Stroke incidence and subtypes in Aboriginal people in remote Australia: a healthcare network population-based study

First stroke incidence, causes, treatments, and outcomes for Aboriginal Peoples in South Australia and the Northern Territory: a pilot prospective study

OBJECTIVE

We performed a pilot stroke incidence study, focused on feasibility and inclusion of the CONSIDER reporting guidelines, to model the design of a future population-based study aiming to definitively determine stroke incidence, antecedents, treatment, and outcomes.

STUDY DESIGN

Prospective stroke incidence study (pilot study).

SETTING, PARTICIPANTS

All people aged 15 years or older who lived in postcode-defined areas of South Australia and Northern Territory (885 472 people, including 45 127 Aboriginal people [5.1%]) diagnosed with stroke for the first time during 1 October - 31 December 2015 and admitted to public hospitals or stroke and transient ischaemic attack clinics.

MAIN OUTCOME MEASURES

Feasibility of a prospective population-based stroke incidence study.

RESULTS

Of the 123 participants with first strokes, ten were Aboriginal (8%); the median age of Aboriginal people was 45 years (interquartile range [IQR], 33-55 years), of non-Indigenous people 73 years (IQR, 62-84 years). For Aboriginal people, the age-standardised incidence of stroke was 104 (95% confidence interval [CI], 84-124) per 100 000 person-years, for non-Indigenous people 33 (95% CI, 22-44) per 100 000 person-years. We found that a prospective population-based stroke incidence study in Aboriginal people was feasible, including with respect to establishing an adequate sample size, diagnostic confirmation, identification of incident stroke, confirming stroke subtypes, establishing a stable statistical population, standardising data reporting for comparison with other stroke incidence studies, and ethical research reporting that conforms to CONSIDER guidelines.

CONCLUSIONS

A larger, population-based study of the incidence of stroke in Aboriginal people is both feasible and needed to provide robust estimates of stroke incidence, antecedents, treatments and outcomes to help guide strategies for reducing the risk of and outcomes of stroke in Aboriginal people.

Healing Right Way randomised control trial enhancing rehabilitation services for Aboriginal people with brain injury in Western Australia: translation principles and activities

Background This report provides the theory, method and practice of culturally secure translation and knowledge exchange in the Healing Right Way Clinical Trial (2017-2022), outlining activities to date. Healing Right Way was a stepped wedge cluster randomised controlled trial conducted in Western Australia, aimed at enhancing rehabilitation services and quality of life for Aboriginal Australians following acquired brain injury. The trial translation plan was aspirational and action-oriented, with its implementation iterative and ongoing. Translational activities aimed to inform service and research planning for Aboriginal people with brain injury. Situated in the intercultural space, the work guards against undertaking activities that are monocultural, colonial and appropriating in favour of work that is authentically viewed through the dual lens of whiteness and Aboriginal and Torres Strait Islander ways of knowing, being and doing, and is strengths-based. Methods Three translational and knowledge exchange components were identified, relating to the role of Aboriginal Brain Injury Coordinators, cultural training of hospital staff and the research process itself. Knowledge plans were developed for key audiences, with potential translation products to be monitored for ongoing impact. Results Results demonstrate that translational and knowledge exchange were iteratively embedded throughout the trial life cycle. Data sources included community engagement, partnership meetings and interviews. Activities involved presentations to diverse audiences including bureaucrats, community and participants. Conclusions This report provides a snapshot of the first translation knowledge exchange plan and activities constructed in relation to brain injury rehabilitation services for Aboriginal people. Challenges encountered, as well as successes to date, are discussed.

Incidence of Stroke in Indigenous Populations of Countries With a Very High Human Development Index: A Systematic Review

BACKGROUND AND OBJECTIVES

Cardiovascular disease contributes significantly to disease burden among many Indigenous populations. However, data on stroke incidence in Indigenous populations are sparse. We aimed to investigate what is known of stroke incidence in Indigenous populations of countries with a very high Human Development Index (HDI), locating the research in the broader context of Indigenous health.

METHODS

We identified population-based stroke incidence studies published between 1990 and 2022 among Indigenous adult populations of developed countries using PubMed, Embase, and Global Health databases, without language restriction. We excluded non-peer-reviewed sources, studies with fewer than 10 Indigenous people, or not covering a 35- to 64-year minimum age range. Two reviewers independently screened titles, abstracts, and full-text articles and extracted data. We assessed quality using "gold standard" criteria for population-based stroke incidence studies, the Newcastle-Ottawa Scale for risk of bias, and CONSIDER criteria for reporting of Indigenous health research. An Indigenous Advisory Board provided oversight for the study.

RESULTS

From 13,041 publications screened, 24 studies (19 full-text articles, 5 abstracts) from 7 countries met the inclusion criteria. Age-standardized stroke incidence rate ratios were greater in Aboriginal and Torres Strait Islander Australians (1.7-3.2), American Indians (1.2), Sámi of Sweden/Norway (1.08-2.14), and Singaporean Malay (1.7-1.9), compared with respective non-Indigenous populations. Studies had substantial heterogeneity in design and risk of bias. Attack rates, male-female rate ratios, and time trends are reported where available. Few investigators reported Indigenous stakeholder involvement, with few studies meeting any of the CONSIDER criteria for research among Indigenous populations.

DISCUSSION

In countries with a very high HDI, there are notable, albeit varying, disparities in stroke incidence between Indigenous and non-Indigenous populations, although there are gaps in data availability and quality. A greater understanding of stroke incidence is imperative for informing effective societal responses to socioeconomic and health disparities in these populations. Future studies into stroke incidence in Indigenous populations should be designed and conducted with Indigenous oversight and governance to facilitate improved outcomes and capacity building.

REGISTRATION INFORMATION

PROSPERO registration: CRD42021242367.

Temporal and age-specific trends in incidence and 1-year case-fatality of hospitalized ischaemic stroke in Victoria, Australia

OBJECTIVES

Investigate temporal and age-specific trends in the incidence of ischaemic stroke and case-fatality risk in Victoria, Australia.

MATERIALS AND METHODS

Patients hospitalised with first ischaemic stroke between 2012 and 2018 were included. Trends in age-standardised incidence rates of ischaemic stroke were assessed using linear regression models. Cox proportional hazard regression models were used to examine the case-fatality risk.

RESULTS

Overall age-standardised incidence of ischaemic stroke was stable from 2012/13 to 2017/18 (87.6 to 84.8 events per 100,000 population; Annual percentage change [APC] -0.32; 95% Confidence interval [CI] -1.13 to 0.50). The incidence declined in females (APC -1.00; 95% CI -1.49 to -0.50), people aged 75-84 years (APC -1.60; 95% CI -2.83 to -0.36) and in metropolitan areas (APC -0.74; 95% CI -1.02 to -0.45). The risk of 1-year case-fatality (HR 0.85; 95% CI 0.78 to 0.93) significantly declined in 2016/17 compared to 2012/13.

CONCLUSIONS

Overall ischaemic stroke incidence remained stable while decreasing trends were observed in females, elderly and metropolitan areas. 1-year case-fatality declined from 2012 to 2017.

Incidence and epidemiology of aneurysmal subarachnoid haemorrhage in Australian Aboriginal and Torres Strait Islanders; a ten-year population study

Health disparity between Aboriginal and Torres Strait Islander (ATSI) Australians and non ATSI Australians is well established. Incidence and epidemiology of aneurysmal subarachnoid haemorrhage (aSAH) in the ATSI population is less well described. An observational, cross-sectional study was conducted to identify all acute spontaneous subarachnoid haemorrhage in the Hunter New England and Mid North Coast population of New South Wales, Australia. Population and baseline information was obtained from the Australian Consens data. The size of the population was 1.1 million. Over the 9.8 year period, 959 admissions for subarachnoid haemorrhage were identified, of which, 531 were due to aneurysm rupture. The ATSI population represented 6 % of the study population and had a higher incidence of aSAH (11.5 per 100,000 person years' vs 5.8 per 100,000 person years). The mean age at presentation was 8.6 years younger than the non-ATSI group (48.8 years vs 57.4 years). The ATSI population had higher rates of smoking and family history of aneurysms, but lower rates of premorbid hypertension. The overall rate of hospitalization for aneurysmal subarachnoid haemorrhage was higher in the indigenous Australian group, especially in younger patients. Higher smoking rates could be a contributing factor.

Statistical analysis plan for the stepped wedge clinical trial Healing Right Way-enhancing rehabilitation services for Aboriginal Australians after brain injury

BACKGROUND

Aboriginal Australians are known to suffer high levels of acquired brain injury (stroke and traumatic brain injury) yet experience significant barriers in accessing rehabilitation services. The aim of the Healing Right Way trial is to evaluate a culturally secure intervention for Aboriginal people with newly acquired brain injury to improve their rehabilitation experience and quality of life. Following publication of the trial protocol, this paper outlines the statistical analysis plan prior to locking the database.  METHODS: The trial involves a stepped wedge design with four steps over 3 years. Participants were 108 adult Aboriginal Australians admitted to one of eight hospitals (four rural, four urban) in Western Australia within 6 weeks of onset of a new stroke or traumatic brain injury who consented to follow-up for 26 weeks. All hospital sites started in a control phase, with the intervention assigned to pairs of sites (one metropolitan, one rural) every 26 weeks until all sites received the intervention. The two-component intervention involves training in culturally safe care for hospital sites and enhanced support provided to participants by Aboriginal Brain Injury Coordinators during their hospital stay and after discharge. The primary outcome is quality of life as measured by the Euro QOL-5D-3L VAS. A mixed effects linear regression model will be used to assess the between-group difference at 26 weeks post-injury. The model will control for injury type and severity, age at recruitment and time since commencement of the trial, as fixed effects. Recruitment site and participant will be included as random effects. Secondary outcomes include measurements of function, independence, anxiety and depression, carer strain, allied health occasions of service received and hospital compliance with minimum processes of care based on clinical guidelines and best practice models of care.

DISCUSSION

The trial will provide the first data surrounding the effectiveness of an intervention package for Aboriginal people with brain injury and inform future planning of rehabilitation services for this population. The statistical analysis plan outlines the analyses to be undertaken.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry ACTRN12618000139279. Registered 30 January, 2018.

Aneurysmal subarachnoid haemorrhage in Indigenous and non-Indigenous Australians: A retrospective study assessing patient characteristics and outcome

INTRODUCTION

Smoking and hypertension are prevalent among Indigenous Australians (Aboriginal and Torres Strait Islanders). We investigated if these risk factors suggest a greater rate of aneurysmal subarachnoid haemorrhage in Indigenous Australians (IA) compared to non-IA.

MATERIALS AND METHODS

A retrospective cross-sectional study was performed on data retrieved from the Nationwide Hospital Morbidity Database for all aSAH cases in Australia between 2012 and 2018. Patient characteristics, radiological findings, aneurysm characteristics, treatment characteristics and discharge outcomes were assessed. Crude and age-adjusted incidences, trends of aSAH and case fatality rate over time were calculated.

RESULTS

A total of 12,286 patients were included (285 IA, 12,001 non-IA). Indigenous aSAH patients were significantly younger than non-IA, with 89.8 percent of IA younger than 65 years old (p < 0.001). Crude annual incidences were similar between the 2 cohorts, however age-adjusted incidence shows a RR = 1.4 at 45-59 years in IA patients, compared with their non-IA counterparts. 30-day mortality was similar between the two groups, at 25.3 and 26.9% for IA and non-IA groups, respectively.

CONCLUSION

This 10 year nationwide retrospective study highlights a disparity between the crude and age-adjusted incidence of aSAH in IA compared to non-IA.

Glycemic profile and associated factors in indigenous Munduruku, Amazonas

OBJECTIVE

To evaluate the glycemic profile and its association with sociodemographic, anthropometric, clinical and lifestyle factors of Munduruku indigenous people.

METHOD

Cross-sectional study with a quantitative and analytical approach, a total of 459 indigenous people (57.1% men, aged 36.3 ± 14.7 years old) belonging to the Munduruku ethnic group from the Kwatá-Laranjal Indigenous Land, in Amazonas, Brazil, were selected by probabilistic sampling in all households in the four most populous villages. Sociodemographic and anthropometric variables, blood pressure levels and lipid profile were evaluated. Fasting capillary blood glucose was measured with a digital device. The associations were assessed by multinomial logistic regression, and p-values≤0.05 were considered significant.

RESULTS

For pre-diabetes, prevalence was 74.3% and, for diabetes, 12.2%. The variables associated with the risk for pre-diabetes were the following: age (OR = 1.03; 95% CI = 1.00 - 1.06) and obesity (OR = 9.69; 95% CI = 1.28 - 73.58). The positive associations indicating risk for diabetes were as follows: age (OR = 1.05; 95% CI = 1.03 - 1.08), overweight (OR = 4.17; 95% CI = 1.69 - 10.32) and obesity (OR = 35.26; 95% CI = 4.12 - 302.08).

CONCLUSIONS

The risks associated with pre-diabetes and diabetes among the Munduruku indigenous people revealed a worrying index. It is necessary to consider changes in eating habits and lifestyle, as well as possible environmental and social changes that can affect this and other groups, with emphasis on those who live in vulnerable conditions.

Patients characteristics and health outcomes in patients hospitalized with hypomagnesemia: a retrospective study from a single center in the Northern Territory of Australia

AIM

This research aimed to study the clinical and biochemical characteristics and health outcomes of patients admitted and found to have hypomagnesemia in an Australian hospital with a high proportion of Indigenous Australians.

METHODS

A retrospective cohort study was conducted of all patients with hypomagnesemia hospitalised between 1st August 2008 and 31st December 2014 at Royal Darwin Hospital (RDH). All relevant demographic, clinical, and biochemical were collected from patients' medical records. The hospital database was reviewed in January 2018 for mortality of all included patients.

RESULTS

876 patients had been admitted with a confirmed diagnosis of hypomagnesemia during the study period, with mean follow up period of 4.0 ±2.7 years. The mean age at admission was 52.4 ± 19.1 years, 52.2% were females and, 56.5% were Indigenous Australians. Chronic kidney disease (99.7%), excessive alcohol consumption (45.7%), hypertension (43.9%), and respiratory diseases (15.0%) were the most common conditions in these patients. Hypomagnesemia was associated with prolonged length of hospital stay. Most patients did not receive treatment for hypomagnesaemia during admission. During the follow-up period, 38.6% of patients died, and the most common causes of death were malignancies (29.9%).

CONCLUSION

Hypomagnesemia was a common and under-treated condition in hospitalised patients and was associated with poor health outcomes. Therefore, hospitals should develop guidelines for replacing and monitoring magnesium levels during hospitalisation, achieving better outcomes. This article is protected by copyright. All rights reserved.

Atrial Fibrillation in Remote Indigenous and Non-Indigenous Individuals Hospitalised in Central Australia

BACKGROUND

The epidemiology of atrial fibrillation (AF) amongst Indigenous populations remains poorly characterised. We studied hospitalisations for AF in Central Australia, the most populous Indigenous region in the country.

METHODS

Patients with a diagnosis of AF admitted to Alice Springs Hospital, the only secondary health care facility and provider of cardiac care in remote Central Australia, were identified from 2006 to 2016. Age and gender-specific hospitalised AF prevalence, comorbidities, and CHA₂DS₂-VASc scores were ascertained.

RESULTS

Of 57,056 admitted patients over the study period, 1,210 (2.1%; 46% Indigenous) had a diagnosis of AF. For Indigenous and non-Indigenous individuals <45 years, hospitalised AF prevalence per 10,000 population was 105 (CI 84-131) and 50 (CI 36-68) in males (ratio=2.10), and 98 (CI 77-123) and 12 (CI 6-23) in females (ratio=7.92), respectively. For Indigenous and non-Indigenous individuals ≥65 years, hospitalised AF prevalence per 10,000 was 1,577 (CI 1,194-2,026) and 2,326 (CI 2,047-2,623) in males (ratio=0.68), and 1,713 (CI 1,395-2,069) and 1,897 (1,623-2,195) in females (ratio=0.90). Indigenous individuals had higher rates of cardiometabolic comorbidities, particularly at younger ages. CHA₂DS₂-VASc scores were greater in Indigenous individuals, particularly those <45 years (2.5±1.5 versus 0.7±1.1, p<0.001).

CONCLUSIONS

The prevalence of hospitalised AF amongst Indigenous people in remote Central Australia was significantly higher than in non-Indigenous individuals, particularly in younger age groups and females. Indigenous individuals with hospitalised AF also had a markedly greater prevalence of cardiometabolic comorbidities and elevated stroke risk. These data suggest that AF may be contributing to the gap in morbidity and mortality experienced by Indigenous Australians.