National sex-specific trends in hospital-based stroke rates

Home-based rehabilitation versus hospital-based rehabilitation for stroke patients in post-acute care stage: Comparison on the quality of life

BACKGROUND

This study focused on the integrated post-acute care (PAC) stage of stroke patients, and employed a retrospective study to examine the satisfaction with life quality in two groups, one that received home-based rehabilitation and one that received hospital-based rehabilitation. A secondary purpose was to analyze the correlations among the index and components concerning their quality of life (QOL) and compare the advantages and disadvantages of these two approaches to PAC.

METHODS

This research was a retrospective study of 112 post-acute stroke patients. The home-based group received rehabilitation for one to two weeks, and two to four sessions per week. The hospital-based group received the rehabilitation for three to six weeks, and 15 sessions per week. The home-based group mainly received the training and guidance of daily activities at the patients' residence. The hospital-based group mainly received physical facilitation and functional training in the hospital setting.

RESULTS

The mean scores of QOL assessment for both groups were found to be significantly improved after intervention. Between-group comparisons showed that the hospital-based group had better improvement than the home-based group in mobility, self-care, pain/discomfort and depression/anxiety. In the home-based group, the MRS score and the participant's age can explain 39.4% of the variance of QOL scores.

CONCLUSION

The home-based rehabilitation was of lower intensity and duration than the hospital-based one, but it still achieved a significant improvement in QOL for the PAC stroke patients. The hospital-based rehabilitation offered more time and treatment sessions. Therefore hospital-based patients responded with better QOL outcomes than the home-based patients.

Temporal trends in validated ischaemic stroke hospitalizations in the USA

BACKGROUND

Accurate assessment of the burden of stroke, a major cause of disability and death, is crucial. We aimed to estimate rates of validated ischaemic stroke hospitalizations in the USA during 1998-2011.

METHODS

We used the Atherosclerosis Risk in Communities (ARIC) study cohort's adjudicated stroke data for participants aged ≥55 years, to construct validation models for each International Classification of Diseases (ICD)-code group and patient covariates. These models were applied to the Nationwide Inpatient Sample (NIS) data to estimate the probability of validated ischaemic stroke for each eligible hospitalization. Rates and trends in NIS using ICD codes vs estimates of validated ischaemic stroke were compared.

RESULTS

After applying validation models, the estimated annual average rate of validated ischaemic stroke hospitalizations in the USA during 1998-2011 was 3.37 [95% confidence interval (CI): 3.31, 3.43) per 1000 person-years. Validated rates declined during 1998-2011 from 4.7/1000 to 2.9/1000; however, the decline was limited to 1998-2007, with no further decline subsequently through 2011. Validation models showed that the false-positive (∼23% of strokes) and false-negative rates of ICD-9-CM codes in primary position for ischaemic stroke approximately cancel. Therefore, estimates of ischaemic stroke hospitalizations did not substantially change after applying validation models.

CONCLUSIONS

Overall, ischaemic stroke hospitalization rates in the USA have declined during 1998-2007, but no further decline was observed from 2007 to 2011. Validated ischaemic stroke hospitalizations estimates were similar to published estimates of hospitalizations with ischaemic stroke ICD codes in primary position. Validation of national discharge data using prospective chart review data is important to estimate the accuracy of reported burden of stroke.

Bioanalytical HPLC method development for simultaneous determination of valsartan and co-administered clopidogrel bisulfate and fenofibrate in stroke prevention in raw materials, spiked human plasma and tablets

This study reports about simple, robust and reproducible method for simultaneous bioanalytical determination of Valsartan (VAL) and co-administered Clopidogrel bisulfate (CGB) and Fenofibrate (FEN) in raw materials, spiked human plasma and tablets using isocratic RP-HPLC method. The chromatographic separation is carried out using isocratic binary mobile phase consisting of 80 mM phosphate buffer pH 3: Acetonitrile (30: 70 %; v/v) at the flow rate of 1.1 mL/min and 33 °C. A Diode array detector at wavelength 214 nm was used. Retention times for VAL, CGB and FEN were 3.1, 5.1 and 6.4 min, respectively. The calibration curves obtained were linear over the concentration ranges of 2.5 - 100 μg/mL for both VAL and CGB and 5 -100 μg/mL for FEN. The mean extraction recoveries of VAL, CGB and FEN from spiked plasma were 75.38±1.34 %, 89.91±2.17 % and 96.92±6.02 %, respectively. The limits of detection and quantification were 0.86, 0.67, 1.11 μg/mL and 2.60, 2.03, 3.36 μg/mL for VAL, CGB and FEN, respectively. The method was applied to the analysis of these drugs in spiked human plasma and in tablets as they are commonly used as a combination for prevention of stroke. Results obtained show good accuracy, precision and acceptable recoveries from plasma samples.

Knowledge, attitudes and practices related to stroke in Ghana and Nigeria: A SIREN call to action

INTRODUCTION

Stroke is a prominent cause of death, disability, and dementia in sub-Saharan Africa (SSA). The Stroke Investigative Research and Education Network works collaboratively with stroke survivors and individuals serving as community controls to comprehensively characterize the genomic, sociocultural, economic and behavioral risk factors for stroke in SSA.

PURPOSE

In this paper, we aim to: i) explore the attitudes, beliefs, and practices related to stroke in Ghana and Nigeria using the process of qualitative description; and ii) propose actions for future research and community-based participation and education.

METHODS

Stroke survivors, their caregivers, health care professionals, and community representatives and faith-based leaders participated in one of twenty-six focus groups, which qualitatively explored community beliefs, attitudes and practices related to stroke in Ghana and Nigeria. Arthur Kleinman's Explanatory Model of Illness and the Social Ecological Model guided the questions and/or thematic analysis of the qualitative data. We hereby describe our focus group methods and analyses of qualitative data, as well as the findings and suggestions for improving stroke outcomes.

RESULTS AND DISCUSSION

The major findings illustrate the fears, causes, chief problems, treatment, and recommendations related to stroke through the views of the participants, as well as recommendations for working effectively with the SIREN communities. Findings are compared to SIREN quantitative data and other qualitative studies in Africa. As far as we are aware, this is the first paper to qualitatively explore and contrast community beliefs, attitudes, and practices among stroke survivors and their caregivers, community and faith-based leaders, and health professionals in multiple communities within Nigeria and Ghana.

Functional Outcomes, Subsequent Healthcare Utilization, and Mortality of Stroke Postacute Care Patients in Taiwan: A Nationwide Propensity Score-matched Study

OBJECTIVE

To evaluate the benefits of the national stroke postacute care (PAC) program on clinical outcomes and subsequent healthcare utilization.

DESIGN

Propensity score-matched case-control study using the National Health Insurance data.

PARTICIPANTS

A total of 1480 stroke cases receiving PAC services and 3159 matched controls with similar stroke severity but without PAC services.

MEASUREMENTS

Demographic characteristics, functional outcomes (modified Rankin Scale, Barthel Index, Lawton-Brody Instrumental Activities of Daily Living, Functional Oral Intake Scale, Mini-Nutritional Assessment, Berg Balance Test, Usual Gait Speed Test, 6-Minute Walk Test, Fugl-Meyer Assessment (modified sensation and motor), Mini-Mental State Examination, Motor Activity Log, and the Concise Chinese Aphasia Test), subsequent healthcare utilization (90-day stroke re-admission and emergency department visits), and 90-day mortality.

RESULTS

After propensity score matching, baseline characteristics, stroke severity, and status of healthcare utilization before index stroke admission were similar between cases and controls. After PAC services, the case group obtained significant improvement in all functional domains and may have reduced subsequent disability. Among all functional assessments, balance was the most significantly improved domain and was suggestive for the reduction of subsequent falls risk and related injuries. Compared with controls, patients receiving PAC services had significantly lower 90-day hospital re-admissions [11.1% vs 21.0%, adjusted odds ratio (aOR) 0.47 with 95% confidence interval (CI) 0.34-0.64], stroke-related re-admissions (2.1% vs 8.8%, aOR 0.22, 95% CI 0.12-0.41), and emergency department visits (13.5% vs 24.0%, aOR 0.49, 95% CI 0.37-0.65), but the 90-day mortality rate remained similar between groups (1.4% case group vs 2.0% control group, aOR 0.68, 95% CI 0.29-1.62).

CONCLUSIONS

PAC significantly improved the recovery of stroke patients in all functional domains through the program, with universal interorganizational staff training, periodic functional assessment, and high-intensity rehabilitation. Further longitudinal research is needed to evaluate the long-term survival benefits and healthcare utilization.

Phone-based Intervention under Nurse Guidance after Stroke (PINGS): study protocol for a randomized controlled trial

BACKGROUND

Hypertension is the premier modifiable risk factor for recurrent stroke. In sub-Saharan Africa (SSA) where the stroke burden is escalating, little is known about the role of behavioral interventions in enhancing blood pressure (BP) control after stroke. Our objective is to test whether an m-Health technology-enabled, nurse-led, multilevel integrated approach is effective in improving BP control among Ghanaian stroke patients within 1 month of symptom onset compared with standard of care.

METHODS

This two-arm cluster randomized controlled feasibility pilot trial will involve 60 recent-stroke survivors. Using a computer-generated sequence, patients will be randomly allocated into four clusters of 15 patients each per physician: two clusters in the intervention arm and two in the control arm. Patients in the intervention arm will receive a simple pillbox, a Blue-toothed UA-767Plus BT BP device and smartphone for monitoring and reporting BP measurements and medication intake under nurse guidance for 3 months. Tailored motivational text messages will be delivered based upon levels of adherence to the medication intake. Both groups will be followed up for 6 months to compare BP control at months 3, 6 and 9 as primary outcome measure. Physicians assessing BP control will be blinded to arms into which patients are allocated. Secondary outcome measures will include medication adherence scores and Competence and Autonomous Self-regulation Scale scores. A qualitative study is planned after follow-up to explore the lived experiences of participants in the intervention arm.

DISCUSSION

A feasible and preliminarily effective intervention would lead to a larger more definitive efficacy/effectiveness randomized controlled trial powered to look at clinical events, with the potential to reduce stroke-related morbidity and mortality in a low- to middle-income country.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02568137 , registered on 13 July 2015.

A comparison of risk factors and prognosis between intra and extracranial acute atherosclerotic stroke in the Turkish population: a prospective study

BACKGROUND

The aim of this study was to compare the differences in risk factors and prognosis between acute stroke caused by definitive intracranial atherosclerosis (ICAS) or extracranial atherosclerosis (ECAS) in the Turkısh population.

METHODS

This study was prospectively designed in a single centre and conducted with patients who were hospitalised due to acute ischaemic stroke. Inclusion criteria were the diagnosis of atherosclerotic ischaemic stroke, defined as more than 50% stenosis or occlusion in the arterial structure supplying the ischaemic area, having excluded other possible causes.

RESULTS

Information on 58 ICAS and 57 ECAS stroke patients was collected in a 13-month period. The ECAS patients had male gender predominance (p = 0.003). Ageing, stroke history and hyperlipidaemia were related with stroke severity in ECAS, and gender was associated with severity in ICAS. Hypertension and being female were related with poor prognosis in ICAS (p = 0.081 vs. 0.087). Congestive heart failure (p = 0.002) was associated with poor prognosis and alcohol with a favourable outcome (p = 0.087) in ECAS. Stroke severity was related with poor prognosis in both groups (p < 0.001).

CONCLUSIONS

The prevalence of risk factors differs between ICAS and ECAS, and their influence differs for stroke severity and prognosis.

Stroke Investigative Research and Education Network: Community Engagement and Outreach Within Phenomics Core

Stroke is the leading cause of neurological hospital admissions in sub-Saharan Africa (SSA) and the second leading cause of death globally. The Stroke Investigative Research and Education Network seeks to comprehensively characterize the genomic, sociocultural, economic, and behavioral risk factors for stroke and to build effective teams for research to address and decrease the burden of stroke and other noncommunicable diseases in SSA. One of the first steps to address this goal is to effectively engage the communities that suffer the high burden of disease. The purpose of this article is to describe plans to elucidate information about knowledge, attitudes, beliefs, and practices about stroke and genomics from patients, caregivers, and local leaders, to recruit participation in research activities and dissemination of ongoing results, as well as to facilitate research uptake and impact within the broader communities of scientists, health professionals, policy makers, and others. We describe the (a) study sites and their communities; (b) plans for community advisory boards, focus groups, and surveys; (c) methods for data management in REDCap database; (d) analyses of qualitative data; (e) evaluation of community and public engagement across multiple sites and research teams in SSA and the United States; (f) use of RE-AIM for presentation of evaluation data; and (g) community indicators of success. This is the first of its kind public outreach engagement initiative to evaluate stroke and genomics in SSA, and has implications as a model for assessment in other high-stroke risk populations.

Trends in Incident and Recurrent Rates of First-Ever Ischemic Stroke in Taiwan between 2000 and 2011

Background and Purpose

The burden of stroke is comparatively greater in Asian countries than in the Western world. While there has been a documented recent decline in the incidence of stroke in several Western nations due to better risk factor management, much less is known about the nature and trajectory of stroke in Asia over the last decade. The objective of this study was to explore risk factors, medication use, incidence, and one-year recurrence of stroke in Taiwan.

Methods

We conducted a nationwide cohort study by reviewing all hospitalized patients (≥ 18 years) with a primary diagnosis of ischemic stroke between 2001 and 2011 from Taiwan National Health Insurance Research Database.

Results

A total of 291,381 first-ever ischemic stroke patients were enrolled between 2000 and 2011. The average age was about 70 years and approximately 58.6% of them were men. While prevalence of diabetes mellitus and hyperlipidemia, as well as use of statins, antiplatelet agents, and oral anticoagulant agents for atrial fibrillation significantly increased; incidence (142.3 vs. 129.5 per 100,000 in 2000 and 2011, respectively) and one-year recurrence (9.6% vs. 7.8% in 2000 and 2011, respectively) of stroke declined during this period of time.

Conclusions

Over the last decade in Taiwan, rates of primary ischemic stroke and one-year recurrent stroke decreased by 9% and 18% respectively.

Trends in stroke admission and mortality rates from 1983 to 2013 in central Ghana

BACKGROUND

Accumulating data based on model-derived estimates suggest rising rates of stroke in sub-Saharan Africa over the next several decades. Stroke is a leading cause of death, disability, and dementia worldwide. Directly enumerated hospital-based data on the longitudinal trajectory of stroke admissions and deaths in sub-Saharan Africa could help hospital administrators, public health officials, and government policy-makers with planning and utilization of scarce resources.

OBJECTIVE

To evaluate 30-year trends in stroke admission and mortality rates in central Ghana.

METHODS

We undertook a retrospective analysis of data on stroke admissions and mortality at a tertiary referral hospital in central Ghana between 1983 and 2013. Rates of stroke admissions and mortality were expressed as stroke admissions or deaths divided by total number of hospital admissions or deaths respectively. Yearly crude case fatality from stroke was calculated and predictors of stroke mortality were determined using Cox proportional hazards regression analysis.

RESULTS

Over the period, there were 12,233 stroke admissions with equal gender distribution. The rate of stroke admissions increased progressively from 5.32/1000 admissions in 1983 to 13.85/1000 admissions in 2010 corresponding to a 260% rise over the period. Stroke mortality rates also increased from 3.40/1000 deaths to 6.66/1000 deaths over the 30-year period. The average 28-day mortality over the period was 41.1%. Predictors of in-patient mortality were increasing age-aHR of 1.31 (1.16-1.47) for age>80years compared with <40years and admissions in 2000's compared with 1980's; aHR of 1.32 (1.26-1.39). Of the 1132 stroke patients with neuroimaging data: 569 (50.3%) had intracerebral hemorrhage, 382 (33.7%) had ischemic stroke and 181 (16.0) had sub-arachnoid hemorrhage. Patients with ischemic stroke were significantly older than those with ICH and SAH respectively.

CONCLUSION

Rates of stroke admission and mortality have increased steadily over the past three decades in central Ghana. More intensive risk modification and optimization of acute stroke care are urgently needed to stem these worrisome trends.

Phone-based intervention under nurse guidance after stroke: concept for lowering blood pressure after stroke in Sub-Saharan Africa

Over the last 4 decades, rates of stroke occurrence in low- and middle-income countries (LMIC) have roughly doubled, whereas they have substantively decreased in high-income countries. Most of these LMIC are in Sub-Saharan Africa (SSA) where the burden of stroke will probably continue to rise over the next few decades because of an ongoing epidemiologic transition. Moreover, SSA is circumstantially distinct: socioeconomic obstacles, cultural barriers, underdiagnosis, uncoordinated care, and shortage of physicians impede the ability of SSA countries to implement cardiovascular disease prevention among people with diabetes mellitus in a timely and sustainable manner. Reducing the burden of stroke in SSA may necessitate an initial emphasis on high-risk individuals motivated to improve their health, multidisciplinary care coordination initiatives with clinical decision support, evidence-based interventions tailored for cultural relevance, task shifting from physicians to nurses and other health providers, use of novel patient-accessible tools, and a multilevel approach that incorporates individual- and system-level components. This article proposes a theory-based integrated blood pressure (BP) self-management intervention called Phone-based Intervention under Nurse Guidance after Stroke (PINGS) that could be tested among hospitalized stroke patients with poorly controlled hypertension encountered in SSA. PINGS would comprise the implementation of nurse-run BP control clinics and administration of health technology (personalized phone text messaging and home telemonitoring), aimed at boosting patient self-efficacy and intrinsic motivation for sustained adherence to antihypertensive medications.

Optimal combination secondary prevention drug treatment and stroke outcomes

OBJECTIVE

To investigate the effect of optimal combination of evidence-based drug therapies including antihypertensive agents, lipid modifiers, and antithrombotic agents on risk of recurrent vascular events after stroke.

METHODS

We analyzed the database of a multicenter trial involving 3,680 recent noncardioembolic stroke patients aged 35 years or older and followed for 2 years. Patients were categorized by appropriateness level 0 to III depending on the number of drugs prescribed divided by the number of drugs potentially indicated for each patient (0 = none of the indicated medications prescribed and III = all indicated medications prescribed). Independent associations of medication appropriateness level with recurrent stroke (primary outcome), stroke/coronary heart disease/vascular death as major vascular events (secondary outcome), and death (tertiary outcome) were assessed.

RESULTS

The unadjusted rate of stroke declined with increasing medication appropriateness level (15.9% for level 0, 10.3% for level I, 8.6% for level II, and 7.3% for level III). Compared with level 0: the adjusted hazard ratio of stroke for level I was 0.51 (95% confidence interval, 0.21-1.25), level II 0.50 (0.23-1.09), and level III 0.39 (0.18-0.84); of stroke/coronary heart disease/vascular death for level I 0.60 (0.32-1.14), level II 0.45 (0.25-0.80), and level III 0.39 (0.22-0.69); and of death for level I 0.89 (0.30-2.64), level II 0.71 (0.26-1.93), and level III 0.35 (0.13-0.96).

CONCLUSIONS

Optimal combination of secondary prevention medication classes after a recent noncardioembolic stroke is associated with a significantly lower risk of stroke, major vascular events, and death.

Temporal trends in the population attributable risk for cardiovascular disease: the Atherosclerosis Risk in Communities Study

BACKGROUND

The extent to which the relative contributions of traditional cardiovascular risk factors to incident cardiovascular disease (CVD) may have changed over time remains unclear.

METHODS AND RESULTS

We studied 13 541 participants (56% women, 26% black) in the Atherosclerosis Risk in Communities Study, aged 52 to 66 years and free of CVD at exams in 1987 through 1989, 1990 through 1992, 1993 through 1995, or 1996 through 1998. At each examination, we estimated the population attributable risks (PAR) of traditional risk factors (hypertension, diabetes mellitus, obesity, hypercholesterolemia, and smoking) for the 10-year incidence of CVD. Overall, the PAR of all risk factors combined appeared to decrease from the late 1980s to the late 1990s (0.58 to 0.53). The combined PAR was higher in women than men in 1987 through 1989 (0.68 versus 0.51, P<0.001) but not by the late 1990s (0.58 versus 0.48, P=0.08). The combined PAR was higher in blacks than whites in the late 1980s (0.67 versus 0.57, P=0.049), and this difference was more pronounced by the late 1990s (0.67 versus 0.48, P=0.002). By the late 1990s, the PAR of hypertension had become higher in women than men (P=0.02) and also appeared higher in blacks than whites (P=0.08). By the late 1990s, the PAR of diabetes mellitus remained higher in women than men (P<0.0001) and in blacks than whites (P<0.0001).

CONCLUSIONS

The contribution to CVD of all traditional risk factors combined is greater in blacks than whites, and this difference may be increasing. The contributions of hypertension and diabetes mellitus remain especially high, in women as well as blacks. These findings underscore the continued need for individual as well as population approaches to CVD risk factor modification.

Persistent racial disparity in stroke hospitalization and economic impact in young adults in the buckle of stroke belt

BACKGROUND AND PURPOSE

Mounting evidence points to a decline in stroke incidence. However, little is known about recent patterns of stroke hospitalization within the buckle of the stroke belt. This study aims to investigate the age- and race-specific secular trends in stroke hospitalization rates, inpatient stroke mortality rates, and related hospitalization charges during the past decade in South Carolina.

METHODS

Patients from 2001 to 2010 were identified from the State Inpatient Hospital Discharge Database with a primary discharge diagnosis of stroke (International Classification of Diseases, Ninth Revision codes: 430-434, 436, 437.1). Age- and race-stroke-specific hospitalization rates, hospital charges, charges associated with racial disparity, and 30-day stroke mortality rates were compared between blacks and whites.

RESULTS

Of the 84,179 stroke hospitalizations, 31,137 (37.0%) were from patients aged<65 years and 29,846 (35.5%) were blacks. Stroke hospitalization rates decreased in the older population (aged≥65 years) for both blacks and whites (P<0.001) but increased among the younger group (aged<65 years; P=0.004); however, this increase was mainly driven by a 17.3% rise among blacks (P=0.001), with no difference seen among whites (P=0.84). Of hospital charges totaling $2.77 billion, $453.2 million (16.4%) are associated with racial disparity (79.6% from patients aged<65 years). Thirty-day stroke mortality rates decreased in all age-race-stroke-specific groups (P<0.001).

CONCLUSIONS

The stroke hospitalization rate increased in the young blacks only, which results in a severe and persistent racial disparity. It highlights the urgent need for a racial disparity reduction in the younger population to alleviate the healthcare burden.

Sex differences in antiplatelet response in ischemic stroke

Sex differences exist in the occurrence, treatment and outcome of ischemic stroke. Compared with men, women have more stroke events and are less likely to fully recover from a stroke. Given the rapidly aging population, stroke incidence and mortality among women are projected to substantially rise by 2050. This has important public health consequences. Mitigating the burden of stroke among women will require a fundamental understanding of sex differences and sex-specific issues including cerebrovascular disease pathophysiology, treatment and outcome. An aspect of stroke treatment receiving increasing but insufficient attention involves possible interactions between estrogen levels, antiplatelet drugs and stroke outcome. Emerging evidence suggests that antiplatelet therapy may provide primary stroke protection but not primary myocardial infarction prevention in women, while the opposite may be true among men. Understanding sex-specific issues related to women who experience stroke is critical to clinicians who treat women with antiplatelet medications as part of a secondary stroke prevention regimen; however, the ideal antiplatelet medication, and dose, in women requires further research. In this article we present a conceptual framework for sex differences in antiplatelet treatment response in ischemic stroke, thrombus formation and the mediating role of estrogen, sex differences in antiplatelet treatment response in clinical trials, and sex differences in antiplatelet treatment use in ischemic stroke.

Stroke epidemiology: advancing our understanding of disease mechanism and therapy

Stroke is the fourth killer and number one cause of adult disability in the United States. The estimated direct and indirect costs of stroke care in this country are $68.9 billion for 2009. The prevalence of stroke and its cost will undoubtedly rise as the aging population increases. In addition, stroke incidence and mortality are increasing in less developed countries in which the lifestyles and population restructuring are rapidly changing. More population-based research to assess incidence, risk factors, and outcomes are needed in these countries. Epidemiologic studies can help identify groups of individuals or regions at higher risk for stroke. They can also help us better understand the natural history of certain conditions and therefore push the direction of therapeutic investigations. Furthermore, the study of trends across different time periods and different populations can help investigators evaluate the effects of stroke care programs and treatment options.