Surveillance of stroke: a South-East Asia Region (SEAR) perspective

Surveillance of stroke is critical to track its burden and assess progress in prevention and treatment. We reviewed the literature to evaluate stroke surveillance efforts in the South-East Asia Region (SEAR) countries, identify progress and assess gaps. Epidemiological data on all the major parameters such as the incidence, prevalence and mortality of stroke were available for India and Thailand but for none of the other SEAR countries. Most of the epidemiological data came from investigator-initiated studies. National stroke surveillance was present only in India in the form of a National Stroke Registry Programme and Thailand has a national database that was used to obtain epidemiological data for stroke. Research on novel methods for stroke registration, such as using information technology, was absent. This review identified serious gaps in the monitoring and surveillance of stroke in SEAR countries. Systematic efforts are needed to fill those gaps.

A prospective population-based study of stroke in the Central Region of Iran: The Qom Incidence of Stroke Study

OBJECTIVE

Based on the few population-based studies that have been conducted in the Middle East, we determined the incidence of stroke in Qom, one of the central provinces of Iran.

METHODS

The Qom province includes an estimated at-risk population of about 1 million. During a 12-month period (November 2018-November 2019), all first-ever strokes occurring in the target population were registered. Hospitalized cases were ascertained by discharge codes. Out-of-hospital cases were ascertained by a prospective screening of emergency medical services, emergency departments, ambulances records, primary care clinics, rural and urban public health centers, primary care physician offices, and neurologists' offices. Crude and age-adjusted incidence rates (per 100,000 person-years) were calculated.

RESULTS

During the study period, 1462 first-ever strokes occurred with a mean age of 68.1 (17-103) years; of these 45.2% were females (661 cases). The crude annual incidence rate per 100,000 at-risk populations was 145.4 (95% confidence interval, 138.1-153.0) for all types of stroke (156.5 for males and 134.3 for females), 26.4 (95% confidence interval, 23.5-29.8) for hemorrhagic stroke, and 114 (95% confidence interval, 105-121) for ischemic stroke. The incidence rate adjusted to the world population was 201.4 (95% confidence interval, 193-210) per 100,000 at-risk populations (adj incidence, 218.5 for males vs 187.4 for females). The total fatality rate during the first 28 days was 19.6%.

CONCLUSION

This study states that in this region there is a high incidence of stroke, which occurs at a younger age than the global average. There was a high prevalence of underlying stroke risk factors.

Incidence & prevalence of stroke in India: A systematic review

BACKGROUND & OBJECTIVES

There has been more than 100 per cent increase in incidence of stroke in low- and middle-income countries including India from 1970-1979 to 2000-2008. Lack of reliable reporting mechanisms, heterogeneity in methodology, study population, and small sample size in existing epidemiological studies, make an accurate estimation of stroke burden in India challenging. We conducted a systematic review of epidemiologic studies on stroke conducted in India to document the magnitude of stroke.

METHODS

All population-based, cross-sectional studies and cohort studies from India which reported the stroke incidence rate or cumulative stroke incidence and/or the prevalence of stroke in participants from any age group were included. Electronic databases (Ovid, PubMed, Medline, Embase and IndMED) were searched and studies published during 1960 to 2015 were included. A total of 3079 independent titles were identified for screening, of which 10 population-based cross-sectional studies were considered eligible for inclusion. Given the heterogeneity of the studies, meta-analysis was not carried out.

RESULTS

The cumulative incidence of stroke ranged from 105 to 152/100,000 persons per year, and the crude prevalence of stroke ranged from 44.29 to 559/100,000 persons in different parts of the country during the past decade. These values were higher than those of high-income countries.

INTERPRETATION & CONCLUSIONS

A paucity of good-quality epidemiological studies on stroke in India emphasizes the need for a coordinated effort at both the State and national level to study the burden of stroke in India. Future investment in the population-based epidemiological studies on stroke would lead to better preventive measures against stroke and better rehabilitation measures for stroke-related disabilities in the country.

Utility of single-energy and dual-energy computed tomography in clot characterization: An in-vitro study

Background and purpose Because computed tomography (CT) is the most commonly used imaging modality for the evaluation of acute ischemic stroke patients, developing CT-based techniques for improving clot characterization could prove useful. The purpose of this in-vitro study was to determine which single-energy or dual-energy CT techniques provided optimum discrimination between red blood cell (RBC) and fibrin-rich clots. Materials and methods Seven clot types with varying fibrin and RBC densities were made (90% RBC, 99% RBC, 63% RBC, 36% RBC, 18% RBC and 0% RBC with high and low fibrin density) and their composition was verified histologically. Ten of each clot type were created and scanned with a second generation dual source scanner using three single (80 kV, 100 kV, 120 kV) and two dual-energy protocols (80/Sn 140 kV and 100/Sn 140 kV). A region of interest (ROI) was placed over each clot and mean attenuation was measured. Receiver operating characteristic curves were calculated at each energy level to determine the accuracy at differentiating RBC-rich clots from fibrin-rich clots. Results Clot attenuation increased with RBC content at all energy levels. Single-energy at 80 kV and 120 kV and dual-energy 80/Sn 140 kV protocols allowed for distinguishing between all clot types, with the exception of 36% RBC and 18% RBC. On receiver operating characteristic curve analysis, the 80/Sn 140 kV dual-energy protocol had the highest area under the curve for distinguishing between fibrin-rich and RBC-rich clots (area under the curve 0.99). Conclusions Dual-energy CT with 80/Sn 140 kV had the highest accuracy for differentiating RBC-rich and fibrin-rich in-vitro thrombi. Further studies are needed to study the utility of non-contrast dual-energy CT in thrombus characterization in acute ischemic stroke.

Challenges in understanding the epidemiology of acquired brain injury in India

An acquired brain injury (ABI) is an injury to the brain, which is not hereditary, congenital, degenerative, or induced by birth trauma. In India, rapid urbanization, economic growth and changes in lifestyle have led to a tremendous increase in the incidence of ABI, so much so that it is being referred to as a 'silent epidemic'. Unlike developed countries, there is no well-established system for collecting and managing information on various diseases in India. Thus it is a daunting task to obtain reliable information about acquired brain injury. In the course of conducting a systematic review on the epidemiology of ABI in India, we recognized several challenges which hampered our effort. Inadequate case definition, lack of centralized reporting mechanisms, lack of population based studies, absence of standardized survey protocols and inadequate mortality statistics are some of the major obstacles. Following a standard case definition, linking multiple hospital-based registries, initiating a state or nationwide population-based registry, conducting population-based studies that are methodologically robust and introducing centralized, standard reporting mechanisms for ABI, are some of the strategies that could help facilitate a thorough investigation into the epidemiology and understanding of ABI. This may help improve policies on prevention and management of acquired brain injury in India.

Speech pathology services for people with aphasia: what is the current practice in Singapore?

PURPOSE

This study reports on current provision of aphasia services by speech pathologists in Singapore.

METHOD

A 44-item web-based survey was conducted looking into areas of service delivery, assessment, cultural and linguistic adaptations, clinical approaches, education of clients, recovery, goal setting and discharge as well as scope and challenges to practice.

RESULTS

A total of 36 surveys were completed representing approximately 86% of the potential target population. The intensity of aphasia services provided was well below that recommended by the literature. Participants reported embracing approaches to aphasia rehabilitation that spanned across the ICF domains. Numerous challenges were reported in providing aphasia services. These included the lack of locally relevant resources for aphasia, lack of family support and patient motivation, manpower shortages as well as barriers such as transport and cost restricting access to services.

CONCLUSIONS

This research reveals several findings with considerable implications for practice planning and future direction in aphasia rehabilitation. There is a need for the development of locally relevant aphasia resources to enable comprehensive provision of aphasia services. In addition, further investigation is required to tackle the resource challenges faced by the profession and improve community support for people with aphasia. Implications for Rehabilitation Speech pathology services for aphasia in Singapore This article has identified the challenges of providing aphasia services in the Singapore context. Further investigation is required to address the key issues to improve aphasia services in Singapore. This includes developing locally relevant resources, looking at means like telerehabilition to tackle resource challenges, and improving community support for people with aphasia.