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Abstract
BACKGROUND The lifetime risk (LTR) articulates the probability of disease in the residual lifetime for an index age. These estimates can be useful for general audience-targeted knowledge translation activities against hypertension. There are only a few reports on lifetime of impact of hypertension on stroke events in Asians in whom stroke incidence is higher than Westerners. METHODS The Suita Study, a cohort study of cardiovascular diseases in Japan, was established in 1989. We included all participants who were stroke free at baseline. Age (in years) was used as the time scale. Age-specific incidence rates were calculated with person-year method within 10-year bands. We estimated the sex and index-age specific LTR of first-ever stroke with taking the competing risk of death into account. RESULTS We followed 5783 men and women during 1989-2007 for 74 933 person-years. During the follow-up period, 276 (149 men and 127 women) participants had incident stroke. Of them, majority were cerebral infarction; 166 (102 men and 64 women). The LTR of stroke, accounted for competing risk of death, at 45 years of age for men without hypertension was 17.21% and it was 32.79% for hypertensive men. Among the hypertensive patients, participants with stage 2 or greater hypertension had higher LTR of stroke than the participants with stage 1 hypertension. This increased LTR of stroke for hypertensive patients were also observed among women and across all index ages for stroke. CONCLUSION In this urban community-based population, we observed that hypertension has significant effect on the residual LTR of stroke among both men and women of middle age, specifically for ischemic stroke.
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Ramirez L, Kim-Tenser MA, Sanossian N, Cen S, Wen G, He S, Mack WJ, Towfighi A. Trends in Acute Ischemic Stroke Hospitalizations in the United States. J Am Heart Assoc 2016; 5:JAHA.116.003233. [PMID: 27169548 PMCID: PMC4889194 DOI: 10.1161/jaha.116.003233] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background Population‐based studies have revealed declining acute ischemic stroke (AIS) hospitalization rates in the United States, but no study has assessed recent temporal trends in race/ethnic‐, age‐, and sex‐specific AIS hospitalization rates. Methods and Results Temporal trends in hospitalization for AIS from 2000 to 2010 were assessed among adults ≥25 years using the Nationwide Inpatient Sample. Age‐, sex‐, and race/ethnic‐specific and age‐adjusted stroke hospitalization rates were calculated using the weighted number of hospitalizations and US census data. From 2000 to 2010, age‐adjusted stroke hospitalization rates decreased from 250 to 204 per 100 000 (overall rate reduction 18.4%). Age‐specific AIS hospitalization rates decreased for individuals aged 65 to 84 years (846 to 605 per 100 000) and ≥85 years (2077 to 1618 per 100 000), but increased for individuals aged 25 to 44 years (16 to 23 per 100 000) and 45 to 64 years (149 to 156 per 100 000). Blacks had the highest age‐adjusted yearly hospitalization rates, followed by Hispanics and whites (358, 170, and 155 per 100 000 in 2010). Age‐adjusted AIS hospitalization rates increased for blacks but decreased for Hispanics and whites. Age‐adjusted AIS hospitalization rates were lower in women and declined more steeply compared to men (272 to 212 per 100 000 in women versus 298 to 245 per 100 000 in men). Conclusions Although overall stroke hospitalizations declined in the United States, the reduction was more pronounced among older individuals, women, Hispanics, and whites. Renewed efforts at targeting risk factor control among vulnerable individuals may be warranted.
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Affiliation(s)
- Lucas Ramirez
- Keck School of Medicine, University of Southern California, Los Angeles, CA Department of Neurology, University of Southern California, Los Angeles, CA
| | - May A Kim-Tenser
- Keck School of Medicine, University of Southern California, Los Angeles, CA Department of Neurology, University of Southern California, Los Angeles, CA Roxanna Todd Hodges Comprehensive Stroke Clinic, University of Southern California, Los Angeles, CA
| | - Nerses Sanossian
- Keck School of Medicine, University of Southern California, Los Angeles, CA Department of Neurology, University of Southern California, Los Angeles, CA Roxanna Todd Hodges Comprehensive Stroke Clinic, University of Southern California, Los Angeles, CA Department of Neurology, Rancho Los Amigos National Rehabilitation Center, Downey, CA
| | - Steven Cen
- Keck School of Medicine, University of Southern California, Los Angeles, CA Department of Neurology, University of Southern California, Los Angeles, CA Department of Neurosurgery, University of Southern California, Los Angeles, CA Roxanna Todd Hodges Comprehensive Stroke Clinic, University of Southern California, Los Angeles, CA
| | - Ge Wen
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Shuhan He
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - William J Mack
- Keck School of Medicine, University of Southern California, Los Angeles, CA Department of Neurosurgery, University of Southern California, Los Angeles, CA Roxanna Todd Hodges Comprehensive Stroke Clinic, University of Southern California, Los Angeles, CA
| | - Amytis Towfighi
- Keck School of Medicine, University of Southern California, Los Angeles, CA Department of Neurology, University of Southern California, Los Angeles, CA Department of Neurology, Rancho Los Amigos National Rehabilitation Center, Downey, CA
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Lolli V, Molinari F, Pruvo JP, Soto Ares G. Radiological and clinical features of cerebral sinovenous thrombosis in newborns and older children. J Neuroradiol 2016; 43:280-9. [PMID: 26970861 DOI: 10.1016/j.neurad.2015.12.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 12/08/2015] [Accepted: 12/19/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE Cerebral sinovenous thrombosis (CSVT) represents an increasingly recognized cause of pediatric stroke. Our purpose was to assess gender and age differences in the etiology, clinical presentation, and imaging features of CSVT in neonates and older children. METHODS Subjects aged newborn to 18 years diagnosed with CSVT at the Lille university hospital between 2011 and 2014 were included. RESULTS Eleven neonates and 16 non-neonates constituted the study population. The incidence of CSVT was significantly higher in male newborns. Clinical presentation did not vary significantly between the groups. Risk factors were age-dependent, with acute systemic illnesses significantly predominating in neonates (54%), whereas local infections, prothrombotic conditions, and trauma were more common in older children (36, 27, and 27% respectively). No predisposing factor could be identified in 36% of the neonates as compared to less than 5% of the non-neonates. Thrombosis of the deep venous structures was documented in 73% of the neonates whereas involvement of the superficial sinuses was significantly more frequent in the non-neonates group. Venous infarctions and extraparenchymal hemorrhages were significantly more frequent in the neonates group. CONCLUSION Male patients are at higher risk for CSVT than females. In neonates, involvement of the deep venous structures is significantly more common. Brain parenchymal and extraparenchymal changes occur more frequently in this age group than in older children.
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Affiliation(s)
- Valentina Lolli
- Radiology department, Erasmus university hospital, 808, route de Lennik, 1070 Brussels, Belgium.
| | | | - Jean-Pierre Pruvo
- Neuroradiology department, Roger-Salengro hospital, 59037 Lille, France
| | - Gustavo Soto Ares
- Neuroradiology department, Roger-Salengro hospital, 59037 Lille, France
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McMillan A, Bratton DJ, Faria R, Laskawiec-Szkonter M, Griffin S, Davies RJ, Nunn AJ, Stradling JR, Riha RL, Morrell MJ. A multicentre randomised controlled trial and economic evaluation of continuous positive airway pressure for the treatment of obstructive sleep apnoea syndrome in older people: PREDICT. Health Technol Assess 2016; 19:1-188. [PMID: 26063688 DOI: 10.3310/hta19400] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The therapeutic and economic benefits of continuous positive airway pressure (CPAP) for the treatment of obstructive sleep apnoea syndrome (OSAS) have been established in middle-aged people. In older people there is a lack of evidence. OBJECTIVE To determine the clinical efficacy of CPAP in older people with OSAS and to establish its cost-effectiveness. DESIGN A randomised, parallel, investigator-blinded multicentre trial with within-trial and model-based cost-effectiveness analysis. METHODS Two hundred and seventy-eight patients, aged ≥ 65 years with newly diagnosed OSAS [defined as oxygen desaturation index at ≥ 4% desaturation threshold level for > 7.5 events/hour and Epworth Sleepiness Scale (ESS) score of ≥ 9] recruited from 14 hospital-based sleep services across the UK. INTERVENTIONS CPAP with best supportive care (BSC) or BSC alone. Autotitrating CPAP was initiated using standard clinical practice. BSC was structured advice on minimising sleepiness. COPRIMARY OUTCOMES Subjective sleepiness at 3 months, as measured by the ESS (ESS mean score: months 3 and 4) and cost-effectiveness over 12 months, as measured in quality-adjusted life-years (QALYs) calculated using the European Quality of Life-5 Dimensions (EQ-5D) and health-care resource use, information on which was collected monthly from patient diaries. SECONDARY OUTCOMES Subjective sleepiness at 12 months (ESS mean score: months 10, 11 and 12) and objective sleepiness, disease-specific and generic quality of life, mood, functionality, nocturia, mobility, accidents, cognitive function, cardiovascular risk factors and events at 3 and 12 months. RESULTS Two hundred and seventy-eight patients were randomised to CPAP (n = 140) or BSC (n = 138) over 27 months and 231 (83%) patients completed the trial. Baseline ESS score was similar in both groups [mean (standard deviation; SD) CPAP 11.5 (3.3), BSC 11.4 (4.2)]; groups were well balanced for other characteristics. The mean (SD) in ESS score at 3 months was -3.8 (0.4) in the CPAP group and -1.6 (0.3) in the BSC group. The adjusted treatment effect of CPAP compared with BSC was -2.1 points [95% confidence interval (CI) -3.0 to -1.3 points; p < 0.001]. At 12 months the effect was -2.0 points (95% CI -2.8 to -1.2 points; p < 0.001). The effect was greater in patients with increased CPAP use or higher baseline ESS score. The number of QALYs calculated using the EQ-5D was marginally (0.005) higher with CPAP than with BSC (95% CI -0.034 to 0.044). The average cost per patient was £1363 (95% CI £1121 to £1606) for those allocated to CPAP and £1389 (95% CI £1116 to £1662) for those allocated to BSC. On average, costs were lower in the CPAP group (mean -£35; 95% CI -£390 to £321). The probability that CPAP was cost-effective at thresholds conventionally used by the NHS (£20,000 per QALY gained) was 0.61. QALYs calculated using the Short Form questionnaire-6 Dimensions were 0.018 higher in the CPAP group (95% CI 0.003 to 0.034 QALYs) and the probability that CPAP was cost-effective was 0.96. CPAP decreased objective sleepiness (p = 0.02), increased mobility (p = 0.03) and reduced total and low-density lipoprotein cholesterol (p = 0.05, p = 0.04, respectively) at 3 months but not at 12 months. In the BSC group, there was a fall in systolic blood pressure of 3.7 mmHg at 12 months, which was not seen in the CPAP group (p = 0.04). Mood, functionality, nocturia, accidents, cognitive function and cardiovascular events were unchanged. There were no medically significant harms attributable to CPAP. CONCLUSION In older people with OSAS, CPAP reduces sleepiness and is marginally more cost-effective than BSC over 12 months. Further work is required in the identification of potential biomarkers of sleepiness and those patients at increased risk of cognitive impairment. Early detection of which could be used to inform the clinician when in the disease cycle treatment is needed to avert central nervous system sequelae and to assist patients decision-making regarding treatment and compliance. Treatment adherence is also a challenge in clinical trials generally, and adherence to CPAP therapy in particular is a recognised concern in both research studies and clinical practice. Suggested research priorities would include a focus on optimisation of CPAP delivery or support and embracing the technological advances currently available. Finally, the improvements in quality of life in trials do not appear to reflect the dramatic changes noted in clinical practice. There should be a greater focus on patient centred outcomes which would better capture the symptomatic improvement with CPAP treatment and translate these improvements into outcomes which could be used in health economic analysis. TRIAL REGISTRATION Current Controlled Trials ISRCTN90464927. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 40. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Alison McMillan
- Academic Unit of Sleep and Ventilation, National Heart and Lung Institute, Imperial College, London, UK
| | - Daniel J Bratton
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Rita Faria
- Centre for Health Economics, University of York, York, UK
| | | | - Susan Griffin
- Oxford University and Oxford Biomedical Research Centre, Churchill Hospital, Oxford, UK
| | - Robert J Davies
- Oxford Respiratory Trials Unit, University of Oxford, Churchill Hospital, Oxford, UK
| | - Andrew J Nunn
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - John R Stradling
- Oxford Respiratory Trials Unit, University of Oxford, Churchill Hospital, Oxford, UK
| | - Renata L Riha
- Department of Sleep Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Mary J Morrell
- Academic Unit of Sleep and Ventilation, National Heart and Lung Institute, Imperial College, London, UK
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Etter NM, Dressler EV, Andreatta RD. The relationship between labial vibrotactile detection and pure-tone hearing thresholds in healthy, ageing adults. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2016; 18:89-96. [PMID: 28425368 DOI: 10.3109/17549507.2015.1060527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE Orofacial anatomy is unique from other body systems in that oral musculature inserts directly into the underlying cutaneous skin, allowing for tight temporal synchronicity between somatosensory and auditory performance feedback to maintain correct orofacial behaviours across the lifespan. Unfortunately, little is currently known regarding the changes in orofacial sensory capacities associated with ageing and how these somatosensory and auditory changes may impact feedback during functional behaviours such as speech or swallowing. The purpose of this descriptive study was to begin assessing the relationship between the auditory and labial somatosensory system in healthy ageing adults. METHOD Pure-tone hearing thresholds were determined for 500, 1000, 2000 and 4000 Hz. Using a 2-alternative forced choice paradigm, 60 adults (19-84 years) completed vibrotactile detection thresholds (VDT) at the 5 and 10 Hz test frequencies. RESULT A significant difference for age by group was identified at the 5 Hz test frequency. Spearman Correlations identified a significant correlation between age and pure tone hearing thresholds and the 5 Hz test frequency threshold. CONCLUSION A relationship between pure tone hearing thresholds and labial somatosensory was identified. Future studies will begin the processing of modelling the complex multivariate sensorimotor relationship in healthy individuals before moving to a disordered population.
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Affiliation(s)
- Nicole M Etter
- a Communication Sciences and Disorders, The Pennsylvania State University, University Park , PA , USA
| | | | - Richard D Andreatta
- c Department of Rehabilitation Sciences , University of Kentucky , Lexington , KY , USA
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Iwasaki M, Sato M, Yoshihara A, Ansai T, Miyazaki H. Association between tooth loss and medical costs related to stroke in healthy older adults aged over 75 years in Japan. Geriatr Gerontol Int 2016; 17:202-210. [PMID: 26799814 DOI: 10.1111/ggi.12687] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2015] [Indexed: 11/30/2022]
Abstract
AIM Growing evidence suggests that tooth loss is associated with increased risk of stroke. In the current study, we investigated cumulative medical costs related to stroke using data from the Advanced Elderly Medical Service System. We hypothesized that tooth loss was associated with an increase in medical costs related to stroke among older Japanese adults. METHODS A total of 273 Japanese adults aged 80 years were enrolled in the current study. Baseline medical and dental examinations were carried out in June 2008. Medical care use and costs were monitored by linkage with National Health Insurance claim files from baseline to the end of February 2011. Medical costs related to stroke per month were calculated and examined for any association with the baseline number of remaining teeth using a linear regression model with robust standard errors. RESULTS A total of 19 individuals were admitted to hospital for stroke during the follow-up period. A significant negative association was found between the number of teeth and medical costs related to stroke per month. The regression coefficients of the number of teeth in relation to medical costs related to stroke was -248 (95% CI -438 to -58, P = 0.011) in the crude model and -226 (95% CI -413 to -38, P = 0.018) after adjusting for other confounders. CONCLUSION Within the limitations of the present study, the reported findings suggest an independent relationship of tooth loss with increase in medical cost related to stroke among older Japanese adults. Further studies are necessary to substantiate these findings. Geriatr Gerontol Int 2017; 17: 202-210.
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Affiliation(s)
- Masanori Iwasaki
- Division of Preventive Dentistry, Department of Oral Health Science, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.,Division of Community Oral Health Development, Kyushu Dental University, Kitakyushu, Japan
| | - Misuzu Sato
- Division of Preventive Dentistry, Department of Oral Health Science, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Akihiro Yoshihara
- Division of Oral Science for Health Promotion, Department of Oral Health and Welfare, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Toshihiro Ansai
- Division of Community Oral Health Development, Kyushu Dental University, Kitakyushu, Japan
| | - Hideo Miyazaki
- Division of Preventive Dentistry, Department of Oral Health Science, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Zhang XJ, Ma WP, Zhao NQ, Wang XL. Time series analysis of the association between ambient temperature and cerebrovascular morbidity in the elderly in Shanghai, China. Sci Rep 2016; 6:19052. [PMID: 26750421 PMCID: PMC4707484 DOI: 10.1038/srep19052] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 12/02/2015] [Indexed: 11/24/2022] Open
Abstract
Research on the association between ambient temperature and cerebrovascular morbidity is scarce in China. In this study, we applied mixed generalized additive model (MGAM) to daily counts of cerebrovascular disease of Shanghai residents aged 65 years or older from 2007-2011, stratified by gender. Weighted daily mean temperature up to lags of one week was smoothed by natural cubic spline, and was added into the model to assess both linear and nonlinear effects of temperature. We found that when the mean temperature increased by 1 °C, the male cases of cerebrovascular disease reduced by 0.95% (95% Confidence Interval (CI): 0.80%, 1.10%) or reduced by 0.34% (95% CI: -0.68, 1.36%) in conditions of temperature was below or above 27 °C. However, for every 1 °C increase in temperature, the female cases of cerebrovascular disease increased by 0.34% (95% CI: -0.26%, 0.94%) or decreased by 0.92% (95% CI: 0.72, 1.11%) in conditions of temperature was below or above 8 °C, respectively. Temperature and cerebrovascular morbidity is negatively associated in Shanghai. MGAM is recommended in assessing the association between environmental hazards and health outcomes in time series studies.
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Affiliation(s)
- Xian-Jing Zhang
- Shanghai Insurance Medical Center, Shanghai 200032, People’s Republic of China
| | - Wei-Ping Ma
- Department of Biostatistics, School of Public Health and Key Laboratory of Public Health Safety, Fudan University, Shanghai 200032, People’s Republic of China
- Department of Genetics and Genomics Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, US
| | - Nai-Qing Zhao
- Department of Biostatistics, School of Public Health and Key Laboratory of Public Health Safety, Fudan University, Shanghai 200032, People’s Republic of China
| | - Xi-Ling Wang
- Department of Biostatistics, School of Public Health and Key Laboratory of Public Health Safety, Fudan University, Shanghai 200032, People’s Republic of China
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Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, Das SR, de Ferranti S, Després JP, Fullerton HJ, Howard VJ, Huffman MD, Isasi CR, Jiménez MC, Judd SE, Kissela BM, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Magid DJ, McGuire DK, Mohler ER, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Rosamond W, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Woo D, Yeh RW, Turner MB. Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association. Circulation 2015; 133:e38-360. [PMID: 26673558 DOI: 10.1161/cir.0000000000000350] [Citation(s) in RCA: 3736] [Impact Index Per Article: 415.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
The Rotterdam Study is a prospective cohort study ongoing since 1990 in the city of Rotterdam in The Netherlands. The study targets cardiovascular, endocrine, hepatic, neurological, ophthalmic, psychiatric, dermatological, otolaryngological, locomotor, and respiratory diseases. As of 2008, 14,926 subjects aged 45 years or over comprise the Rotterdam Study cohort. The findings of the Rotterdam Study have been presented in over 1200 research articles and reports (see www.erasmus-epidemiology.nl/rotterdamstudy ). This article gives the rationale of the study and its design. It also presents a summary of the major findings and an update of the objectives and methods.
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Avelar WM, D'Abreu A, Coan AC, Lima FO, Guimarães R, Yassuda CL, Oliveira GP, Guillaumon AT, Filho AA, Min LL, Cendes F. Asymptomatic carotid stenosis is associated with gray and white matter damage. Int J Stroke 2015; 10:1197-203. [PMID: 26235564 DOI: 10.1111/ijs.12574] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 06/01/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cognitive deficits in patients with asymptomatic carotid stenosis have been reported. The ultimate mechanism of cognitive deficits remains unclear and might be related to subtle structural brain damage. AIMS The aim of the present study was to evaluate the presence of subtle white and grey matter abnormalities associated with asymptomatic carotid stenosis. METHODS Twenty-five patients with asymptomatic ≥70%/occlusion carotid stenosis and 25 healthy controls, matched for gender and age, underwent 3 Tesla brain magnetic resonance imaging. Gray and white matter macrostructural abnormalities were evaluated with voxel-based morphometry using spm8 software. White matter microstructural abnormalities were evaluated with diffusion tensor images with the Diffusion Toolbox package and tract-based spatial statistics from FMRIB Software Library. RESULTS We observed significant macro- and microstructural white matter abnormalities, and these findings were diffuse and symmetrical in both hemispheres. In contrast, gray matter atrophy was observed in the areas corresponding to the anterior circulation of the hemisphere ipsilateral to the carotid stenosis. CONCLUSIONS Patients with asymptomatic carotid stenosis have different patterns of gray and white matter abnormalities. While the white matter damage is diffuse, the gray matter atrophy is localized in the territory of anterior circulation ipsilateral to the stenosis. The role of asymptomatic carotid stenosis in the gray matter damage must be further investigated with longitudinal studies and comparison with neuropsychological evaluation.
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Affiliation(s)
- Wagner M Avelar
- Neuroimaging Laboratory, Department of Neurology, University of Campinas, Campinas, SP, Brazil
| | - Anelyssa D'Abreu
- Neuroimaging Laboratory, Department of Neurology, University of Campinas, Campinas, SP, Brazil
| | - Ana C Coan
- Neuroimaging Laboratory, Department of Neurology, University of Campinas, Campinas, SP, Brazil
| | - Fabrício Oliveira Lima
- Neuroimaging Laboratory, Department of Neurology, University of Campinas, Campinas, SP, Brazil
| | - Rachel Guimarães
- Neuroimaging Laboratory, Department of Neurology, University of Campinas, Campinas, SP, Brazil
| | - Clarissa L Yassuda
- Neuroimaging Laboratory, Department of Neurology, University of Campinas, Campinas, SP, Brazil
| | | | - Ana T Guillaumon
- Department of Surgery, University of Campinas, Campinas, SP, Brazil
| | - Augusto A Filho
- Department of Radiology, University of Campinas, Campinas, SP, Brazil
| | - Li L Min
- Neuroimaging Laboratory, Department of Neurology, University of Campinas, Campinas, SP, Brazil
| | - Fernando Cendes
- Neuroimaging Laboratory, Department of Neurology, University of Campinas, Campinas, SP, Brazil
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Parke HL, Epiphaniou E, Pearce G, Taylor SJC, Sheikh A, Griffiths CJ, Greenhalgh T, Pinnock H. Self-Management Support Interventions for Stroke Survivors: A Systematic Meta-Review. PLoS One 2015. [PMID: 26204266 PMCID: PMC4512724 DOI: 10.1371/journal.pone.0131448] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There is considerable policy interest in promoting self-management in patients with long-term conditions, but it remains uncertain whether these interventions are effective in stroke patients. DESIGN Systematic meta-review of the evidence for self-management support interventions with stroke survivors to inform provision of healthcare services. METHODS We searched MEDLINE, EMBASE, CINAHL, PsychINFO, AMED, BNI, Database of Abstracts of Reviews for Effectiveness, and Cochrane Database of Systematic Reviews for systematic reviews of self-management support interventions for stroke survivors. Quality was assessed using the R-AMSTAR tool, and data extracted using a customised data extraction form. We undertook a narrative synthesis of the reviews' findings. RESULTS From 12,400 titles we selected 13 systematic reviews (published 2003-2012) representing 101 individual trials. Although the term 'self-management' was rarely used, key elements of self-management support such as goal setting, action planning, and problem solving were core components of therapy rehabilitation interventions. We found high quality evidence that supported self-management in the context of therapy rehabilitation delivered soon after the stroke event resulted in short-term (< 1 year) improvements in basic and extended activities of daily living, and a reduction in poor outcomes (dependence/death). There is some evidence that rehabilitation and problem solving interventions facilitated reintegration into the community. CONCLUSIONS Self-management terminology is rarely used in the context of stroke. However, therapy rehabilitation currently successfully delivers elements of self-management support to stroke survivors and their caregivers with improved outcomes. Future research should focus on managing the emotional, medical and social tasks of long-term survivorship.
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Affiliation(s)
- Hannah L. Parke
- Multidisciplinary Evidence Synthesis Hub (mEsh), Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, United Kingdom
| | - Eleni Epiphaniou
- Multidisciplinary Evidence Synthesis Hub (mEsh), Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, United Kingdom
| | - Gemma Pearce
- Centre for Technology Enabled Health Research (CTEHR), Coventry University, Coventry, United Kingdom
| | - Stephanie J. C. Taylor
- Multidisciplinary Evidence Synthesis Hub (mEsh), Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, United Kingdom
| | - Aziz Sheikh
- Usher Institute of Medical Informatics and Population Health Sciences, The University of Edinburgh, Edinburgh, United Kingdom
| | - Chris J. Griffiths
- Multidisciplinary Evidence Synthesis Hub (mEsh), Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, United Kingdom
| | - Trish Greenhalgh
- Nuffield Department of Primary Care Health Sciences, Medical Sciences division, University of Oxford, Oxford, United Kingdom
| | - Hilary Pinnock
- Usher Institute of Medical Informatics and Population Health Sciences, The University of Edinburgh, Edinburgh, United Kingdom
- * E-mail:
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Pistoia F, Sacco S, Degan D, Tiseo C, Ornello R, Carolei A. Hypertension and Stroke: Epidemiological Aspects and Clinical Evaluation. High Blood Press Cardiovasc Prev 2015; 23:9-18. [DOI: 10.1007/s40292-015-0115-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 07/01/2015] [Indexed: 11/28/2022] Open
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Pietzsch JB, Liu S, Garner AM, Kezirian EJ, Strollo PJ. Long-Term Cost-Effectiveness of Upper Airway Stimulation for the Treatment of Obstructive Sleep Apnea: A Model-Based Projection Based on the STAR Trial. Sleep 2015; 38:735-44. [PMID: 25348126 DOI: 10.5665/sleep.4666] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 10/05/2014] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES Upper airway stimulation (UAS) is a new approach to treat moderate-to-severe obstructive sleep apnea. Recently, 12-month data from the Stimulation Treatment for Apnea Reduction (STAR) trial were reported, evaluating the effectiveness of UAS in patients intolerant or non-adherent to continuous positive airway pressure therapy. Our objective was to assess the cost-effectiveness of UAS from a U.S. payer perspective. DESIGN A 5-state Markov model was used to predict cardiovascular endpoints (myocardial infarction [MI], stroke, hypertension), motor vehicle collisions (MVC), mortality, quality-adjusted life years (QALYs), and costs. We computed 10-year relative event risks and the lifetime incremental cost-effectiveness ratio (ICER) in $/QALY, comparing UAS therapy to no treatment under the assumption that the STAR trial-observed reduction in mean apnea-hypopnea index from 32.0 to 15.3 events/h was maintained. Costs and effects were discounted at 3% per year. SETTING U.S. healthcare system; third-party payer perspective. PARTICIPANTS 83% male cohort with mean age of 54.5 years. INTERVENTIONS UAS vs. no treatment. MEASUREMENTS AND RESULTS UAS substantially reduced event probabilities over 10 years (relative risks: MI 0.63; stroke 0.75; MVC 0.34), and was projected to add 1.09 QALYs over the patient's lifetime. Costs were estimated to increase by $42,953, resulting in a lifetime ICER of $39,471/QALY. CONCLUSIONS Relative to the acknowledged willingness-to-pay threshold of $50,000-$100,000/QALY, our results indicate upper airway stimulation is a cost-effective therapy in the U.S. healthcare system.
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Affiliation(s)
| | - Shan Liu
- Wing Tech Inc., Menlo Park, CA.,University of Washington, Seattle, WA
| | | | - Eric J Kezirian
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
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Nyboe C, Olsen MS, Nielsen-Kudsk JE, Hjortdal VE. Atrial fibrillation and stroke in adult patients with atrial septal defect and the long-term effect of closure. Heart 2015; 101:706-11. [DOI: 10.1136/heartjnl-2014-306552] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 01/27/2015] [Indexed: 11/03/2022] Open
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Whedon JM, Song Y, Mackenzie TA, Phillips RB, Lukovits TG, Lurie JD. Risk of stroke after chiropractic spinal manipulation in medicare B beneficiaries aged 66 to 99 years with neck pain. J Manipulative Physiol Ther 2015; 38:93-101. [PMID: 25596875 DOI: 10.1016/j.jmpt.2014.12.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 10/29/2014] [Accepted: 10/31/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The purpose of this study was to quantify risk of stroke after chiropractic spinal manipulation, as compared to evaluation by a primary care physician, for Medicare beneficiaries aged 66 to 99 years with neck pain. METHODS This is a retrospective cohort analysis of a 100% sample of annualized Medicare claims data on 1 157 475 beneficiaries aged 66 to 99 years with an office visit to either a chiropractor or primary care physician for neck pain. We compared hazard of vertebrobasilar stroke and any stroke at 7 and 30 days after office visit using a Cox proportional hazards model. We used direct adjusted survival curves to estimate cumulative probability of stroke up to 30 days for the 2 cohorts. RESULTS The proportion of subjects with stroke of any type in the chiropractic cohort was 1.2 per 1000 at 7 days and 5.1 per 1000 at 30 days. In the primary care cohort, the proportion of subjects with stroke of any type was 1.4 per 1000 at 7 days and 2.8 per 1000 at 30 days. In the chiropractic cohort, the adjusted risk of stroke was significantly lower at 7 days as compared to the primary care cohort (hazard ratio, 0.39; 95% confidence interval, 0.33-0.45), but at 30 days, a slight elevation in risk was observed for the chiropractic cohort (hazard ratio, 1.10; 95% confidence interval, 1.01-1.19). CONCLUSIONS Among Medicare B beneficiaries aged 66 to 99 years with neck pain, incidence of vertebrobasilar stroke was extremely low. Small differences in risk between patients who saw a chiropractor and those who saw a primary care physician are probably not clinically significant.
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Affiliation(s)
- James M Whedon
- Instructor, The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Grantham, NH.
| | - Yunjie Song
- Research Associate, The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Grantham, NH
| | - Todd A Mackenzie
- Associate Professor, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Grantham, NH
| | - Reed B Phillips
- President Emeritus, Southern California University of Health Sciences, Whittier, CA
| | - Timothy G Lukovits
- Associate Professor of Neurology, Geisel School of Medicine, Dartmouth College, Grantham, NH
| | - Jon D Lurie
- Associate Professor, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Grantham, NH
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Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, de Ferranti S, Després JP, Fullerton HJ, Howard VJ, Huffman MD, Judd SE, Kissela BM, Lackland DT, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Matchar DB, McGuire DK, Mohler ER, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Willey JZ, Woo D, Yeh RW, Turner MB. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation 2014; 131:e29-322. [PMID: 25520374 DOI: 10.1161/cir.0000000000000152] [Citation(s) in RCA: 4464] [Impact Index Per Article: 446.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Progression of carotid intima media thickness after radiotherapy: A long-term prospective cohort study. Radiother Oncol 2014; 113:359-63. [DOI: 10.1016/j.radonc.2014.10.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 10/21/2014] [Accepted: 10/24/2014] [Indexed: 11/16/2022]
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Moran GM, Calvert M, Feltham MG, Marshall T. Retrospective case review of missed opportunities for primary prevention of stroke and TIA in primary care: protocol paper. BMJ Open 2014; 4:e006622. [PMID: 25387760 PMCID: PMC4244480 DOI: 10.1136/bmjopen-2014-006622] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Stroke is a major health problem and transient ischaemic attack (TIA) is an important risk factor for stroke. Primary prevention of stroke and TIA will have the greatest impact on reducing the burden of these conditions. Evidence-based guidelines for stroke/TIA prevention identify individuals eligible for preventative interventions in primary care. This study will investigate: (1) the proportion of strokes/TIAs with prior missed opportunities for prevention in primary care; (2) the influence of patient characteristics on missed prevention opportunities and (3) how the proportion of missed prevention opportunities has changed over time. METHODS AND ANALYSIS A retrospective case review will identify first-ever stroke and patients with TIA between 2000 and 2013 using anonymised electronic medical records extracted from the health improvement network (THIN) database. Four categories of missed opportunities for stroke/TIA prevention will be sought: untreated high blood pressure in patients eligible for treatment (either blood pressure ≥160/100 or ≥140/90 mm Hg in patients at high cardiovascular disease (CVD) risk); patients with atrial fibrillation with high stroke risk and no anticoagulant therapy; no lipid modifying drug therapy prescribed in patients at high CVD risk or with familial hypercholesterolaemia. The proportion of patients with each missed opportunity and multiple missed opportunities will be calculated. Mixed effect logistic regression will model the relationship between demographic and patient characteristics and missed opportunities for care; practice will be included as a random effect. ETHICS AND DISSEMINATION THIN data collection was approved by the NHS South East Multi-centre Research Ethics Committee (MREC) in 2003. This study was approved by the independent scientific review committee in May 2013. Dissemination of findings has the potential to change practice, improve the quality of care provided to patients and ultimately reduce the incidence of strokes and TIAs. Findings will be published in a peer-reviewed journal and disseminated at national and international conferences.
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Affiliation(s)
- Grace M Moran
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Melanie Calvert
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Max G Feltham
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Tom Marshall
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
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Blomstrand A, Blomstrand C, Ariai N, Bengtsson C, Björkelund C. Stroke incidence and association with risk factors in women: a 32-year follow-up of the Prospective Population Study of Women in Gothenburg. BMJ Open 2014; 4:e005173. [PMID: 25351597 PMCID: PMC4212180 DOI: 10.1136/bmjopen-2014-005173] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To study stroke incidence among women over 32 years of age with a focus on subdividing by stroke type, to consolidate end points and associations with risk factors. DESIGN Prospective population study initiated in 1968-1969 with follow-ups in 1974, 1980, 1992 and 2001. SETTING Gothenburg, Sweden. PARTICIPANTS A sample of 1462 women from five age strata examined in 1968-1969, representative of women in the general population. MAIN OUTCOME MEASURES Main types of first-ever stroke and fatal stroke during 1968-2001 identified and validated. Stroke incidence rates in different age strata. Association with baseline smoking, body mass index (BMI), waist-hip ratio, hypertension, serum lipids, physical inactivity, perceived mental stress and education. Associations with atrial fibrillation (AF), diabetes, baseline hypertension and myocardial infarction (MI). Blood pressure (BP) levels 1-3, corresponding to modern guidelines, in relation to stroke risk. RESULTS 184 (12.6%) cases of first-ever stroke, 33 (18%) of them fatal. Validation reduced unspecified stroke diagnoses from 37% to 11%. Age-standardised incidence rate per 100,000 person-years was 448. A multivariate model showed a significant association between ischaemic stroke and high BMI: HR 1.07 (95% CI 1.02 to 1.12), smoking 1.78 (1.23 to 2.57) and low education 1.17 (1.01 to 1.35). Significant association was seen between haemorrhagic stroke and, besides age, physical inactivity 2.18 (1.04 to 4.58) and for total stroke also hypertension 1.45 (1.02 to 2.08). Survival analysis showed a significantly increased risk of stroke in participants with diabetes (p<0.001), AF (p<0.001) and hypertension (p=0.001), but not MI. Stroke risk increased with increasing BP levels but was already seen for diastolic pressure grade 1 and particularly when combined with systolic BP grade 1; 1.62 (1.17 to 2.25). CONCLUSIONS Hypertension, smoking, AF, diabetes and high BMI were associated with increased stroke risk. Low education was associated with stroke. Validation of National Patient Registry diagnoses to increase specified diagnoses improved data quality.
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Affiliation(s)
- Ann Blomstrand
- Primary Health Care Unit, Department of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Christian Blomstrand
- Stroke Centre West, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nashmil Ariai
- Primary Health Care Unit, Department of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Calle Bengtsson
- Primary Health Care Unit, Department of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Cecilia Björkelund
- Primary Health Care Unit, Department of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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70
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Malmivaara A, Meretoja A, Peltola M, Numerato D, Heijink R, Engelfriet P, Wild SH, Belicza É, Bereczki D, Medin E, Goude F, Boncoraglio G, Tatlisumak T, Seppälä T, Häkkinen U. Comparing ischaemic stroke in six European countries. The EuroHOPE register study. Eur J Neurol 2014; 22:284-91, e25-6. [PMID: 25196190 DOI: 10.1111/ene.12560] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 07/25/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE The incidence of hospitalizations, treatment and case fatality of ischaemic stroke were assessed utilizing a comprehensive multinational database to attempt to compare the healthcare systems in six European countries, aiming also to identify the limitations and make suggestions for future improvements in the between-country comparisons. METHODS National registers of hospital discharges for ischaemic stroke identified by International Classification of Diseases codes 433-434 (ICD-9) and code I63 (ICD-10), medication purchases and mortality were linked at the patient level in each of the participating countries and regions: Finland, Hungary, Italy, the Netherlands, Scotland and Sweden. Patients with an index admission in 2007 were followed for 1 year. RESULTS In all, 64,170 patients with a disease code for ischaemic stroke were identified. The number of patients registered per 100,000 European standard population ranged from 77 in Scotland to 407 in Hungary. Large differences were observed in medication use. The age- and sex-adjusted all-cause case fatality amongst hospitalized patients at 1 year from stroke was highest in Hungary at 31.0% (95% confidence interval 30.5-31.5). Regional differences in age- and sex-adjusted 1-year case fatality within countries were largest in Hungary (range 23.6%-37.6%) and smallest in the Netherlands (20.5%-27.3%). CONCLUSIONS It is feasible to link population-wide register data amongst European countries to describe incidence of hospitalizations, treatment patterns and case fatality of ischaemic stroke on a national level. However, the coverage and validity of administrative register data for ischaemic stroke should be developed further, and population-based and clinical stroke registers should be created to allow better control of case mix.
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Affiliation(s)
- A Malmivaara
- Centre for Health and Social Economics, National Institute for Health and Welfare, Helsinki, Finland
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Abstract
Cerebrovascular disease is a leading cause of death-from-disease and of disability worldwide, affecting some 15 million people. The incidence of stroke or "brain attack" is unlikely to recede for a decade at minimum by most predictions, despite large public health initiatives in stroke prevention. It has been well established that stroke is also one of the most strikingly sex-specific diseases in its epidemiology, and in some cases, in patient outcomes. For example, women sustain lower rates of ischemic stroke relative to men, even beyond their menopausal years. In contrast, outcomes are worse in women in many clinical studies. The biological basis for this sexual dimorphism is a compelling story, and both hormone-dependent and hormone-independent factors are involved, the latter of which is the subject of this brief review. Understanding the molecular and cell-based mechanisms underlying sex differences in ischemic brain injury is an important step toward personalized medicine and effective therapeutic interventions in patients of both sexes.
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Affiliation(s)
- Paco S Herson
- Departments of Anesthesiology and Pharmacology, University of Colorado, Denver
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Gorgui J, Gorshkov M, Khan N, Daskalopoulou SS. Hypertension as a Risk Factor for Ischemic Stroke in Women. Can J Cardiol 2014; 30:774-82. [DOI: 10.1016/j.cjca.2014.01.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 01/12/2014] [Accepted: 01/13/2014] [Indexed: 12/24/2022] Open
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Co-Occurrence of Arthritis and Stroke amongst Middle-Aged and Older Adults in Canada. Stroke Res Treat 2014; 2014:651921. [PMID: 24834358 PMCID: PMC4009210 DOI: 10.1155/2014/651921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 03/18/2014] [Accepted: 04/01/2014] [Indexed: 11/23/2022] Open
Abstract
Arthritis is a chronic inflammatory condition commonly associated with mobility restriction and reduced activity. To date, the extent to which arthritis is an independent risk factor for stroke is unclear, and important, in light of an aging population. The purpose of this study was to (i) quantify the cross-sectional association between stroke and arthritis and (ii) to determine whether the relationship differed in physically active and inactivemiddle-aged and older adults. Data was derived from the 2010 Canadian Community Health Survey (N = 47 188; ≥30 y). Multivariable logistic regression was used to estimate the association between arthritis and stroke in models adjusted for age, physical activity (PA), and demographic factors. Overall, individuals with arthritis were 4 times more likely to report a history of stroke (OR = 3.8, 95% CI = 3.06–4.68), whereas those who were engaged in at least moderate PA (≥ 1.5 kcal/kg/day) were less than half as likely (0.45, 0.92−0.62). This effect was moderated by age, as younger (30–65 y: 3.27, 2.22–4.83) but not older adults (>65 y: 1.04, 0.8–1.35) with arthritis had elevated odds of stroke. Both physical inactivity and arthritis are associated with higher odds of stroke, effects of which are the strongest amongst 30–65 year olds.
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74
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Etter NM, van Meter EM, Andreatta RD. Labial Vibrotactile Somatosensory Perception: A Pilot Study in Healthy Aging versus Young Adult Participants. Percept Mot Skills 2014; 118:622-35. [DOI: 10.2466/10.24.pms.118k23w6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this pilot study was to begin characterizing changes in labial vibrotactile somatosensation in healthy older adults as a foundational step in determining how changes in orofacial sensation can affect functional behaviors, such as speech and feeding. Labial vibrotactile perception capacity of healthy older adults ( n = 15) was compared to a cohort of healthy young adults ( n = 5). Vibrotactile inputs were delivered to the glabrous surface of the left lower lip at 5, 10, 50, and 150 Hz. A modified von Bekesy (staircase) method was used to identify participants' thresholds and response standard deviations for each test frequency. Consistent with findings in other body regions, a decrease in labial vibrotactile detection sensitivity was expected in healthy older adults. The threshold values for the 5 and 10 Hz test frequencies were higher in the older group and the differences in response standard deviations at these frequencies were statistically significant. This pilot study identified changes in labial perception among healthy older adults.
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75
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Quillinan N, Deng G, Grewal H, Herson PS. Androgens and stroke: good, bad or indifferent? Exp Neurol 2014; 259:10-5. [PMID: 24512750 DOI: 10.1016/j.expneurol.2014.02.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 01/28/2014] [Accepted: 02/02/2014] [Indexed: 12/16/2022]
Abstract
Cerebral ischemia caused by loss of blood supply to the brain during cardiac arrest or stroke are major causes of death and disability. Biological sex is an important factor in predicting vulnerability of the brain to an ischemic insult, with males being at higher risk for cardio-cerebrovascular events than females of the same age. However, relative incidence of stroke between the genders appears to normalize at advanced ages. Therefore, many scientists have focused on the mechanisms of sex differences in outcome following brain ischemic injury, with a particular emphasis on the role of sex steroids. The majority of studies indicate that female sex steroids, such as estrogen and progesterone, play important roles in the relative neuroprotection following cerebral ischemia observed in females. However, less is known about male sex steroids and brain damage. This review describes the state of our knowledge of androgen-related contributions to neurological injury and recovery following cerebral ischemia that occurs following stroke. Experimental studies examining the effects of castration, androgenic agonists and antagonists and aging provide valuable insights into the role of androgens in clinical outcome following cerebrovascular events.
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Affiliation(s)
- Nidia Quillinan
- Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, 12800 E. 19th Ave., Aurora, CO 80045, USA
| | - Guiying Deng
- Department of Pharmacology, University of Colorado Denver, Anschutz Medical Campus, 12800 E. 19th Ave., Aurora, CO 80045, USA
| | - Himmat Grewal
- Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, 12800 E. 19th Ave., Aurora, CO 80045, USA
| | - Paco S Herson
- Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, 12800 E. 19th Ave., Aurora, CO 80045, USA; Department of Pharmacology, University of Colorado Denver, Anschutz Medical Campus, 12800 E. 19th Ave., Aurora, CO 80045, USA.
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Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Blaha MJ, Dai S, Ford ES, Fox CS, Franco S, Fullerton HJ, Gillespie C, Hailpern SM, Heit JA, Howard VJ, Huffman MD, Judd SE, Kissela BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Mackey RH, Magid DJ, Marcus GM, Marelli A, Matchar DB, McGuire DK, Mohler ER, Moy CS, Mussolino ME, Neumar RW, Nichol G, Pandey DK, Paynter NP, Reeves MJ, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Wong ND, Woo D, Turner MB. Heart disease and stroke statistics--2014 update: a report from the American Heart Association. Circulation 2014; 129:e28-e292. [PMID: 24352519 PMCID: PMC5408159 DOI: 10.1161/01.cir.0000441139.02102.80] [Citation(s) in RCA: 3531] [Impact Index Per Article: 353.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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77
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Chen YM, Lin YJ, Po HL. Comparison of the Risk Factor Profile, Stroke Subtypes, and Outcomes Between Stroke Patients Aged 65 Years or Younger and Elderly Stroke Patients: A Hospital-based Study. INT J GERONTOL 2013. [DOI: 10.1016/j.ijge.2012.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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78
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Hofman A, Darwish Murad S, van Duijn CM, Franco OH, Goedegebure A, Ikram MA, Klaver CCW, Nijsten TEC, Peeters RP, Stricker BHC, Tiemeier HW, Uitterlinden AG, Vernooij MW. The Rotterdam Study: 2014 objectives and design update. Eur J Epidemiol 2013; 28:889-926. [PMID: 24258680 DOI: 10.1007/s10654-013-9866-z] [Citation(s) in RCA: 259] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 11/08/2013] [Indexed: 02/06/2023]
Abstract
The Rotterdam Study is a prospective cohort study ongoing since 1990 in the city of Rotterdam in The Netherlands. The study targets cardiovascular, endocrine, hepatic, neurological, ophthalmic, psychiatric, dermatological, oncological, and respiratory diseases. As of 2008, 14,926 subjects aged 45 years or over comprise the Rotterdam Study cohort. The findings of the Rotterdam Study have been presented in over a 1,000 research articles and reports (see www.erasmus-epidemiology.nl/rotterdamstudy ). This article gives the rationale of the study and its design. It also presents a summary of the major findings and an update of the objectives and methods.
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Affiliation(s)
- Albert Hofman
- Department of Epidemiology, Erasmus Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands,
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Schols AMR, Schreuder FHBM, van Raak EPM, Schreuder THCML, Rooyer FA, van Oostenbrugge RJ, Staals J. Incidence of oral anticoagulant-associated intracerebral hemorrhage in the Netherlands. Stroke 2013; 45:268-70. [PMID: 24203841 DOI: 10.1161/strokeaha.113.003003] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The aim of this study was to estimate the annual adult incidence and risk of intracerebral hemorrhage (ICH) and oral anticoagulant-associated ICH (OAC-ICH) in the Netherlands. METHODS We retrospectively selected all consecutive adult patients with a nontraumatic ICH seen in 1 of 3 hospitals in the region South-Limburg, the Netherlands, from 2007 to 2009. Crude incidences were age-adjusted to Dutch and European population. RESULTS We identified 652 ICH cases, of which 168 (25.8%) were OAC associated. The adult Dutch age-adjusted annual incidence of ICH and OAC-ICH was 34.8 (95% confidence interval, 32.0-37.8) and 8.7 (95% confidence interval, 7.3-10.3) per 100 000 person-years, respectively. The absolute risk of OAC-ICH was estimated at 0.46% per patient-year of OAC treatment. CONCLUSIONS The annual incidences of ICH and OAC-ICH are relatively high in the Netherlands when compared with international literature.
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Affiliation(s)
- Angel M R Schols
- From the Department of Neurology (A.M.R.S., F.H.B.M.S., E.P.M.v.R., R.J.v.O., J.S.) and Cardiovascular Research Institute Maastricht (F.H.B.M.S., R.J.v.O., J.S.), Maastricht University Medical Center, Maastricht, The Netherlands; Department of Neurology, Atrium Medical Center, Heerlen, The Netherlands (T.H.C.M.L.S.); and Department of Neurology, Orbis Medical Center, Sittard, The Netherlands (F.A.R.)
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Holmes S, Abbassi B, Su C, Singh M, Cunningham RL. Oxidative stress defines the neuroprotective or neurotoxic properties of androgens in immortalized female rat dopaminergic neuronal cells. Endocrinology 2013; 154:4281-92. [PMID: 23959938 PMCID: PMC3800758 DOI: 10.1210/en.2013-1242] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Males have a higher risk for developing Parkinson's disease and parkinsonism after ischemic stroke than females. Although estrogens have been shown to play a neuroprotective role in Parkinson's disease, there is little information on androgens' actions on dopamine neurons. In this study, we examined the effects of androgens under conditions of oxidative stress to determine whether androgens play a neuroprotective or neurotoxic role in dopamine neuronal function. Mitochondrial function, cell viability, intracellular calcium levels, and mitochondrial calcium influx were examined in response to androgens under both nonoxidative and oxidative stress conditions. Briefly, N27 dopaminergic cells were exposed to the oxidative stressor, hydrogen peroxide, and physiologically relevant levels of testosterone or dihydrotestosterone, applied either before or after oxidative stress exposure. Androgens, alone, increased mitochondrial function via a calcium-dependent mechanism. Androgen pretreatment protected cells from oxidative stress-induced cell death. However, treatment with androgens after the oxidative insult increased cell death, and these effects were, in part, mediated by calcium influx into the mitochondria. Interestingly, the negative effects of androgens were not blocked by either androgen or estrogen receptor antagonists. Instead, a putative membrane-associated androgen receptor was implicated. Overall, our results indicate that androgens are neuroprotective when oxidative stress levels are minimal, but when oxidative stress levels are elevated, androgens exacerbate oxidative stress damage.
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Affiliation(s)
- Shaletha Holmes
- PhD, Department of Pharmacology and Neuroscience, University of North Texas Health Science Center, 3400 Camp Bowie Boulevard, Fort Worth, Texas 76107-2699.
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81
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Psoriasis Is Not Associated with Atherosclerosis and Incident Cardiovascular Events: The Rotterdam Study. J Invest Dermatol 2013; 133:2347-2354. [DOI: 10.1038/jid.2013.131] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 02/07/2013] [Accepted: 02/08/2013] [Indexed: 12/26/2022]
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Sebastiani P, Sun FX, Andersen SL, Lee JH, Wojczynski MK, Sanders JL, Yashin A, Newman AB, Perls TT. Families Enriched for Exceptional Longevity also have Increased Health-Span: Findings from the Long Life Family Study. Front Public Health 2013; 1:38. [PMID: 24350207 PMCID: PMC3859985 DOI: 10.3389/fpubh.2013.00038] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 09/12/2013] [Indexed: 11/17/2022] Open
Abstract
Hypothesizing that members of families enriched for longevity delay morbidity compared to population controls and approximate the health-span of centenarians, we compared the health-spans of older generation subjects of the Long Life Family Study (LLFS) to controls without family history of longevity and to centenarians of the New England Centenarian Study (NECS) using Bayesian parametric survival analysis. We estimated hazard ratios, the ages at which specific percentiles of subjects had onsets of diseases, and the gain of years of disease-free survival in the different cohorts compared to referent controls. Compared to controls, LLFS subjects had lower hazards for cancer, cardiovascular disease, severe dementia, diabetes, hypertension, osteoporosis, and stroke. The age at which 20% of the LLFS siblings and probands had one or more age-related diseases was approximately 10 years later than NECS controls. While female NECS controls generally delayed the onset of age-related diseases compared with males controls, these gender differences became much less in the older generation of the LLFS and disappeared amongst the centenarians of the NECS. The analyses demonstrate extended health-span in the older subjects of the LLFS and suggest that this aging cohort provides an important resource to discover genetic and environmental factors that promote prolonged health-span in addition to longer life-span.
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Affiliation(s)
- Paola Sebastiani
- Department of Biostatistics, Boston University School of Public Health , Boston, MA , USA
| | - Fangui X Sun
- Department of Biostatistics, Boston University School of Public Health , Boston, MA , USA
| | - Stacy L Andersen
- Geriatrics Division, Department of Medicine, Boston University School of Medicine and Boston Medical Center , Boston, MA , USA
| | - Joseph H Lee
- Department of Epidemiology, Sergievsky Center, Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Columbia University , New York, NY , USA
| | | | - Jason L Sanders
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh , Pittsburgh, PA , USA
| | - Anatoli Yashin
- Social Science Research Institute, Duke University , Durham, NC , USA
| | - Anne B Newman
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh , Pittsburgh, PA , USA
| | - Thomas T Perls
- Geriatrics Division, Department of Medicine, Boston University School of Medicine and Boston Medical Center , Boston, MA , USA
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83
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Simons CT, Cipriano LE, Shah RU, Garber AM, Owens DK, Hlatky MA. Transcatheter aortic valve replacement in nonsurgical candidates with severe, symptomatic aortic stenosis: a cost-effectiveness analysis. Circ Cardiovasc Qual Outcomes 2013; 6:419-28. [PMID: 23838104 DOI: 10.1161/circoutcomes.113.000280] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) seems to improve the survival and quality of life of patients with aortic stenosis ineligible for surgical aortic valve replacement. METHODS AND RESULTS We used a decision analytic Markov model to estimate lifetime costs and benefits in a hypothetical cohort of patients with severe, symptomatic aortic stenosis who were ineligible for surgical aortic valve replacement. The model compared transfemoral TAVR with medical management and was calibrated to the Placement of Aortic Transcatheter Valves (PARTNER) trial. TAVR increased life expectancy from 2.08 to 2.93 years and quality-adjusted life expectancy from 1.19 to 1.93 years. TAVR also reduced subsequent hospitalizations by 1.40 but increased complications, particularly stroke (from 1% to 11% lifetime risk), and also increased lifetime costs from $83,600 to $169,100. The incremental cost-effectiveness of TAVR was $116,500 per quality-adjusted life-year gained ($99,900 per life-year gained). Results were robust to reasonable changes in individual variables but were sensitive to the level of annual healthcare costs caused by noncardiac diseases and to the projected life expectancy of medically treated patients. CONCLUSIONS TAVR seems to be an effective but somewhat expensive alternative to medical management among patients with symptomatic aortic stenosis ineligible for surgery. TAVR is more cost-effective for patients with a lower burden of noncardiac disease.
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Affiliation(s)
- Cyrena T Simons
- Department of Medicine, Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA.
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84
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Sabayan B, Gussekloo J, de Ruijter W, Westendorp RG, de Craen AJ. Framingham Stroke Risk Score and Cognitive Impairment for Predicting First-Time Stroke in the Oldest Old. Stroke 2013; 44:1866-71. [DOI: 10.1161/strokeaha.113.001460] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Behnam Sabayan
- From the Department of Gerontology and Geriatrics (B.S., R.G.J.W., A.J.M.d.C.), Department of Radiology (B.S.), and Department of Public Health and Primary Care (J.G., W.d.R.), Leiden University Medical Center, Leiden, The Netherlands; and Netherlands Consortium for Healthy Ageing, Leiden, The Netherlands (R.G.J.W., A.J.M.d.C.)
| | - Jacobijn Gussekloo
- From the Department of Gerontology and Geriatrics (B.S., R.G.J.W., A.J.M.d.C.), Department of Radiology (B.S.), and Department of Public Health and Primary Care (J.G., W.d.R.), Leiden University Medical Center, Leiden, The Netherlands; and Netherlands Consortium for Healthy Ageing, Leiden, The Netherlands (R.G.J.W., A.J.M.d.C.)
| | - Wouter de Ruijter
- From the Department of Gerontology and Geriatrics (B.S., R.G.J.W., A.J.M.d.C.), Department of Radiology (B.S.), and Department of Public Health and Primary Care (J.G., W.d.R.), Leiden University Medical Center, Leiden, The Netherlands; and Netherlands Consortium for Healthy Ageing, Leiden, The Netherlands (R.G.J.W., A.J.M.d.C.)
| | - Rudi G.J. Westendorp
- From the Department of Gerontology and Geriatrics (B.S., R.G.J.W., A.J.M.d.C.), Department of Radiology (B.S.), and Department of Public Health and Primary Care (J.G., W.d.R.), Leiden University Medical Center, Leiden, The Netherlands; and Netherlands Consortium for Healthy Ageing, Leiden, The Netherlands (R.G.J.W., A.J.M.d.C.)
| | - Anton J.M. de Craen
- From the Department of Gerontology and Geriatrics (B.S., R.G.J.W., A.J.M.d.C.), Department of Radiology (B.S.), and Department of Public Health and Primary Care (J.G., W.d.R.), Leiden University Medical Center, Leiden, The Netherlands; and Netherlands Consortium for Healthy Ageing, Leiden, The Netherlands (R.G.J.W., A.J.M.d.C.)
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85
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Age-specific trends in morbidity, mortality and case-fatality from cardiovascular disease, myocardial infarction and stroke in advanced age: evaluation in the Swedish population. PLoS One 2013; 8:e64928. [PMID: 23741426 PMCID: PMC3669144 DOI: 10.1371/journal.pone.0064928] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 04/20/2013] [Indexed: 12/01/2022] Open
Abstract
Background It is not clear if the downward trend in cardiovascular disease (CVD) observed for ages up to 85 years can be extended to the oldest old, those 85 years and above. Methods and Findings This nationwide cohort study presents age specific trends of CVD as well as for myocardial infarction (MI) and stroke separately for the period 1994 to 2010 for individuals 85 to 99 years old in Sweden. Data were extracted from national registries. All analyses were based on one-year age- and sex- specific figures. The risk for CVD increased with every age above 85 years although the rate of increase leveled off with age. Over time, the risk for CVD and MI decreased for all ages, and for stroke for ages up to 89 years. However, the risk of MI increased until around 2001 in all age groups and both sexes but decreased after that. The overall mortality improved for all outcomes over the period 1994 to 2010, so did the survival within 28 days from an event. The average annual decline in mortality over all ages, 85 and above was 3% for MI, 2% for stroke and for 2% CVD. Corresponding figures for ages 60–84 was 4% for each of MI, stroke and CVD. The results were similar for men and women. Conclusions Improvements in CVD risks observed among ages up to 85 years appear to have extended also to ages above 85 years, even if the rate of improvement plateaued with age. The improvements in survival for all ages up to 99 years give no support to the hypothesis that more fragile individuals reach higher ages. Additional research is needed to find out if improvement in survival can be seen also for the second and third event of CVD, stroke and MI.
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86
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Zuo W, Zhang W, Chen NH. Sexual dimorphism in cerebral ischemia injury. Eur J Pharmacol 2013; 711:73-9. [PMID: 23652162 DOI: 10.1016/j.ejphar.2013.04.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Revised: 04/24/2013] [Accepted: 04/26/2013] [Indexed: 12/19/2022]
Abstract
Stroke is a leading cause of permanent disability and death. A complex series of biochemical and molecular mechanisms (e.g. the release of ROS/NOS, proapoptotic proteins and proinflammatory cytokine; neuronal depolarization, Ca2+ accumulation and so on) impair the neurologic functions of cerebral ischemia and stroke. We have known for some time that the epidemiology of human stroke is sexually dimorphic until late in life, well beyond the years of reproductive senescence and menopause. The principal mammalian estrogen (17β estradiol or E2) is neuroprotective in many types of brain injury and has been the major focus of investigation over the past several decades. However the incidence of stroke in women is lower than in men until decades past menopause, suggesting that factors beyond sex hormone contribute to these epidemiological sex differences. So a new concept is emerging: both sex steroids and biologic sex are important factors in clinical and experimental strokes. In this review, we will address sex steroids and gender differences in influencing the mechanisms and outcomes of brain ischemia stroke. These sex differences need to be identified which could help future translation to human neuroprotection.
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Affiliation(s)
- Wei Zuo
- Key Laboratory of Bioactive Substances and Resources Utilization, Ministry of Education, Department of Pharmacology, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China.
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87
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Bertolino G, De Araujo FLB, Souza HCD, Coimbra NC, De Araujo JE. Neuropathology and behavioral impairments after bilateral global ischemia surgery and exposure to static magnetic field: Evidence in the motor cortex, the hippocampal CA1 region and the neostriatum. Int J Radiat Biol 2013; 89:595-601. [DOI: 10.3109/09553002.2013.784422] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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88
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Chu CN, Chen PC, Bai LY, Muo CH, Sung FC, Chen SW. Young nasopharyngeal cancer patients with radiotherapy and chemotherapy are most prone to ischaemic risk of stroke: a national database, controlled cohort study. Clin Otolaryngol 2013. [PMID: 23194286 DOI: 10.1111/coa.12064] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- C.-N. Chu
- Department of Radiation Oncology; China Medical University Hospital; Taichung; Taiwan
| | | | | | - C.-H. Muo
- Management Office for Health Data; China Medical University Hospital; Taichung; Taiwan
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89
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Persky RW, Liu F, Xu Y, Weston G, Levy S, Roselli CE, McCullough LD. Neonatal testosterone exposure protects adult male rats from stroke. Neuroendocrinology 2013; 97:271-82. [PMID: 23051877 PMCID: PMC3617085 DOI: 10.1159/000343804] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 09/27/2012] [Indexed: 01/01/2023]
Abstract
BACKGROUND Men have a higher stroke incidence compared to women until advanced age. The contribution of hormones to these sex differences has been extensively debated. In experimental stroke, estradiol is neuroprotective, whereas androgens are detrimental. However, prior studies have only examined the effects of acute treatment paradigms; therefore, the timing and mechanism by which ischemic sexual dimorphism arises are unknown. METHODS The effects of exogenous neonatal androgen exposure on subsequent injury induced by middle cerebral artery occlusion in adulthood in male rats were examined. Rats were administered vehicle (oil), testosterone propionate (TP) or the non-aromatizable androgen dihydrotestosterone (DHT) for 5 days after birth. At 3 months of age, a focal stroke was induced. RESULTS Testosterone-treated rats (but not DHT-treated animals) had decreased infarct volumes (20 vs. 33%, p < 0.05) as well as increased estradiol levels (39.4 vs. 18.6 pg/ml, p < 0.0001) compared to oil-treated animals. TP-injected males had increased testicular aromatase (P450arom) levels (3.6 vs. 0.2 ng/ml, p < 0.0001) compared to oil-treated males. The level of X-linked inhibitor of apoptosis, the primary endogenous inhibitor of caspase-induced apoptosis, was increased in TP-treated rats compared with the oil-treated males. CONCLUSIONS Neonatal exposure to exogenous testosterone upregulates testicular aromatase expression in male rats and leads to adult neuroprotection secondary to changes in serum estradiol levels and cell death proteins. This study suggests that early exposure to gonadal hormones can have dramatic effects on the response to adult cerebrovascular injury.
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Affiliation(s)
- Rebecca W. Persky
- Department of Neuroscience and Neurology, University of Connecticut Health Center, Farmington, CT, USA
| | - Fudong Liu
- Department of Neuroscience and Neurology, University of Connecticut Health Center, Farmington, CT, USA
| | - Yan Xu
- Department of Neuroscience and Neurology, University of Connecticut Health Center, Farmington, CT, USA
| | - Gillian Weston
- Department of Neuroscience and Neurology, University of Connecticut Health Center, Farmington, CT, USA
| | - Stephanie Levy
- Department of Neuroscience and Neurology, University of Connecticut Health Center, Farmington, CT, USA
| | - Charles E. Roselli
- Department of Physiology and Pharmacology, Oregon Health and Science University, Portland, Oregon, USA
| | - Louise D. McCullough
- Department of Neuroscience and Neurology, University of Connecticut Health Center, Farmington, CT, USA
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Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, Bravata DM, Dai S, Ford ES, Fox CS, Franco S, Fullerton HJ, Gillespie C, Hailpern SM, Heit JA, Howard VJ, Huffman MD, Kissela BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Magid D, Marcus GM, Marelli A, Matchar DB, McGuire DK, Mohler ER, Moy CS, Mussolino ME, Nichol G, Paynter NP, Schreiner PJ, Sorlie PD, Stein J, Turan TN, Virani SS, Wong ND, Woo D, Turner MB. Heart disease and stroke statistics--2013 update: a report from the American Heart Association. Circulation 2013; 127:e6-e245. [PMID: 23239837 PMCID: PMC5408511 DOI: 10.1161/cir.0b013e31828124ad] [Citation(s) in RCA: 3357] [Impact Index Per Article: 305.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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91
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van Kempen BJH, Ferket BS, Hofman A, Steyerberg EW, Colkesen EB, Boekholdt SM, Wareham NJ, Khaw KT, Hunink MGM. Validation of a model to investigate the effects of modifying cardiovascular disease (CVD) risk factors on the burden of CVD: the rotterdam ischemic heart disease and stroke computer simulation (RISC) model. BMC Med 2012; 10:158. [PMID: 23217019 PMCID: PMC3566939 DOI: 10.1186/1741-7015-10-158] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 12/06/2012] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND We developed a Monte Carlo Markov model designed to investigate the effects of modifying cardiovascular disease (CVD) risk factors on the burden of CVD. Internal, predictive, and external validity of the model have not yet been established. METHODS The Rotterdam Ischemic Heart Disease and Stroke Computer Simulation (RISC) model was developed using data covering 5 years of follow-up from the Rotterdam Study. To prove 1) internal and 2) predictive validity, the incidences of coronary heart disease (CHD), stroke, CVD death, and non-CVD death simulated by the model over a 13-year period were compared with those recorded for 3,478 participants in the Rotterdam Study with at least 13 years of follow-up. 3) External validity was verified using 10 years of follow-up data from the European Prospective Investigation of Cancer (EPIC)-Norfolk study of 25,492 participants, for whom CVD and non-CVD mortality was compared. RESULTS At year 5, the observed incidences (with simulated incidences in brackets) of CHD, stroke, and CVD and non-CVD mortality for the 3,478 Rotterdam Study participants were 5.30% (4.68%), 3.60% (3.23%), 4.70% (4.80%), and 7.50% (7.96%), respectively. At year 13, these percentages were 10.60% (10.91%), 9.90% (9.13%), 14.20% (15.12%), and 24.30% (23.42%). After recalibrating the model for the EPIC-Norfolk population, the 10-year observed (simulated) incidences of CVD and non-CVD mortality were 3.70% (4.95%) and 6.50% (6.29%). All observed incidences fell well within the 95% credibility intervals of the simulated incidences. CONCLUSIONS We have confirmed the internal, predictive, and external validity of the RISC model. These findings provide a basis for analyzing the effects of modifying cardiovascular disease risk factors on the burden of CVD with the RISC model.
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Affiliation(s)
- Bob J H van Kempen
- Department of Epidemiology, Erasmus MC Rotterdam, dr Molewaterplein 50, Rotterdam, 3015 GE, the Netherlands
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Dias EDM, Giollo LT, Martinelli DD, Mazeti C, Júnior HM, Vilela-Martin JF, Yugar-Toledo JC. Carotid intima-media thickness is associated with cognitive deficiency in hypertensive patients with elevated central systolic blood pressure. Cardiovasc Ultrasound 2012; 10:41. [PMID: 23078629 PMCID: PMC3495224 DOI: 10.1186/1476-7120-10-41] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 09/18/2012] [Indexed: 11/18/2022] Open
Abstract
Background The role of hypertension in the loss of cognitive function is controversial. Relationships between hypertension and increases in cerebral vascular resistance, diffused lesions and multiple lacunar infarcts of the white matter are well known. Thus, the objectives of this study were: to evaluate the relationship between hypertension and cognitive dysfunction (CD), identify risk factors and determine the association between early markers of vascular disease and CD in hypertensive individuals. Methods Two hundred individuals aged between 40 and 80 years old were evaluated in this cross-sectional prospective study. Fifty participants were controls (CT). The remaining 150 hypertensive patients were subdivided into two groups, those with CD (HCD) and those without CD (HNCD). All participants underwent clinical evaluations and biochemical blood tests were performed. CD was investigated using the Mini Mental State Examination (MMSE) following the guidelines for its use in Brazil. The impact of hypertension on the arterial bed was assessed by identifying and measuring changes in the intima-media thickness (IMT) by vascular ultrasonography of the carotid arteries and analyses of the central blood pressure and Augmentation Index by applanation tonometry of the radial artery. Results There were no significant differences in the total cholesterol, high-density lipoprotein cholesterol and triglycerides plasma concentrations between the three groups. The serum creatinine and estimated glomerular filtration rate were within normal ranges for all three groups. A significantly lower MMSE score was recorded for the HCD Group compared to the HNCD and CT Groups (p-value < 0.05). The IMT was significantly different between the HNCD and HCD Groups (p-value = 0.0124). A significant difference in the IMT was also observed between hypertensive patients and the CT Group (p-value < 0.0001). Age, low-density cholesterol, high-density cholesterol, triglycerides and IMT increased the Odds Ratio for cognitive dysfunction. The central systolic pressure was significantly higher in the HCD and HNCD Groups compared to CT Group (p-value < 0.0001). Conclusions Hypertensive patients with CD have changes in the vascular morphology characterized by an increased carotid IMT, enhanced atherosclerotic lipid profile and impaired hemodynamic functional manifested by elevated central systolic blood pressure.
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Affiliation(s)
- Eros da Mota Dias
- Hypertension Clinic, Department of Internal Medicine, State Medical School of São José do Rio Preto, Brazil
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93
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Liu F, McCullough LD. Interactions between age, sex, and hormones in experimental ischemic stroke. Neurochem Int 2012; 61:1255-65. [PMID: 23068990 DOI: 10.1016/j.neuint.2012.10.003] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 10/01/2012] [Accepted: 10/05/2012] [Indexed: 12/27/2022]
Abstract
Age, sex, and gonadal hormones have profound effects on ischemic stroke outcomes, although how these factors impact basic stroke pathophysiology remains unclear. There is a plethora of inconsistent data reported throughout the literature, primarily due to differences in the species examined, the timing and methods used to evaluate injury, the models used, and confusion regarding differences in stroke incidence as seen in clinical populations vs. effects on acute neuroprotection or neurorepair in experimental stroke models. Sex and gonadal hormone exposure have considerable independent impact on stroke outcome, but these factors also interact with each other, and the contribution of each differs throughout the lifespan. The contribution of sex and hormones to experimental stroke will be the focus of this review. Recent advances and our current understanding of age, sex, and hormone interactions in ischemic stroke with a focus on inflammation will be discussed.
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Affiliation(s)
- Fudong Liu
- Department of Neuroscience, University of Connecticut Health Center, Farmington, CT, USA
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Taussky P, Hanel RA, Meyer FB. Clinical considerations in the management of asymptomatic carotid artery stenosis. Neurosurg Focus 2012; 31:E7. [PMID: 22133180 DOI: 10.3171/2011.9.focus11222] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Incidental findings pose considerable management dilemmas for the treating physician and psychological burden for the respective patient. With an aging population, more patients will be diagnosed with asymptomatic internal carotid artery stenosis. Patients will have to be counseled with regard to treatment options according to their individual risk profile and according to professionals' knowledge of evidence-based data derived from large randomized control trials. Treatment consensus has long been lacking for patients with asymptomatic carotid artery stenosis prior to any randomized controlled trials. Additionally, an individual's risk profile may be hard to assess according to knowledge gained from randomized controlled trials. Moreover, while earlier studies compared carotid endarterectomy and medical therapy, in the past years, a new therapeutic modality, carotid artery angioplasty and stenting, has emerged as a possible alternative. This has been evaluated in a recent randomized controlled trial, the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), which compared carotid endarterectomy with angioplasty and stenting in both symptomatic and asymptomatic patients. The following review summarizes current knowledge of the natural history, diagnosis, and treatment strategies to counsel patients with asymptomatic carotid artery stenosis.
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Affiliation(s)
- Philipp Taussky
- Department of Neurosurgery, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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Andersson M, Guo X, Börjesson-Hanson A, Liebetrau M, Östling S, Skoog I. A population-based study on dementia and stroke in 97 year olds. Age Ageing 2012; 41:529-33. [PMID: 22431153 DOI: 10.1093/ageing/afs040] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND the number of nonagenarians increases dramatically worldwide. OBJECTIVES to examine the prevalence of stroke/transient ischaemic attack (TIA) and dementia, their inter-relationship and their relation to 2-year mortality and institutionalisation in 97 year olds. METHODS a population-based sample of 97 year olds (n=591) was examined. Information on stroke/TIA was obtained from self-reports, key informants and hospital discharge registers. Dementia was diagnosed according to DSM-III-R criteria. RESULTS the response rate was 65%. The prevalence of dementia was 32.7% in men and 59.3% in women (P<0.001). The prevalence of stroke/TIA was 21.5% (17.8% in men, 22.3% in women). Stroke/TIA was related to dementia in women (odds ratio=1.9, 95% CI: 1.2-3.0), but not in men. Dementia, but not stroke/TIA, was related to 2-year mortality and institutionalisation in logistic regression models. CONCLUSION dementia was very common in this age group, and related to mortality and institutionalisation. Stroke/TIA in 97 year olds showed less association with dementia, mortality and institutionalisation than reported in studies of younger elderly populations. The finding that stroke was not associated with dementia in men needs to be taken cautiously due to the small number of men. The findings also emphasise that more studies are needed to scrutinise the aetiology of dementia in nonagenarians.
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Affiliation(s)
- Mats Andersson
- Neuropsykiatri, Neuropsychiatric Epidemiology, Wallinsgatan 6, SU/Mölndal SE-431 41, Sweden.
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96
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Timóteo AT, Carmo MM, Ferreira RC. Can metabolic syndrome presence predict carotid intima-media thickness? J Clin Hypertens (Greenwich) 2012; 14:507-13. [PMID: 22863158 DOI: 10.1111/j.1751-7176.2012.00630.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The aim of this investigation was to analyze metabolic syndrome (MS) impact on carotid intima-media thickness (cIMT). Prospective study of 300 patients with suspected coronary artery disease admitted for an elective coronary angiography were evaluated. Patients with previously known cardiac disease were excluded. In the population, 23.0% were diabetics and 40.5% had MS (but no diabetes). cIMT was not significantly different in patients with MS, but was significantly higher in diabetic patients compared with MS and control patients. Independent predictors of cIMT were age, male gender, insulin, and high-density lipoprotein (HDL) cholesterol (the last one with an inverse association). In patients without MS, only age and HDL cholesterol were associated. In patients with MS, independent predictors were age, male gender, and glucose, and abdominal obesity showed an inverse relationship. In patients with stable angina, MS is not an independent predictor of cIMT. Nonmodifiable variables (age and gender) are the most important determinants of cIMT, as well as blood glucose, in MS patients. Abdominal obesity was protective. J Clin Hypertens (Greenwich). 2012;00:00-00. ©2012 Wiley Periodicals, Inc.
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Affiliation(s)
- Ana T Timóteo
- Department of Cardiology, Santa Marta Hospital, Centro Hospitalar Lisboa Central, EPE, Lisbon, Portugal.
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Sealy-Jefferson S, Wing JJ, Sánchez BN, Brown DL, Meurer WJ, Smith MA, Morgenstern LB, Lisabeth LD. Age- and ethnic-specific sex differences in stroke risk. GENDER MEDICINE 2012; 9:121-8. [PMID: 22445684 PMCID: PMC3481549 DOI: 10.1016/j.genm.2012.02.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 01/30/2012] [Accepted: 02/22/2012] [Indexed: 11/22/2022]
Abstract
BACKGROUND In white populations, age seems to modify the effect of sex on stroke risk, and compared with men, women are protected from stroke until approximately age 75 to 85 years, after which the protection is lost or reversed. Compared with non-Hispanic whites (NHWs), Mexican Americans (MAs) are at higher risk of stroke; however, age- and sex-specific stroke incidence data are currently not available for this population. OBJECTIVE This study was performed to compare the age-specific sex differences in stroke risk in MAs and NHWs. METHODS Data were derived from the BASIC (Brain Attack Surveillance in Corpus Christi) Project, a population-based stroke surveillance study conducted in Nueces County Texas. Incident strokes (n = 2421, including ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage) that occurred between January 1, 2000 and May 25, 2007 in individuals aged 45 years or older were included in the analysis. Poisson regression using the generalized additive models framework was used to analyze the relationship between sex, age (5-year intervals), and race/ethnicity (NHW or MA) and incident stroke risk. RESULTS Among both NHWs and MAs aged 45 to 79 years, men were at higher risk of stroke than women were. The magnitude of increased stroke risk in men compared with women diminished with age, and after age 79 years, no sex difference in stroke risk was observed. CONCLUSIONS Reasons for the loss of protection from stroke in aging women of all races/ethnicities are not fully understood, and further study is warranted.
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Affiliation(s)
- Shawnita Sealy-Jefferson
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
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98
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Van Schie MC, Wieberdink RG, Koudstaal PJ, Hofman A, Ikram MA, Witteman JCM, Breteler MMB, Leebeek FWG, De Maat MPM. Genetic determinants of von Willebrand factor plasma levels and the risk of stroke: the Rotterdam Study. J Thromb Haemost 2012; 10:550-6. [PMID: 22257027 DOI: 10.1111/j.1538-7836.2012.04634.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND High von Willebrand factor (VWF) plasma levels are associated with an increased risk of stroke. VWF levels are strongly heritable. A previous meta-analysis of five large genome-wide association studies identified single-nucleotide polymorphisms (SNPs) within eight genetic loci as determinants of VWF levels. Whether these SNPs are associated with stroke risk is not known. The aim of our study was to investigate the association between genetic determinants of VWF levels and stroke risk. METHODS The study was part of the Rotterdam Study, a large population-based cohort study among subjects aged ≥ 55 years. A total of 5763 participants for whom DNA was available, and who were free of stroke at baseline, were eligible for analysis. VWF antigen (VWF:Ag) levels were measured in 3379 eligible participants. Within each of the eight loci, one top SNP was defined. The association between the eight SNPs and the risk of stroke was analyzed. Then, a genetic score, based on these eight SNPs, was constructed, and its total contribution to VWF plasma levels and stroke risk was investigated. RESULTS None of the eight SNPs was individually associated with stroke risk. A higher genetic score was significantly associated with a higher VWF:Ag level, but was not associated with an increased risk of stroke. CONCLUSION Eight SNPs that strongly determine VWF levels are not associated with stroke risk, either individually, or combined in a genetic score.
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Affiliation(s)
- M C Van Schie
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
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99
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Garcia PY, Roussel M, Bugnicourt JM, Lamy C, Canaple S, Peltier J, Loas G, Deramond H, Godefroy O. Cognitive impairment and dementia after intracerebral hemorrhage: a cross-sectional study of a hospital-based series. J Stroke Cerebrovasc Dis 2012; 22:80-6. [PMID: 22421024 DOI: 10.1016/j.jstrokecerebrovasdis.2011.06.013] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 06/12/2011] [Accepted: 06/16/2011] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Frequencies of cognitive impairment and dementia have not been assessed in spontaneous intracerebral hemorrhage (ICH). The objective of this study was to determine the frequencies and patterns of cognitive impairment and dementia in a cross-sectional study of consecutive patients hospitalized in a single university medical center. METHODS Of 183 consecutive patients hospitalized between 2002 and 2006, 80 survivors were contacted and 78 were included (mean time since stroke 40 months). Thirty patients were scored with the Informant Questionnaire on Cognitive Decline in the Elderly and Instrumental Activities of Daily Living in a telephone interview, and 48 underwent a comprehensive clinical and neuropsychological assessment. RESULTS Dementia was observed in 18 of 78 patients (23%; 95% confidence interval [CI] 13-32%) and cognitive impairment without dementia was seen in 37 of 48 patients (77%; 95% CI 65-89%). The cognitive disorders mainly concerned episodic memory (52%), psychomotor speed (44%), and executive function (37%), followed by language and visuoconstructive abilities. In a logistic regression analysis, Rankin score >1 at discharge and hemorrhage volume were the initial factors to be selected as a predictor of long-term dementia. CONCLUSIONS This single-center, cross-sectional study revealed that the prevalence of dementia and cognitive impairment without dementia after ICH are high and are similar to those observed in cerebral infarct. Further longitudinal, prospective studies are required to assess accurately the prevalence, mechanisms and predictors of post-ICH dementia.
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100
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de Weerd L, Rutgers AWF, Groenier KH, van der Meer K. Health care in patients 1 year post-stroke in general practice: research on the utilisation of the Dutch Transmural Protocol transient ischaemic attack/cerebrovascular accident. Aust J Prim Health 2012; 18:42-9. [PMID: 22394661 DOI: 10.1071/py10085] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Accepted: 08/04/2011] [Indexed: 11/23/2022]
Abstract
This study evaluates the kind of aftercare that ischaemic stroke patients receive and the extent that aftercare fulfils the criteria of the 'Dutch Transmural Protocol transient ischaemic attack/cerebrovascular accident'. Fifty-seven patients were interviewed 1 year post-stroke about secondary prevention and aftercare. Forty general practitioners (GPs) completed a questionnaire about guidance and secondary prevention (concerning medication and lifestyle advice). Most patients would like to see their GP more regularly. More aftercare was required than was planned. The use of aspirin remained the same, fewer patients used statins and more used antihypertensives. Of the 40 GPs who participated, 12% did not apply prevention. Blood pressure, glucose and cholesterol were measured in 84%, 28% and 40% of patients. All of these measures were often elevated, but treatment was not given. Lifestyle advice was offered to one-quarter of patients. Considering all of the advice given in the Dutch Protocol, several aspects can be improved in relation to secondary prevention. Too little attention is paid to giving lifestyle advice, stricter medical checkups by GPs are necessary and there is a decrease in use of preventive medication, partly because GPs monitors use of medication inadequately. The use of the Dutch Protocol in aftercare can be improved by a more detailed description of advice.
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Affiliation(s)
- L de Weerd
- Department of General Practice, University Medical Center Groningen, Groningen, The Netherlands.
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