Hospitalized stroke in blacks and Hispanics in northern Manhattan

Health Care Disparities in Stroke Rehabilitation

Stroke outcomes are influenced by factors such as education, lifestyle, and access to care, which determine the extent of functional recovery. Disparities in stroke rehabilitation research have traditionally included age, race/ethnicity, and sex, but other areas make up a gap in the literature. This article conducted a literature review of original research articles published between 2008 and 2022. The article also expands on research that highlights stroke disparities in risk factors, rehabilitative stroke care, language barriers, outcomes for stroke survivors, and interventions focused on rehabilitative stroke disparities.

Association Between Ischemic Stroke Subtype and Stroke Severity: The Atherosclerosis Risk in Communities Study

BACKGROUND AND OBJECTIVES

Disability after stroke occurs across ischemic stroke subtypes, with a suggestion that embolic strokes are more devastating. Whether this difference is as a result of differences in comorbidities or differences in severity at the time of the stroke event is not known. The primary hypothesis was that participants with embolic stroke would have more severe stroke at the time of admission and a higher risk of mortality, compared with thrombotic stroke participants even with consideration of confounders over time, with a secondary hypothesis that this association would differ by race and sex.

METHODS

Atherosclerosis Risk in Communities (ARIC) study participants with incident adjudicated ischemic stroke, stroke severity and mortality data, and complete covariates were included. Multinomial logistic regression models determined the association between stroke subtype (embolic vs thrombotic) and admission NIH Stroke Scale (NIHSS) category (minor [≤5], mild [6-10], moderate [11-15], severe [16-20], and very severe [>20]) adjusted for covariates from visits most proximal to the stroke. Separate ordinal logistic models evaluated for interaction by race and sex. Adjusted Cox proportional hazard models estimated the association between stroke subtype and all-cause mortality (through December 31, 2019).

RESULTS

Participants (N = 940) were mean age 71 years (SD = 9) at incident stroke, 51% female, and 38% Black. Using adjusted multinomial logistic regression, the risk of having a more severe stroke (reference NIHSS ≤5) was higher among embolic stroke vs thrombotic stroke patients, with a step-wise increase for embolic stroke patients when moving from mild (odds ratio [OR] 1.95, 95% CI 1.14-3.35) to very severe strokes (OR 4.95, 95% CI 2.34-10.48). After adjusting for atrial fibrillation, there was still a higher risk of having a worse NIHSS among embolic vs thrombotic strokes but with attenuation of effect (very severe stroke OR 3.91, 95% CI 1.76-8.67). Sex modified the association between stroke subtype and severity (embolic vs thrombotic stroke, p interaction = 0.03, per severity category, females OR 2.38, 95% CI 1.55-3.66; males OR 1.75, 95% CI 1.09-2.82). The risk of death (median follow-up 5 years, interquartile range 1-12) was also increased for embolic vs thrombotic stroke patients (hazard ratio 1.66, 95% CI 1.41-1.97).

DISCUSSION

Embolic stroke was associated with greater stroke severity at the time of the event and a higher risk of death vs thrombotic stroke, even after careful adjustment for patient-level differences.

Cumulative rehospitalizations and implications for subsequent mortality after first-ever ischemic stroke

INTRODUCTION

Clinical implications of readmission following initial hospitalization for acute ischemic stroke (AIS) are not known. We examined predictors of readmissions and impact of readmissions on subsequent mortality after first-ever AIS.

MATERIALS AND METHODS

Adults aged ≥18 years who survived to discharge after hospitalization for first-ever AIS from 2003 to 2019 were included in the study. For each patient, the overall burden of hospitalizations was measured as total number of hospitalizations and aggregate days spent hospitalized during follow-up. We used Poisson regression to estimate incident rate ratios (IRR) for predictors of re-hospitalization and time-dependent Cox regression to estimate hazard ratios (HR) for mortality.

RESULTS

Of 908 AIS survivors, 537 died, 669 had 2,645 readmissions over 4,535 person-years follow-up. Adjusted independent predictors of cumulative readmission inlcuded being white (IRR 1.21, 95% CI 1.03-1.42), dependency on discharge (IRR 1.27, 95% CI 1.17-1.38), cardio-embolism (IRR 1.35, 95% CI 1.18-1.45), smoking (IRR 1.21, 95% CI 1.08-1.35), anemia (IRR 1.40, 95% CI 1.24-1.57), arthritis (IRR 1.20, 95% CI 1.10-1.31), coronary artery disease (IRR 1.34, 95% CI 1.23-1.47), cancer (IRR 1.96, 95% CI 1.64-2.30), chronic kidney disease (IRR 1.36, 95% CI 1.21-1.57), COPD (IRR 1.18, 95% CI 1.04-1.34), depression (IRR 1.50, 95% CI 1.37-1.66), diabetes mellitus (IRR 1.48, 95% CI 1.36-1.48), and heart failure (IRR 1.17, 95% CI 1.03-1.34). Conversely, hyperlipidemia was associated with a lower risk of readmission (IRR 0.79, 95% CI 0.71-0.88). Mortality was significantly increased with each hospitalization and cumulative days spent in hospital.

CONCLUSIONS

Among survivors of AIS hospitalization, certain sociodemographic indicators, stroke-specific features, and several key comorbid conditions were associated with increased risk of readmissions, which in turn correlated with increased mortality. Therefore, lifestyle modification and optimal treatment of comorbidities are likely to improve the outcome after AIS.

Using machine learning to estimate the effect of racial segregation on COVID-19 mortality in the United States

This study examines the role that racial residential segregation has played in shaping the spread of COVID-19 in the United States as of September 30, 2020. The analysis focuses on the effects of racial residential segregation on mortality and infection rates for the overall population and on racial and ethnic mortality gaps. To account for potential confounding, I assemble a dataset that includes 50 county-level factors that are potentially related to residential segregation and COVID-19 infection and mortality rates. These factors are grouped into eight categories: demographics, density and potential for public interaction, social capital, health risk factors, capacity of the health care system, air pollution, employment in essential businesses, and political views. I use double-lasso regression, a machine learning method for model selection and inference, to select the most important controls in a statistically principled manner. Counties that are 1 SD above the racial segregation mean have experienced mortality and infection rates that are 8% and 5% higher than the mean. These differences represent an average of four additional deaths and 105 additional infections for each 100,000 residents in the county. The analysis of mortality gaps shows that, in counties that are 1 SD above the Black-White segregation mean, the Black mortality rate is 8% higher than the White mortality rate. Sensitivity analyses show that an unmeasured confounder that would overturn these findings is outside the range of plausible covariates.

Epidemiology of Stroke in Costa Rica: A 7-Year Hospital-Based Acute Stroke Registry of 1319 Consecutive Patients

BACKGROUND

Limited data on stroke exist for Costa Rica. Therefore, we created a stroke registry out of patients with stroke seen in the Acute Stroke Unit of the Hospital Calderon Guardia.

METHODS

We analyzed 1319 patients enrolled over a 7-year period, which incorporated demographic, clinical, laboratory, and neuroimaging data.

RESULTS

The mean age of patients with stroke was 68.0 ± 15.5 years. Seven hundred twenty-five were men and the age range was 13-104 years. The most prevalent risk factors were hypertension (78.8%), dyslipidemia (36.3%), and diabetes (31.9%). Fifteen percent had atrial fibrillation and 24.7% had a previous stroke or transient ischemic attack. Prevalence of hypertension and atrial fibrillation increased with age; however, younger patients were more associated with thrombophilia. We documented 962 (72.9%) ischemic and 270 (20.5%) hemorrhagic strokes. Of the ischemic strokes, 174 (18.1%) were considered secondary to large-artery atherothrombosis, 175 (18.2%) were due to cardiac embolism, 19 (2.0%) were due to lacunar infarcts, and 25 (2.6%) were due to other determined causes. Five hundred sixty-nine (59.1%) remained undetermined. Atherothrombotic strokes were mostly associated with dyslipidemia, diabetes, metabolic syndrome, and obesity, whereas lacunar infarcts were associated with hypertension, smoking, sedentary lifestyle, and previous stroke or transient ischemic attack. Of our patients, 69.9% scored between 0 and 9 in the initial National Institutes of Health Stroke Scale (NIHSS).

CONCLUSIONS

We found differences in sociodemographic features, risk factors, and stroke severity among stroke subtypes. Risk factor prevalence was similar to other registries involving Hispanic populations.

Systematic Review of Hospital Readmissions in Stroke Patients

Background. Previous evidence on factors and causes of readmissions associated with high-impact users of stroke is scanty. The aim of the study was to investigate common causes and pattern of short- and long-term readmissions stroke patients by conducting a systematic review of studies using hospital administrative data. Common risk factors associated with the change of readmission rate were also examined. Methods. The literature search was conducted from 15 February to 15 March 2016 using various databases, such as Medline, Embase, and Web of Science. Results. There were a total of 24 studies (n = 2,126,617) included in the review. Only 4 studies assessed causes of readmissions in stroke patients with the follow-up duration from 30 days to 5 years. Common causes of readmissions in majority of the studies were recurrent stroke, infections, and cardiac conditions. Common patient-related risk factors associated with increased readmission rate were age and history of coronary heart disease, heart failure, renal disease, respiratory disease, peripheral arterial disease, and diabetes. Among stroke-related factors, length of stay of index stroke admission was associated with increased readmission rate, followed by bowel incontinence, feeding tube, and urinary catheter. Conclusion. Although risk factors and common causes of readmission were identified, none of the previous studies investigated causes and their sequence of readmissions among high-impact stroke users.

Complications following incident stroke resulting in readmissions: an analysis of data from three Scottish health surveys

BACKGROUND AND AIMS

Stroke is widely recognized as the major contributor to morbidity and mortality in the United Kingdom. We analyzed the data obtained from the three consecutive Scottish Health Surveys and the Scottish Morbidity records, with the aim of identifying risk factors for, and timing of, common poststroke complications.

METHODS

There were 19434 individuals sampled during three Scottish Health Surveys in 1995, 1998, and 2001. For these individuals their morbidity and mortality outcomes were obtained in 2007. Incident stroke prevalence, risk factors for a range of poststroke complications, and average times until such complications in the sample were established.

RESULTS

Of the total of 168 incident stroke admissions (0·86% of the survey), 16·1% people died during incident stroke hospitalization. Of the remaining 141 stroke survivors, 75·2% were rehospitalized at least once. The most frequent reason for readmission after stroke was a cardiovascular complication (28·6%), median time until event 1412 days, followed by infection (17·3%, median 1591 days). The risk of cardiovascular readmission was higher in those with 'poor' self-assessed health (odds ratio 7·70; 95% confidence interval 1·64-43·27), smokers (odds ratio 4·24; 95% confidence interval 1·11-21·59), and doubled with every five years increase in age (odds ratio 1·97; 95% confidence interval 1·46-2·65). 'Poor' self-assessed health increased chance of readmission for infection (odds ratio 14·11; 95% confidence interval 2·27-276·56).

CONCLUSIONS

Cardiovascular events and infections are the most frequent poststroke complications resulting in readmissions. The time period until event provides a possibility to focus monitoring on those people at risk of readmission and introduce preventative measures, thereby reducing readmission-associated costs.

Stroke in the young: The multiethnic prospective durban stroke data bank results

AIM

To determine the clinical syndromes, etiopathogenesis, and prognostic factors in a prospectively evaluated multiethnic young stroke population.

METHODS

Only first-ever patients with a World Heath Organization definition of stroke and anatomic brain imaging were included. A hierarchy of investigative modalities divided into three tiers was applied and a range of standardized scales scored in each patient. This allowed quantification of clinical deficit, etiopathogenesis, disability, and handicap. Standardized stroke scales included the Canadian Neurological Scale (CNS), the Oxfordshire Community Stroke Project (OCSP) clinical stroke scale, and TOAST (Trial of Org 10172 in Acute Stroke Study) etiological classification. Disability was measured with the Barthel Index and handicap with the Rankin Scale; cognitive impairment was separately evaluated according to predefined criteria. A prognostication measure was made in some patients with the Cerebral Perfusion Index (CPI).

RESULTS

A total of 236 patients was evaluated of whom 64 were excluded because of no lesion consistent with stroke on brain scanning leaving 172 for analysis. There were 87 women, 85 men, with a mean age of 43.8 years (range, 15 to 49 years). Despite many different predefined symptoms, 38 patients (22%) could not be classified. Hypertension (31%) and smoking (19%) were the most commonly encountered risk factors, with more recently determined risk factors such as infection (6%) and emotional stress (5%) relatively frequent. With respect to etiology, the TOAST category "other" was the most numerous group, numbering 93 of 172 (55%) with prothrombotic states in 25 (15%), vasculitis in 21 (12%), and dissection in 12 (7%) being the most frequent causes. Proportions of the remaining categories were small vessel disease (16%), cardioembolism (13%), large vessel disease (10%), and unknown (6%). X-square analysis for an association between the clinical OCSP and TOAST classifications was not significant. Severity of stroke was generally mild as judged by the CNS and Rankin scales. A high proportion of patients had cognitive impairment (54%). A cerebral perfusion index was possible in 31 patients, most of whom had a medium prognosis.

CONCLUSION

in this hospital-based consecutive series, most young stroke patients in our region were grouped into nonatherogenic (mostly prothrombotic states, infection asssociated and dissection) and noncardiac causes with a definite or probable cause found in 94%. The wide variety of stroke symptoms recorded in this study underscores the heterogeneity of stroke presentation and caution in the emergent evaluation of patients. Cognitive impairment in the majority of stroke patients in the acute and subacute stroke period has important implications for degree of clinical deficit especially as it applies to stroke scales and treatment trials.

Which neuropsychological tests predict progression to Alzheimer's disease in Hispanics?

OBJECTIVE

To investigate which neuropsychological tests predict eventual progression to Alzheimer's disease (AD) in both Hispanic and non-Hispanic individuals. Although our approach was exploratory, we predicted that tests that underestimate cognitive ability in healthy aging Hispanics might not be sensitive to future cognitive decline in this cultural group.

METHOD

We compared first-year data of 22 older adults (11 Hispanic) who were diagnosed as cognitively normal but eventually developed AD (decliners), to 60 age- and education-matched controls (27 Hispanic) who remained cognitively normal. To identify tests that may be culturally biased in our sample, we compared Hispanic with non-Hispanic controls on all tests and asked which tests were sensitive to future decline in each cultural group.

RESULTS

Compared to age-, education-, and gender-matched non-Hispanic controls, Hispanic controls obtained lower scores on tests of language, executive function, and some measures of global cognition. Consistent with our predictions, some tests identified non-Hispanic, but not Hispanic, decliners (vocabulary, semantic fluency). Contrary to our predictions, a number of tests on which Hispanics obtained lower scores than non-Hispanics nevertheless predicted eventual progression to AD in both cultural groups (e.g., Boston Naming Test [BNT], Trails A and B).

CONCLUSIONS

Cross-cultural variation in test sensitivity to decline may reflect greater resistance of medium difficulty items to decline and bilingual advantages that initially protect Hispanics against some aspects of cognitive decline commonly observed in non-Hispanics with preclinical AD. These findings highlight a need for further consideration of cross-cultural differences in neuropsychological test performance and development of culturally unbiased measures.

Tracking stroke hospitalization clusters over time and associations with county-level socioeconomic and healthcare characteristics

BACKGROUND AND PURPOSE

This study evaluated clustering of stroke hospitalization rates, patterns of the clustering over time, and associations with community-level characteristics.

METHODS

We used Medicare hospital claims data from 1995-1996 to 2005-2006 with a principal discharge diagnosis of stroke to calculate county-level stroke hospitalization rates. We identified statistically significant clusters of high- and low-rate counties by using local indicators of spatial association, tracked cluster status over time, and assessed associations between cluster status and county-level socioeconomic and healthcare profiles.

RESULTS

Clearly defined clusters of counties with high- and low-stroke hospitalization rates were identified in each time. Approximately 75% of counties maintained their cluster status from 1995-1996 to 2005-2006. In addition, 243 counties transitioned into high-rate clusters, and 148 transitioned out of high-rate clusters. Persistently high-rate clusters were located primarily in the Southeast, whereas persistently low-rate clusters occurred mostly in New England and in the West. In general, persistently low-rate counties had the most favorable socioeconomic and healthcare profiles, followed by counties that transitioned out of or into high-rate clusters. Persistently high-rate counties experienced the least favorable socioeconomic and healthcare profiles.

CONCLUSIONS

The persistence of clusters of high- and low-stroke hospitalization rates during a 10-year period suggests that the underlying causes of stroke in these areas have also persisted. The associations found between cluster status (persistently high, transitional, persistently low) and socioeconomic and healthcare profiles shed new light on the contributions of community-level characteristics to geographic disparities in stroke hospitalizations.

Association of care by hospitalists on discharge destination and 30-day outcomes after acute ischemic stroke

OBJECTIVES

The use of hospitalists is increasing. Hospitalists have been associated with reductions in length of stay and associated costs while not negatively impacting outcomes. We examine care for stroke patients because it requires complex care in the hospital and has high post discharge complications. We assessed the association of care provided by a hospitalist with length of stay, discharge destination, 30-day mortality, 30-day readmission, and 30-day emergency department visits.

METHODS

This study used the 5% Medicare sample from 2002 to 2006. Models included demographic variables, prior health status, type of admission and hospital, and region. Multinomial logit models, generalized estimating equations, Cox proportional hazard models, and propensity score analyses were explored in the analysis.

RESULTS

After adjusting models for covariates, hospitalists were associated with increased odds of discharge to inpatient rehabilitation or other facilities compared with discharge home (Odds Ratio, 1.24; 95% CI, 1.07-1.43 and Odds Ratio, 1.34; 95% CI 1.05-1.69, respectively). Mean length of stay was 0.37 days lower for patients in hospitalist care compared to nonhospitalist care. This reduction in length of stay was not appreciably changed after adjusting for discharge destination. Hospitalist care was not associated with differences in 30-day emergency department use or mortality. Readmission rates were higher for patients in hospitalist care (Hazard, 1.30; 95% CI, 1.11-1.52).

CONCLUSIONS

Hospitalists are associated with reduced length of stay and higher rates of discharge to inpatient rehabilitation. The higher readmission rates should be further explored.

Long-term neuropsychological and functional outcomes in stroke survivors: current evidence and perspectives for new research

AIMS

To appraise the literature on long-term neuropsychological and functional outcomes in stroke survivors and identify the gaps, challenges and future research in this area.

BACKGROUND

Stroke care resources are scarce, and the number of stroke survivors is likely to increase with the ageing of the population. Thus, evaluating the cost, frequency and prognostic factors of long-terms stroke functional and neuropsychological outcomes is of paramount importance for evidence-based clinical decision making, including the rationale, planning, provision and allocation of health services, and the development of effective interventions. Summary of review Stroke has an enormous physical, emotional and economic impact on the patients, families and society. However, accurate data on frequency, relationship and predictors of various long-term functional (body functioning, activity and participation) outcomes and costs of stroke are scarce, and no accurate and comprehensive data exist on long-term neuropsychological outcomes and their relationships with other functional outcomes poststroke.

CONCLUSIONS

There is a lack of accurate data on the frequency, relationship and predictors of various long-term functional outcomes and costs of stroke. There is a pressing need for good-quality population-based studies for evaluating the frequency and prognostic factors of long-term functional and neuropsychological outcomes of stroke in various populations.

Racial differences in demographics, acute complications, and outcomes in patients with subarachnoid hemorrhage: a large patient series

OBJECT

Few studies have focused on the impact of racial differences in demographics, clinical characteristics, acute complications, and outcomes of patients with aneurysmal subarachnoid hemorrhage (SAH). The purpose of this study was to examine this issue.

METHODS

The authors evaluated prospectively collected data on 1711 adult patients with aneurysmal SAH who were entered into two randomized, double-blind, placebo-controlled trials conducted at neurosurgical centers in North America between 1991 and 1997. Admission characteristics, treatment modalities, in-hospital complications, and 3-month outcomes assessed by application of the Glasgow Outcome Scale were compared using the chi-square test, a t-test, the Wilcoxon rank-sum test, and multiple logistic regressions based on a significance level of 0.05 in 241 African-American, 1342 Caucasian, and 128 other racial minority patients. Caucasian patients were significantly older than patients of other races (p < 0.0001). African-American patients more frequently had a history of hypertension (p < 0.0001) and an elevated blood pressure at the time of admission (p < 0.0001). African-Americans and other racial minorities were more likely to have internal carotid artery aneurysms and Caucasians were more likely to have posterior circulation aneurysms (p = 0.0002). Rates of in-hospital complications were not significantly different except that pulmonary edema occurred more commonly in Caucasians (p = 0.036). After an adjustment was made for significant admission characteristics, the 3-month outcome was not significantly different among the races.

CONCLUSIONS

Race was not found to be a prognostic factor for outcome after aneurysmal SAH. The higher SAH mortality rate previously observed in African-American patients is likely a result of a higher incidence of SAH in this group. These findings highlight the importance of primary prevention programs aimed at modifying risk factors for SAH.

Hemorrhagic stroke after naphazoline exposition: case report

Ten percent of all strokes are due to spontaneous cerebral hemorrhages. They are associated to drugs (licit and illicit) in 9.5% of all cases in young adults. This is a case report of a 44-year-old man, without previous morbidities, who presented a sudden onset headache and arterial hypertension 24 hours after use of naphazoline as nasal decongestant. Cranial tomography showed right thalamus hemorrhage. Cerebral angiography showed no aneurisms, vascular malformations or vasculitis. No other risk factors were found during investigation in this patient and the stroke was attributed to naphazoline exposition.

Association of physical functioning with same-hospital readmission after stroke

OBJECTIVE

Readmission after hospitalization for stroke is an important outcome. We sought to document the frequency of same-hospital readmission and to determine the relative value of physical functioning as a predictor of the outcome.

DESIGN

Consenting patients (n = 228) who were admitted for ischemic stroke were characterized according to demographics, stroke severity, and self-reported prestroke and postadmission physical functioning. The hospital's administrative database was used to track readmissions during the year after index hospitalization.

RESULTS

Same-hospital readmissions were experienced by 37.3% of the patients. The readmissions usually occurred within 100 days of discharge. The most common readmission diagnosis was stroke (14.1%). Lower prestroke and postadmission physical functioning (as reflected by dichotomous Barthel index scores) were weak but significant predictors of readmission (r = -0.165 and -0.268, respectively). Regression analysis showed that once postadmission physical functioning was accounted for, neither prestroke functioning nor any other measured variable added to the explanation of same-hospital readmission.

CONCLUSION

The importance of physical functioning goes beyond rehabilitation. It is a potentially modifiable variable with implications for readmission.

The effect of diabetes combined with stroke on disability, self-rated health, and mortality in older Mexican Americans: results from the Hispanic EPESE

OBJECTIVE

To examine how diabetes in combination with stroke affects functional activities of daily living (ADLs) and instrumental activities of daily living (IADLs), self-rated health, and 5-year mortality in elderly Mexican Americans with or without other comorbid conditions.

DESIGN

Longitudinal study.

SETTING

Five southwestern states.

PARTICIPANTS

A total of 3050 subjects of age 65 years or older, of whom 23% had diabetes and 6% had a stroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

ADL and IADL disabilities, self-rated health, and 5-year mortality.

RESULTS

Subjects with both diabetes and stroke but without other comorbid conditions had almost 18 times higher risk of having any ADL disability (odds ratio [OR]=18.8; 95% confidence interval [CI], 3.3-105.2) and 10 times higher risk of having any IADL disability (OR=10.6; 95% CI, 1.1-101.5), compared with subjects without either of the 2 conditions. The risk of disability was further increased if the subject had a comorbid condition (hypertension, heart attack, cancer, hip fracture, arthritis). The risk of fair or poor self-rated health was 3.5 (95% CI, 1.4-8.6) and the hazard ratio for 5-year mortality was 2.4 (95% CI, 1.7-3.4) in people with both diseases.

CONCLUSIONS

Diabetes and stroke in combination is strongly associated with a higher risk of disabilities, poor self-rated health, and 5-year mortality in elderly Mexican Americans. The effect on outcomes appears to follow an additive model. Information on disability risk and morbidity and mortality should be useful to rehabilitation professionals in discharge planning and allocation of therapy resources.

Stroke: a review with an African perspective

The frequency of stroke and stroke-associated mortality are higher in Blacks than in other races. Several of the known risk factors for stroke, such as hypertension, diabetes and obesity, are more common in Blacks than Whites, and sickle-cell disease and HIV infection are stroke risk factors with particular relevance to Africans. Although the facilities for accurate stroke diagnosis and classification are unavailable in most parts of Africa, careful analysis of the clinical features can minimize the rates of misdiagnosis and misclassification. The high levels of stroke-attributable morbidity and mortality observed in Africans could be markedly reduced by instituting primary and secondary preventive measures and by educating health-care professionals on stroke-management strategies.

Mortality and causes of death after first ischemic stroke: the Northern Manhattan Stroke Study

OBJECTIVE

To analyze the early and long-term causes of death after first ischemic stroke in the multiethnic northern Manhattan community.

METHODS

In the prospective, population-based Northern Manhattan Stroke Study, 980 patients with first ischemic stroke (mean age 70 years; 56% women; 49% Caribbean Hispanic, 31% black, 20% white) were followed for a mean of 3 years. Causes of death were classified as vascular (incident stroke, recurrent stroke, cardiac) or nonvascular. Life table analyses were used to assess mortality risks among different race-ethnic groups. Early (< or =1 month) vs long-term (> 1 month to 5 years) causes of death were compared.

RESULTS

Among the 980 patients followed, 278 (28%) died; 47 (5%) died during the first month. Cumulative mortality risk was 5% at 1 month, 16% after 1 year, 29% after 3 years, and 41% after 5 years. The proportion of vascular deaths among all deaths was 75% at 1 month and 43% thereafter (p = 0.001). Stroke, either incident (53%) or recurrent (4%), caused early deaths in 57% and long-term deaths in 14% (p = 0.001). Overall mortality risks did not differ significantly among race-ethnic groups. However, the proportion of incident stroke-related early deaths was 85% in Caribbean Hispanic patients, 33% in white patients, and 25% in black patients (p = 0.002).

CONCLUSIONS

Among patients with first ischemic stroke, incident stroke is the leading cause of early deaths. A large proportion of long-term deaths are nonvascular in origin. Despite similar overall mortality rates in race-ethnic groups, our data suggest a higher incident stroke-related early mortality among Caribbean Hispanics.

Acidente vascular cerebral em pacientes jovens: análise de 164 casos

Realizamos análise epidemiológica de 164 pacientes com AVC, cujo primeiro episódio ocorreu entre 15 e 49 anos de idade através de um estudo retrospectivo de pacientes ambulatoriais. O principal tipo de apresentação foi AVC isquêmico (AVCI) em 141 pacientes, ocorrendo AVC hemorrágico (AVCH) em16 casos e 7 pacientes com trombose venosa. A presença de fatores de risco aterotrombóticos foi prevalente, em 48,22% dos pacientes com AVCI sendo que a hipertensão arterial sistêmica (HAS), nos casos de AVCH, foi a etiologia mais frequente. Em 32% dos casos não se pode determinar a sua causa. Embora a população jovem possua determinantes diferentes e geralmente deva ter uma investigação etiológica mais abrangente, no grupo estudado foram prevalentes os fatores de risco conhecidos e potencialmente controláveis, sugerindo que campanhas de prevenção e detecção precoce devam ser incentivados.

Ischemic stroke outcome: racial differences in the trial of danaparoid in acute stroke (TOAST)

OBJECTIVE

To determine racial differences in baseline stroke risk factors and other measures in the Trial of ORG 10172 in Acute Stroke Therapy (TOAST). Differences in these factors could influence response to acute stroke therapy and overall stroke outcome.

METHODS

The authors compared baseline demographic, medical, stroke, physical examination, CT, laboratory, and neurologic factors among 292 African-American and 801 white patients who enrolled in the TOAST study. TOAST compared danaparoid (ORG 10172) with placebo among acute ischemic stroke patients who were treated within 24 hours of stroke onset.

RESULTS

African-Americans were younger and more frequently had hypertension, diabetes mellitus, congestive heart failure, and prior strokes. In addition, African-Americans had higher mean diastolic blood pressure, more lacunar strokes, and more severe prestroke disability. There were no significant differences between African-Americans and white patients in outcomes at 7 days, overall number of adverse experiences, or occurrence of serious bleeds or hemorrhagic transformations. However, there was a trend toward a higher rate of favorable outcomes in white patients at 7 days. There was no significant difference in very favorable outcome at 3 months between African-American and white patients, but significantly more white patients had favorable outcome at 3 months.

CONCLUSION

Although African-Americans possess a number of factors that should predict higher rates of poor stroke outcome after acute therapy, they have the capacity to respond similarly to white patients after acute stroke therapy. Perhaps younger age and presence of lacunar infarction are stronger predictors of good outcomes than was appreciated previously.

Weighing the risks and benefits of tamoxifen treatment for preventing breast cancer

BACKGROUND

In response to findings from the Breast Cancer Prevention Trial that tamoxifen treatment produced a 49% reduction in the risk of invasive breast cancer in a population of women at elevated risk, the National Cancer Institute sponsored a workshop on July 7 and 8, 1998, to develop information to assist in counseling and in weighing the risks and benefits of tamoxifen. Our study was undertaken to develop tools to identify women for whom the benefits outweigh the risks.

METHODS

Information was reviewed on the incidence of invasive breast cancer and of in situ lesions, as well as on several other health outcomes, in the absence of tamoxifen treatment. Data on the effects of tamoxifen on these outcomes were also reviewed, and methods were developed to compare the risks and benefits of tamoxifen.

RESULTS

The risks and benefits of tamoxifen depend on age and race, as well as on a woman's specific risk factors for breast cancer. In particular, the absolute risks from tamoxifen of endometrial cancer, stroke, pulmonary embolism, and deep vein thrombosis increase with age, and these absolute risks differ between white and black women, as does the protective effect of tamoxifen on fractures. Tables and aids are developed to describe the risks and benefits of tamoxifen and to identify classes of women for whom the benefits outweigh the risks.

CONCLUSIONS

Tamoxifen is most beneficial for younger women with an elevated risk of breast cancer. The quantitative analyses presented can assist health care providers and women in weighing the risks and benefits of tamoxifen for reducing breast cancer risk.

Racial differences in the incidence of intracerebral hemorrhage: effects of blood pressure and education

OBJECTIVE

To determine the relative risk (RR) of intracerebral hemorrhage (ICH) among African Americans compared with that among whites.

METHODS

Data from the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study were used to determine the incidence of ICH (n = 78) in 10,851 whites and 1,802 African Americans during a 20-year follow-up period. Cox proportional hazards analyses were used to determine the RR of ICH among African Americans compared with that among whites.

RESULTS

The estimated annual incidence of ICH was 50 per 100,000 among African Americans and 28 per 100,000 among whites. The age- and sex-adjusted RR for ICH among African Americans was 1.9 (95% confidence interval [CI], 1.1 to 3.2). With the addition of systolic blood pressure and educational attainment to the Cox proportional hazards model, the RR decreased to 1.6 (95% CI, 0.9 to 2.7). The adjustment for additional cerebrovascular disease risk factors did not change this risk estimate appreciably.

CONCLUSIONS

Compared with whites, African Americans have a twofold increased risk for ICH. Most of this risk may be explained by differences in educational attainment and systolic blood pressure. Unless additional efforts are undertaken to reduce racial differences in the prevalence of stroke risk factors, mainly systolic blood pressure and socioeconomic status, the African American-white disparities in the risk for ICH will likely continue.

Ethnic differences in incidence of stroke: prospective study with stroke register

OBJECTIVE

To identify ethnic differences in the incidence of first ever stroke.

DESIGN

A prospective community stroke register (1995-6) with multiple notification sources. Pathological classification of stroke in all cases was based on brain imaging or necropsy data. Rates were standardised to European and world populations and adjusted for age, sex, and social class in multivariate analysis.

SETTING

A multi-ethnic population of 234 533 in south London, of whom 21% are black.

RESULTS

612 strokes were registered. The crude annual incidence rate was 1.3 strokes per 1000 population per year (95% confidence interval 1.20 to 1.41) and 1.25 per 1000 population per year (1.15 to 1.35) age adjusted to the standard European population. Incidence rates adjusted for age and sex were significantly higher in black compared with white people (P<0.0001), with an incidence rate ratio of 2.21 (1.77 to 2.76). In multivariable analysis increasing age (P<0.0001), male sex (P<0.003), black ethnic group (P<0.0001), and lower social class (P<0.0001) in people aged 35-64 were independently associated with an increased incidence of stroke.

CONCLUSIONS

Incidence rates of stroke are higher in the black population; this is not explained by confounders such as social class, age, and sex. Ethnic differences in genetic, physiological, and behavioural risk factors for stroke require further elucidation to aid development of effective strategies for stroke prevention in multi-ethnic communities.

Subtypes and case-fatality rates of stroke: a hospital-based stroke registry in Taiwan (SCAN-IV)

Stroke data bank can afford important information regarding risk factors, pathogenesis, prognosis, etc. By means of hospital-based stroke registry, we investigated the risk factors and case-fatality rates in different types of stroke and transient ischemic attack (TIA) patients at the National Taiwan University Hospital in 1995. After excluding ineligible patients, 995 patients aged 1-98 years (575 men and 420 women) were recruited. Men predominated in all age groups for stroke and TIA in general except for cerebral hemorrhage (CH) in patients aged < 35 years and subarachnoid hemorrhage (SAH) in patients aged > or = 45 years. Of these, 676 (67.9%), 41 (4.1%), 228 (22.9%) and 50 (5%) patients were classified in the categories of cerebral infarction (CI), TIA, CH and SAH, respectively. The CI/CH ratio was 2.96. Hypertension remained one of the most important risk factors for CI, CH and TIA patients. Severe extracranial carotid artery stenosis (> or = 50%) was found in 12% of the CI patients and 27% of the TIA patients, but not found in the CH and SAH patients. Of these patients, the 30-day case-fatality rate was 10.9%, highest in SAH (30%), followed by CH (24.1%) and CI (5.6%). There were 41 in-hospital stroke patients who had significantly higher case-fatality rates than the other stroke patients (P<0.001 for all stroke, CI and CH patients by chi2 test). As compared to the previous stroke registries in Taiwan, there is a secular trend of increasing CI/CH ratios. These findings in Taiwan were compared with those in other populations, including other Asian, Caucasian and black populations. The CI/CH ratios in Asian populations, including Chinese, Japanese and Korean, were much lower than those in Caucasian and black populations. Dietary, environmental and genetic factors probably play important roles in these differences.

Genetics of stroke--a review

Evidence from twin and family shows that genetic factors contribute to the risk of stroke and that their role may be at least as important in stroke as in coronary heart disease. Additional support for the significance of genetic factors comes from other findings such as epidemiological data showing phenotypic heterogeneity of stroke, genetic influence on many of the risk factors for stroke, and racial and geographic differences in morbidity and mortality in stroke victims. Yet, apart from the reported associations of a small number of cases with Mendelian cerebrovascular diseases, only a few studies have directly investigated gene markers or molecular genetics of stroke. This review presents the existing evidence on the genetic background of stroke and discusses results from the genetic studies of stroke published to date.

Ethnic differences in stroke mortality between non-Hispanic whites, Hispanic whites, and blacks. The National Longitudinal Mortality Study

BACKGROUND AND PURPOSE

Although US blacks are known to have an excess stroke mortality compared with US whites, little is known about the stroke burden of the Hispanic white population. This report will provide estimates of the relative burden of stroke mortality in the US black and Hispanic population relative to the white population and examine the consistency of this relation across age.

METHODS

Data were from participants aged > 45 years from the National Longitudinal Mortality Study. There were 1844 stroke deaths among 239,734 non-Hispanic whites, 46 deaths among 12,527 Hispanic whites, and 234 deaths among 23,468 black participants. Standard statistical methods were used to examine the ethnic differences in stroke mortality.

RESULTS

The hazard ratios for black men and women (relative to non-Hispanic whites) were nearly identical, at > 4.0 at age 45 but marginally < 1.0 by age 85. For both Hispanic men and women, the hazard ratios (relative to non-Hispanic whites) were approximately 1.0 at age 45 but were marginally significantly < 1.0 at older ages. The ethnic differences in stroke death rates reveal differences in age distributions of age at fatal stroke between these groups. Approximately 6% of fatal strokes for non-Hispanic whites occurred before age 60, whereas > 15% occurred in both Hispanic whites and blacks.

CONCLUSIONS

These results suggest that (1) for Hispanics, stroke risk is similar to that for non-Hispanic whites at young ages but is marginally lower at older ages, (2) the excess stroke mortality in blacks mainly occurs at younger ages (between 45 and 55 years), and (3) the relation between stroke risk for blacks and Hispanics relative to whites is similar by sex. The impact of age on relative stroke mortality would argue against simple age adjustment for describing ethnic differences in stroke mortality. Finally, proportionally, more strokes occur at older ages in non-Hispanic whites than in either US blacks or Hispanic whites.

Stroke subtypes among Hispanics living in Guayaquil, Ecuador. Results from the Luis Vernaza Hospital Stroke Registry

BACKGROUND AND PURPOSE

Racial differences in stroke subtypes have been documented. Asians have a higher rate of cerebral hemorrhage than whites; however, there is little information about stroke subtypes among Hispanics. The purpose of this study was to determine the patterns of stroke subtypes in a population of Hispanics.

METHODS

Five hundred consecutive patients with a first stroke were included. Patients were collected from hospital wards, the emergency department, and the outpatient clinic to ensure inclusion of patients with a wide range of stroke severity. Computed tomography was available in all cases. Patients with pure subarachnoid hemorrhage were excluded.

RESULTS

There were 313 (62.6%) patients with an infarct and 187 (37.4%) with a hemorrhage. Hypertensive arteriolopathy was the most common cause of both infarcts and hemorrhages. The carotid territory was involved in 70.6% of the 313 patients with infarcts, the vertebrobasilar territory in 17.9%, multiple territories in 6.7%, and a watershed area in 4.8%. Hemorrhages were most often lobar (36.4%), followed by putaminal (30.5%), brain stem (9.1%), cerebellar (8%), thalamic (8%), ventricular (5.3%), and caudate (2.7%).

CONCLUSIONS

This hospital-based stroke registry suggests that stroke in Hispanics has a pattern different from that in whites but similar to that in Asians. Cerebral hemorrhages occur three times more frequently in Hispanics than in whites.

Free protein S deficiency in acute ischemic stroke. A case-control study

BACKGROUND AND PURPOSE

Deficiency of free protein S, a naturally occurring anticoagulant, may be acquired in the setting of acute illness and increasingly has become recognized as a possible stroke risk factor. We sought to determine whether free protein S deficiency is associated with acute cerebral infarction among older individuals at risk for stroke.

METHODS

Free protein S was measured by Laurell rocket immunoelectrophoresis in 94 adults admitted for acute cerebral infarction and in 94 hospitalized control subjects of similar age, sex, and race. Patients with a history of cerebrovascular disease, acute thrombotic or hematologic diseases, or medical conditions known to cause free protein S deficiency were excluded from the control group.

RESULTS

The percentage of patients with free protein S deficiency (< 20% normal total protein S) was similar in the case and control groups (21% versus 20%, respectively). Among all subjects, free protein S deficiency was more common in blacks than nonblacks (34% versus 13%, p = 0.001). A very low free protein S (< 15% normal total protein S) was more frequent among case patients than control subjects (11% versus 5%), but this trend failed to reach statistical significance.

CONCLUSIONS

Free protein S deficiency is common among hospitalized patients, even in the absence of a recognized predisposing condition. Our findings indicate that acquired deficiency of free protein S is not a major risk factor for ischemic stroke.