present, and future tenses when narrating their experiences of stroke as nurses, patients, and relatives. This was interpreted as an indication of a consciousness of an essential relatedness. Nurses were aware of playing a temporary and secondary role mainly as assistants: firstly to the doctor by carrying out orders and reporting, secondly to the stroke patient and his or her family by carrying out advanced nursing procedures and giving support. The advantages and disadvantages of involving the family in nursing care can be revealed by obtaining views from a different culture, which can provide a contrast against which constructive criticism of the Western nursing tradition can be made.

Development of a hierarchical activities of daily living scale for Chinese stroke patients in geriatric day hospitals

A culture-specific 4-point hierarchical scale covering self-care, household activity and mobility was developed by modifying the Rivermead ADL scale to assess the physical function of Chinese stroke patients. Self-care ability (13 items scored 0/1/2/3 with a maximum of 39) and mobility (8 items scored 0/1/2/3 with a maximum of 24) were routinely assessed by occupational therapists and physiotherapists in stroke patients on admission to and at discharge from two geriatric day hospitals (GDHs). Household activity (6 items scored 0/1/2/3 with a maximum of 18) was assessed by occupational therapists in non-institutionalized patients with self-care scores within 15% of the maximum. The scale was acceptable to patients and staff. Graphical representation in profile format facilitates the identification of items requiring special attention. Internal reliability was high; the Cronbach's alpha for the self-care, household and mobility domains was 0.9732, 0.9530, and 0.9787, respectively. The scale was used to assess the change in physical function of 436 stroke patients discharged from two GDHs in Hong Kong over 18 months. Patients' mean age was 73 years (SD +/- 8.4), and the female/male ratio 1:3. On average, 38 visits (+/- 32) were made over a mean enrollment period of 220 days (+/- 289). Both the self-care and mobility scores showed statistically significant improvements at discharge, and changes in function exceeded 1/4 of the standard deviation of the initial scores. A substudy of 28 stroke patients, in whom household scores were assessed, revealed that for those with better initial physical function, a ceiling effect was apparent with the self-care score but not with the household or mobility scores.(ABSTRACT TRUNCATED AT 250 WORDS)