Current status of stroke epidemiology in Greece: a panorama

Factors associated with social support for family members who care for stroke survivors

Introduction

Vascular strokes are a primary cause of long-term disability for adults, with many social consequences for the patient, the family and healthcare systems worldwide.

Aim

To investigate the relation between patients' and caregivers' characteristics, as well as burden and depression, and the social support received by carers for stroke victims in Greece.

Method

Patients and caregivers were recruited from community settings in the Attica region of Greece, using purposive sampling. They completed a set of questionnaires during face-to-face interviews. Correlational and multiple regression analyses were performed to identify factors associated with caregivers' perceptions of social support.

Results

In total, 109 dyads of patients and their respective caregivers were recruited. The patients' mean age was 69.3 years, while caregivers' mean age was 58.0 years; 51.4% of patients were males, whereas 67.9% of the caregivers were females. The majority of both patients and caregivers were married, with an annual family income less than €10,000. The level of perceived social support was significantly associated with patients' or caregivers' annual family income, caregivers' working status and the daily caring hours (p < 0.01). Greater perceived support was significantly associated with a lower care burden BCOS (r = 0.29, p < 0.01) and female gender (p = 0.023), but not with the patient's functional level nor with depression (p > 0.05).

The effects of alpha-lipoic acid supplementation on fasting glucose and lipid profiles among patients with stroke: a systematic review and meta-analysis of randomized controlled trials

Background and objective

Stroke is a devastating condition with long-term comorbidities including metabolic abnormalities. Alpha lipoic acid (ALA), with its antioxidant properties, might improve metabolic status of patients, though current evidence is still inclusive. This systematic review of randomized controlled trials (RCTs) was conducted to summarize the existing evidence regarding the effects of ALA supplementation on fasting glucose and lipid profiles among patients with stroke.

Methods

We searched Cochrane Library, EMBASE, MEDLINE, and Web of Science from 1990 until April 5th, 2018. The relevant randomized-controlled articles, based on defined key words, were included in the analyses. Two independent researchers investigated study eligibility, extracted data, and assessed the risk of bias for included studies. Heterogeneity among included studies was tested using Q-test and I² statistics. Random-effects models were applied to pool the data and standardized mean differences (WMD) were considered as summary effect size.

Results

A total of five studies (140 patients in each intervention group) were included in our meta-analysis. The findings showed that ALA supplementation significantly decreased fasting glucose levels (WMD -36.93 mg/dL; 95% CI, -65.58, -8.28; P = 0.01; I² = 85.0%) in patients with stroke. We found no significant effect of ALA supplementation on triglycerides (WMD -7.45 mg/dL; 95% CI, -51.35, 36.45; P = 0.739; I² = 83.9%), total cholesterol (WMD -23.23 mg/dL; 95% CI, -48.07, 1.62; P = 0.067; I² = 80.5%), LDL-cholesterol (WMD -10.46 mg/dL; 95% CI, -21.01, 0.09; P = 0.052; I² = 47.4%) and HDL-cholesterol levels (WMD -3.02 mg/dL; 95% CI, -20.18, 14.14; P = 0.730; I² = 85.8%).

Conclusions

This meta-analysis suggested the beneficial impacts of ALA supplementation in improving fasting glucose of patients diagnosed with stroke.

National trends in diabetes mellitus hospitalization in Spain 1997-2010: Analysis of over 5.4 millions of admissions

AIMS

To analyze national trends in the rates of hospitalizations (all-cause and by principal discharge diagnosis) in total diabetic population of Spain.

METHODS

We carried out a nation-wide population-based study of all diabetic patients hospitalized between 1997 and 2010. All-cause hospitalizations, hospitalizations by principal discharge diagnosis, mean age, Charlson Comorbidity Index, readmission rates and length of hospital stay were examined. Annual rates adjusted for age and sex were analyzed and trends were calculated.

RESULTS

Over 14-years-period, all-cause hospitalizations of diabetic patients increased significantly, with an average annual percentage change of 2.5 (95%CI: 1.5-3.5; P_trend < 0.01). The greatest increase was observed in heart failure (5.4; 95%CI: 4.8-6.0; P_trend < 0.001), followed by neoplasms (4.9; 95%CI: 3.6-5.8; P_trend < 0.001), pneumonia (2.7; 95%CI: 2.0-4.0; P_trend < 0.001), stroke (2.4; 95%CI: 1.6-3.4; P_trend < 0.001), chronic obstructive pulmonary disease (2.0; 95%CI: 1.4-3.4; P_trend < 0.001) and coronary artery disease (1.6; 95%CI: 1.1-2.3; P_trend < 0.01). The adjusted number of all-cause hospitalizations of patients with diabetes per 100,000 inhabitants increased 2.6-fold. The increase in hospitalizations was significantly higher among patients ≥75 years old. Males experienced a greater increase in all-cause, neoplasm, heart failure, chronic obstructive pulmonary disease, and pneumonia hospitalizations (p < 0.01 for all). Hospitalized diabetic patients were progressively older and had more comorbidities, higher readmission rates and shorter hospital stays (p < 0.05 for all).

CONCLUSIONS

Hospitalizations of diabetic patients more than doubled in Spain during the study period. Heart failure and neoplasms experienced the greatest annual increases and remained the principal causes of hospitalization, probably associated with advanced age and comorbidities of hospitalized diabetics. Coronary and cerebrovascular diseases experienced a lower annual increase, suggesting an improvement in cardiovascular care in diabetes in Spain.

The Emergency Medical System in Greece: Opening Aeolus' Bag of Winds

An Emergency Medical Service (EMS) system must encompass a spectrum of care, with dedicated pre-hospital and in-hospital medical facilities. It has to be organised in such a way as to include all necessary services&mdash;such as triage accurate initial assessment, prompt resuscitation, efficient management of emergency cases, and transport to definitive care. The global economic downturn has had a direct effect on the health sector and poses additional threats to the healthcare system. Greece is one of the hardest-hit countries. This manuscript aims to present the structure of the Greek EMS system and the impact of the current economic recession on it. Nowadays, primary care suffers major shortages in crucial equipment, unmet health needs, and ineffective central coordination. Patients are also facing economic limitations that lead to difficulties in using healthcare services. The multi-factorial problem of in-hospital EMS overcrowding is also evident and has been linked with potentially poorer clinical outcomes. Furthermore, the ongoing refugee crisis challenges the national EMS. Adoption of a triage scale, expansion of the primary care network, and an effective primary&ndash;hospital continuum of care are urgently needed in Greece to provide comprehensive, culturally competent, and high-quality health care.

Stroke Incidence and Outcomes in Northeastern Greece: The Evros Stroke Registry

BACKGROUND AND PURPOSE

Data are scarce on both stroke incidence rates and outcomes in Greece and in rural areas in particular. We performed a prospective population-based study evaluating the incidence of first-ever stroke in the Evros prefecture, a region of a total 147 947 residents located in North Eastern Greece.

METHODS

Adult patients with first-ever stroke were registered during a 24-month period (2010-2012) and followed up for 12 months. To compare our stroke incidence with that observed in other studies, we standardized our incidence rate data according to the European Standard Population, World Health Organization, and Segi population. We also applied criteria of data quality proposed by the Monitoring Trends and Determinants in Cardiovascular Disease project. Stroke diagnosis and classification were performed using World Health Organization criteria on the basis of neuroimaging and autopsy data.

RESULTS

We prospectively documented 703 stroke cases (mean age: 75±12 years; 52.8% men; ischemic stroke: 80.8%; intracerebral hemorrhage: 11.8%; subarachnoid hemorrhage: 4.4%; undefined: 3.0%) with a total follow-up time of 119 805 person-years. The unadjusted and European Standard Population-adjusted incidences of all strokes were 586.8 (95% confidence interval [CI], 543.4-630.2) and 534.1 (95% CI, 494.6-573.6) per 100 000 person-years, respectively. The unadjusted incidence rates for ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage were 474.1 (95% CI, 435-513), 69.3 (95% CI, 54-84), and 25.9 (95% CI, 17-35) per 100 000 person-years, respectively. The corresponding European Standard Population-adjusted incidence rates per 100 000 person-years were 425.9 (95% CI, 390.9-460.9), 63.3 (95% CI, 49.7-76.9), and 25.8 (95% CI, 16.7-34.9) for ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage, respectively. The overall 28-day case fatality rate was 21.3% (95% CI, 18.3%-24.4%) for all strokes and was higher in hemorrhagic strokes than ischemic stroke (40.4%, 95% CI, 31.3%-49.4% versus 16.2%, 95% CI, 13.2%-19.2%).

CONCLUSIONS

This is the largest to date population-based study in Greece documenting one of the highest stroke incidences ever reported in South Europe, highlighting the need for efficient stroke prevention and treatment strategies in Northeastern Greece.

Recording, analysis, and interpretation of spreading depolarizations in neurointensive care: Review and recommendations of the COSBID research group

Spreading depolarizations (SD) are waves of abrupt, near-complete breakdown of neuronal transmembrane ion gradients, are the largest possible pathophysiologic disruption of viable cerebral gray matter, and are a crucial mechanism of lesion development. Spreading depolarizations are increasingly recorded during multimodal neuromonitoring in neurocritical care as a causal biomarker providing a diagnostic summary measure of metabolic failure and excitotoxic injury. Focal ischemia causes spreading depolarization within minutes. Further spreading depolarizations arise for hours to days due to energy supply-demand mismatch in viable tissue. Spreading depolarizations exacerbate neuronal injury through prolonged ionic breakdown and spreading depolarization-related hypoperfusion (spreading ischemia). Local duration of the depolarization indicates local tissue energy status and risk of injury. Regional electrocorticographic monitoring affords even remote detection of injury because spreading depolarizations propagate widely from ischemic or metabolically stressed zones; characteristic patterns, including temporal clusters of spreading depolarizations and persistent depression of spontaneous cortical activity, can be recognized and quantified. Here, we describe the experimental basis for interpreting these patterns and illustrate their translation to human disease. We further provide consensus recommendations for electrocorticographic methods to record, classify, and score spreading depolarizations and associated spreading depressions. These methods offer distinct advantages over other neuromonitoring modalities and allow for future refinement through less invasive and more automated approaches.

Extraction and separation of lactate dehydrogenase inhibitors from Poria cocos (Schw.) Wolf based on a hyphenated technique and in vitro methods

Stroke is one of the most common diseases worldwide. Lactate dehydrogenase inhibitors are widely used in the treatment of ischemic stroke, with natural products considered a promising source of lactate dehydrogenase inhibitors. In this study, ultrafiltration liquid chromatography coupled with mass spectrometry was used for the screening and identification of lactate dehydrogenase inhibitors from Poria cocos. Five lactate dehydrogenase inhibitors were selected: dehydropachymic acid, pachymic acid, dehydrotrametenolic acid, trametenolic acid, and eburicoic acid. The inhibitors were extracted and isolated with purities of 96.75, 98.15, 97.25, 95.46, and 94.88%, respectively, by using a new "hyphenated" strategy of microwave-assisted extraction coupled with counter-current chromatography and centrifugal partition chromatography by a two-phase solvent system of n-hexane/ethyl acetate/ethanol/water at the volume ratio 0.965:1.000:0.936:0.826 v/v/v/v. The bioactivity of the isolated compounds was assessed using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay in PC12 cells. The results also showed that the hyphenated technique of microwave-assisted extraction coupled with counter-current chromatography and centrifugal partition chromatography was an efficient method for the continuous extraction and online isolation of chemical constituents from medicinal herbs. Furthermore, the research route based on the activity screening, extraction, separation, and activity verification of the compounds offered advantages of efficiency, orientation, and objectivity.

Screening and isolation of potential lactate dehydrogenase inhibitors from five Chinese medicinal herbs: Soybean, Radix pueraria, Flos pueraria, Rhizoma belamcandae, and Radix astragali

Stroke is among the leading causes of death and severe disability worldwide. Flavonoids have been extensively used in the treatment of ischemic stroke by reducing lactate dehydrogenase levels and thereby enhancing blood perfusion to the ischemic region. Here, we used ultrafiltration high-performance liquid chromatography coupled with diode array detection and mass spectrometry for the rapid screening and identification of flavonoids from five Chinese medicinal herbs: soybean, Radix pueraria, Flos pueraria, Rhizoma belamcandae, and Radix astragali. Using PC12 cells as a suitable in vitro model of toxicity, cell viability was quantitated using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay. The results showed that the extracts of soybean and the six major components, namely, acetyldaidzin, malonylgenistin, daidiain, glycitin, genistin, and acetylcitin; the extract of R. pueraria and its main component daidzein; the extract of F. pueraria and its three major components, tectorigenin, tectoridin, and tectorigenin-7-O-xylosylglucosid; and the extract of R. belamcandae and its main component, tectoridin, were strong lactate dehydrogenase inhibitors. Also, the components of R. astragali showed no bioactivity. These findings indicate that the ultrafltration high-performance liquid chromatography coupled with diode array detection and mass spectrometry method could be utilized in rapid screening and separation of bioactive compounds from a complex matrix.

Type 2 Diabetes and Hemorrhagic Stroke: A Population-Based Study in Spain from 2003 to 2012

AIM

The objective of this study is to compare trends in outcomes for intracerebral hemorrhagic stroke in people with or without type 2 diabetes in Spain between 2003 and 2012.

METHODS

We selected all patients hospitalized for hemorrhagic stroke using national hospital discharge data. We evaluated annual incident rates stratified by diabetes status. We analyzed trends in the use of diagnostic and therapeutic procedures, patient comorbidities, in-hospital mortality (IHM), length of hospital stay, and readmission rate in 1 month.

RESULTS

We identified a total of 173,979 discharges of patients admitted with hemorrhagic stroke (19.1% with diabetes). Incidences were higher among those with than those without diabetes in all the years studied. Diabetes was positively associated with stroke (incidence rate ratio [IRR] = 1.38, 95% confidence interval [CI] 1.35-1.40 for men; IRR = 1.31, 95% CI 1.29-1.34 for women). Length of stay decreased significantly and readmission rate remained stable for both groups (around 5%). We observed a significant increase in the use of decompressive craniectomy from 2002 to 2013. Mortality was positively associated with older age, with higher comorbidity and atrial fibrillation as risk factors. We found a negative association with the use of decompressive craniectomy. Mortality did not change over time among diabetic men and women. In those without diabetes, mortality decreased significantly over time. Suffering diabetes was not associated with higher mortality.

CONCLUSIONS

Type 2 diabetes is associated with higher incidence of hemorrhagic stroke but not with IHM. Incidence among diabetic people remained stable over time. In both groups, the use of decompressive craniectomy has increased and is associated with a decreased mortality.

Time Trends in Ischemic Stroke among Type 2 Diabetic and Non-Diabetic Patients: Analysis of the Spanish National Hospital Discharge Data (2003-2012)

BACKGROUND

Type 2 Diabetes (T2DM) is the most rapidly increasing risk factor for ischemic stroke. We aimed to compare trends in outcomes for ischemic stroke in people with or without diabetes in Spain between 2003 and 2012.

METHODS

We selected all patients hospitalized for ischemic stroke using national hospital discharge data. We evaluated annual incident rates stratified by T2DM status. We analyzed trends in the use of diagnostic and therapeutic procedures, patient comorbidities, and in-hospital outcomes. We calculated in-hospital mortality (IHM), length of hospital stay (LOHS) and readmission rate in one month after discharge. Time trend on the incidence of hospitalization was estimated fitting Poisson regression models by sex and diabetes variables. In-hospital mortality was analyzed using logistic regression models separate for men and women. LOHS were compared with ANOVA or Kruskal-Wallis when necessary.

RESULTS

We identified a total of 423,475 discharges of patients (221,418 men and 202,057 women) admitted with ischemic stroke as primary diagnosis. Patients with T2DM accounted for 30.9% of total. The estimated incidence rates of discharges increased significantly in all groups. The incidence of hospitalization due to stroke (with ICD9 codes for stroke as main diagnosis at discharge) was higher among those with than those without diabetes in all the years studied. T2DM was positively associated with ischemic stroke with an adjusted incidence rate ratio (IRR) of 2.27 (95% CI 2.24-2.29) for men and 2.15 (95%CI 2.13-2.17) for women. Over the 10 year period LOHS decreased significantly in men and women with and without diabetes. Readmission rate remained stable in diabetic and non diabetic men (around 5%) while slightly increased in women with and without diabetes. We observed a significant increase in the use of fibrinolysis from 2002-2013. IHM was positively associated with older age in all groups, with Charlson Comorbidity Index > 3 and atrial fibrillation as risk factors. The IHM did not change significantly over time among T2DM men and women ranging from 9.25% to 10.56% and from 13.21% to 14.86%, respectively; neither did among non-diabetic women. However, in men without T2DM IHM decreased significantly over time. Diabetes was associated to higher IHM only in women (OR 1.07; 95% CI, 1.05-1.11).

CONCLUSIONS

Our national data show that incidence rate of ischemic stroke hospitalization increased significantly during the period of study (2003-2012). People with T2DM have more than double the risk of ischemic stroke after adjusting for other risk factors. Women with T2DM had poorer outcomes- IHM and readmission rates- than diabetic men. Diabetes was an independent factor for IHM only in women.

Brain health and shared risk factors for dementia and stroke

Impaired brain health encompasses a range of clinical outcomes, including stroke, dementia, vascular cognitive impairment, cognitive ageing, and vascular functional impairment. Conditions associated with poor brain health represent leading causes of global morbidity and mortality, with projected increases in public health burden as the population ages. Many vascular risk factors are shared predictors for poor brain health. Moreover, subclinical brain MRI markers of vascular damage are risk factors shared between stroke and dementia, and can be used for risk stratification and early intervention. The broad concept of brain health has resulted in a conceptual shift from vascular risk factors to determinants of brain health. Global campaigns to reduce cardiovascular diseases by targeting modifiable risk factors are necessary and will have a broad impact on brain health. Research is needed on the distinct and overlapping aetiologies of brain health conditions, and to define MRI markers to help clinicians identify patients who will benefit from aggressive prevention measures.

Association Between TRAF6 Gene Polymorphisms and Susceptibility of Ischemic Stroke in Southern Chinese Han Population

The tumor necrosis factor receptor-associated factor 6 (TRAF6) gene encodes a protein that acts downstream of the Toll-like receptor (TLR) pathway. TLRs activate inflammatory cascades and mediate inflammatory injury after cerebral ischemia. However, the role of TFAR6 gene polymorphisms in ischemic stroke (IS) remains unknown. This study aims to investigate the associations of TRAF6 gene polymorphisms with susceptibility to IS and IS-related quantitative traits in Southern Chinese Han population. A total of 816 IS cases and 816 age- and gender-matched controls were included. Two variants of the TRAF6 gene (rs5030411 and rs5030416) were genotyped using the Sequenom MassARRAY iPLEX platform. Our study showed that rs5030416 was significantly associated with increased susceptibility to IS in the additive model [ORadj 1.25(1.04-1.51), P adj = 0.019, P Bc = 0.038] and dominant model [ORadj 1.23(1.04-1.60), P adj = 0.021, P Bc = 0.042] after adjusting by age and sex and applying a Bonferroni correction. No significant association was found between rs5030411 and IS susceptibility (all P > 0.05). The haplotype rs5030416 (allele C)-rs5030411 (allele C) was significantly associated with IS susceptibility (P adj = 0.015). Moreover, a significant association of rs5030411 with TC levels in IS patients under the additive model [β 0.16(0.01-0.30), P adj = 0.034] and recessive model [β 0.45(0.12-0.78), P adj = 0.007] was observed after adjustment by age and sex. This association remained statistically significant under the recessive model (P Bc = 0.042) after Bonferroni correction. Our results suggest that TRAF6 gene polymorphisms may be involved in the pathogenesis of IS.