Some epidemiological aspects of stroke: mortality/morbidity trends, age, sex, race, socioeconomic status

Trends in Demographic and Geographic Disparities in Stroke Mortality Among Older Adults in the United States

BACKGROUND

Stroke is a leading cause of morbidity and mortality in the United States among older adults. However, the impact of demographic and geographic risk factors remains ambiguous. A clear understanding of these associations and updated trends in stroke mortality can influence health policies and interventions.

METHODS

This study characterizes stroke mortality among older adults (age ≥55) in the US from January 1999 to December 2020, sourcing data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research. Segmented regression was used to analyze trends in crude mortality rate and age-adjusted mortality rate (AAMR) per 100,000 individuals stratified by stroke subcategory, sex, ethnicity, urbanization, and state.

RESULTS

A total of 3,691,305 stroke deaths occurred in older adults in the US between 1999 and 2020 (AAMR = 233.3), with an overall decrease in AAMR during these years. The highest mortality rates were seen in nonspecified stroke (AAMR = 173.5), those 85 or older (crude mortality rate1276.7), men (AAMR = 239.2), non-Hispanic African American adults (AAMR = 319.0), and noncore populations (AAMR = 276.1). Stroke mortality decreased in all states from 1999 to 2019 with the greatest and least decreases seen in California (-61.9%) and Mississippi (-35.0%), respectively. The coronavirus pandemic pandemic saw increased stroke deaths in most groups.

CONCLUSIONS

While there's a decline in stroke-related deaths among US older adults, outcome disparities remain across demographic and geographic sectors. The surge in stroke deaths during coronavirus pandemic reaffirms the need for policies that address these disparities.

Mortality trends of stroke and dementia: Changing landscapes and new challenges

BACKGROUND/IMPORTANCE

Stroke and dementia are important causes of death in the United States and may be interrelated as competing risks for mortality. No previous studies have simultaneously compared age- and sex-specific mortality trends between stroke and subtypes of dementia at a population level. Insights gained from this study can help identify high-risk populations and inform healthcare service requirements for managing stroke and dementia in the United States.

OBJECTIVES

To examine nationwide trends in mortality from stroke and subtypes of dementia in the United States by age group and sex.

DESIGN

Population-based cross-sectional study.

SETTING

U.S. mortality data from 2007 to 2016.

PARTICIPANTS

All U.S. residents whose primary cause of death was stroke, Alzheimer's disease, vascular dementia, or Lewy body dementia.

MEASUREMENTS

Age-adjusted mortality, mortality trends among men and women were analyzed separately using joinpoint regression.

RESULTS

From 2007 to 2016, age-adjusted stroke mortality fell by 21.6%. Age-adjusted mortality (per 1,000,000) for Alzheimer's disease, vascular dementia, and Lewy body dementia increased by 1.2-fold, 2-fold, and 3-fold, respectively. Annual age-adjusted stroke mortality decreased by an average rate of 2.67% per year, while annual age-adjusted mortality for Alzheimer's disease, vascular dementia, and Lewy body dementia increased by an average rate of 2.06%, 4.90%, and 12.13% per year, respectively. Mortality from stroke and dementia increased with age. Greater reductions in stroke mortality and greater increases in dementia mortality were seen in women than men; and in older than younger (<65 years) people.

CONCLUSIONS

There has been a striking rising trend in dementia mortality coincident with a reduction in stroke mortality in the United States. There are persistent age and sex disparities in stroke and dementia mortality trends. Our findings support the pathophysiological relationship between stroke and dementia, and have important implications for future research, healthcare planning, and provision.

The importance of diversity and outreach in geroscience research: Insights from the Annual Biomedical Research Conference for Minority Students

US academic science lacks racial, ethnic, sex, gender, disability, and socioeconomic diversity. Addressing this problem is essential to drive scientific progress but is confounded by broad misunderstandings regarding diverse groups. Increasing representation in science is particularly relevant in geroscience, where our research to maximize healthy human lifespan must also address existing racial and socioeconomic health disparities. The American Aging Association (AGE) is committed to addressing these issues as part of its larger mission to advance and promote geroscience research. Over the last three years, AGE has sponsored an exhibition booth staffed by trainee leaders to promote our society and research at the Annual Biomedical Research Conference for Minority Students (ABRCMS), an ideal venue to interact with diverse students from across the country. Through our interactions with students, advocates, and representatives from other institutions and societies, we have learned a great deal about how to engage and promote the success of diverse students in the sciences. Here, we share these insights that are helping shape our own outreach efforts. In addition to interacting with ABRCMS attendees, we also learned a great deal about how societies like AGE can partner with other organizations to advance our shared goals and the importance of reaching students early in their academic journey to promote their success. Finally, we consider how to grow our outreach efforts beyond ABRCMS to reach those in disadvantaged areas and support students navigating academic science.

The combination of mannitol and temozolomide increases the effectiveness of stem cell treatment in a chronic stroke model

BACKGROUND

The blood-brain barrier (BBB) presents a significant challenge to the therapeutic efficacy of stem cells in chronic stroke. Various methods have been developed to increase BBB permeability, but these are associated with adverse effects and are, therefore, not clinically applicable. We recently identified that combination drug treatment of mannitol and temozolomide improved BBB permeability in vitro. Here, we investigated whether this combination could increase the effectiveness of stem cell treatment in an animal model of chronic ischemic stroke.

METHODS

Chronic stroke was induced in rats by middle cerebral artery occlusion (MCAo). After then, rats were administered human umbilical cord-derived mesenchymal stromal cells (hUC-MSCs) by intravenous injection with or without combination drug treatment of mannitol and temozolomide. To evaluate the therapeutic efficacy, behavioral and immunohistochemical tests were performed, and the differences among control, stem cell only, combination drug only and stem cell with combination drug treatment were analyzed.

RESULTS

Although no hUC-MSCs were detected in any group, treatment with stem cells and combination drug of mannitol and temozolomide increased the intracerebral delivery of hCD63-positive microvesicles compared with stem cell only treatment. Furthermore, treatment with stem cells and drug combination ameliorated behavioral deficits and increased bromodeoxyuridine-, doublecortin- and Reca-1-positive cells in the perilesional area as compared with other groups.

DISCUSSION

The combination drug treatment of mannitol and temozolomide allowed for the efficient delivery of hUC-MSC-derived microvesicles into the brain in a chronic stroke rat model. This attenuated behavioral deficits, likely by improving neural regeneration and angiogenesis. Thus, combination drug treatment of mannitol and temozolomide could be a novel therapeutic option for patients with chronic ischemic stroke.

Increased ischemic stroke risk in patients with Behçet's disease: A nationwide population-based cohort study

Background

Behçet’s disease (BD) is a recurrent, multisystemic, inflammatory disorder that mainly affects blood vessels. Because recurrent inflammation of blood vessels in the brain plays a crucial role in the development of ischemic stroke, we hypothesized that patients with BD might have an elevated risk of ischemic stroke. This potential association has been suggested in a few case reports, but not epidemiological studies. Hence, the present study aimed to examine the relation between BD and subsequent ischemic stroke in Taiwan using a nationwide, population-based database.

Methods

To establish a study cohort, the longitudinal data of 306 patients newly diagnosed with BD during 2000–2010 were extracted from the National Health Insurance Research Database, Taiwan. For comparison of ischemic stroke incidence, a control cohort of 1224 subjects without BD was established using a frequency-matched ratio of 1:4 for age, sex, and pre-existing comorbidities.

Results

During the 10-year follow-up, 13 (4.2%) patients with BD and 20 (1.6%) control subjects experienced ischemic stroke. Kaplan–Meier analysis revealed the higher prevalence of ischemic stroke in the BD group (log-rank test, p = 0.001). After adjusting for comorbidities and demographic characteristics, Cox regression analysis revealed that patients with BD had a 2.77-fold risk of ischemic stroke (95% confidence interval, 1.38–5.57) compared to control subjects.

Conclusions

Patients with BD have an elevated risk of ischemic stroke. Hence, BD may affect the vascular system in the brain, resulting in a stroke event.

Regional differences in the temporal evolution of stroke: a population-based study of Brazil according to sex in individuals aged 15-49 years between 1997 and 2012

Objective

The present study analyzed the temporal trend of stroke mortality according to sex in individuals aged 15–49 years in the different regions of Brazil between 1997 and 2012.

Results

There was progressive reduction in mortality rate due to stroke in Brazil. The reduction trend was the same for both sexes, although mortality remained slightly higher among men. There was a difference in mortality rates according to the administrative region of the country.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3439-x) contains supplementary material, which is available to authorized users.

(-)-Phenserine inhibits neuronal apoptosis following ischemia/reperfusion injury

Stroke commonly leads to adult disability and death worldwide. Its major symptoms are spastic hemiplegia and discordant motion, consequent to neuronal cell death induced by brain vessel occlusion. Acetylcholinesterase (AChE) is upregulated and allied with inflammation and apoptosis after stroke. Recent studies suggest that AChE inhibition ameliorates ischemia-reperfusion injury and has neuroprotective properties. (-)-Phenserine, a reversible AChE inhibitor, has a broad range of actions independent of its AChE properties, including neuroprotective ones. However, its protective effects and detailed mechanism of action in the rat middle cerebral artery occlusion model (MCAO) remain to be elucidated. This study investigated the therapeutic effects of (-)-phenserine for stroke in the rat focal cerebral ischemia model and oxygen-glucose deprivation/reperfusion (OGD/RP) damage model in SH-SY5Y neuronal cultures. (-)-Phenserine mitigated OGD/PR-induced SH-SY5Y cell death, providing an inverted U-shaped dose-response relationship between concentration and survival. In MCAO challenged rats, (-)-phenserine reduced infarction volume, cell death and improved body asymmetry, a behavioral measure of stoke impact. In both cellular and animal studies, (-)-phenserine elevated brain-derived neurotrophic factor (BDNF) and B-cell lymphoma 2 (Bcl-2) levels, and decreased activated-caspase 3, amyloid precursor protein (APP) and glial fibrillary acidic protein (GFAP) expression, potentially mediated through the ERK-1/2 signaling pathway. These actions mitigated neuronal apoptosis in the stroke penumbra, and decreased matrix metallopeptidase-9 (MMP-9) expression. In synopsis, (-)-phenserine significantly reduced neuronal damage induced by ischemia/reperfusion injury in a rat model of MCAO and cellular model of OGD/RP, demonstrating that its anti-apoptotic/neuroprotective/neurotrophic cholinergic and non-cholinergic properties warrant further evaluation in conditions of brain injury.

Stroke in Northern Sweden

Background: Stroke is one of the most common causes of death and long-term disability worldwide. Although stroke mortality has decreased in most industrialized countries, there are populations, particularly in East Europe, in which the mortality has increased. The WHO initiated, 20 years ago, the MONICA Project. The aim of the study was to measure trends in coronary heart disease and stroke and to assess the extent to which these were related to changes in known risk factors. Design: The Northern Sweden MONICA stroke study started in 1985 and is still ongoing. All individuals with an acute stroke in the age group 25 - 74 years have been included in the stroke register. Death certificates, discharge records, and GPs' records are screened and validated using strict MONICA criteria. Results: Stroke event rates (first ever and recurrent stroke) per 100,000 and year in the age group 25 - 74 years varied little over the years. Between 1985 and 1998 the annual incidence varied between 318 and 372 in men and between 195 and 240 in women, with no secular trends at all. The 28-day case fatality decreased in both men and women, from 19% to 11%. Logistic regression analyses showed a risk reduction in dying from stroke to 0.55 (p<0.0001) the last year compared with the first, with an absolute annual reduction in case fatality of 3%, in both men and women. In international comparison Northern Sweden shows an intermediately high incidence and one of the lowest case fatality rates of all participating populations. The incidence in subarachnoid haemorrhage was among the highest. Conclusion: The ongoing decline in stroke mortality in Sweden is driven exclusively by declining case fatality, whereas event rates (first ever and recurrent stroke) have remained the same since 1985. This, together with more people entering advanced, stroke-prone age groups, implies that the burden of stroke will continue to increase in Sweden.

State-of-the-Art Review: Usefulness of Laboratory Techniques for Evaluating Antithrombotic Efficacy of New Therapeutic Strategies

New drugs and new therapeutic strategies are being introduced for the prevention and the management of cardiovascular and thromboembolic disorders. Extensive clinical studies and large-scale epidemiological investigations are conducted to demonstrate the efficacy of these therapeutic approaches. Laboratory assays are invaluable tools for this exploration. We discuss how the new understanding concerning the regulation of the coagulolytic equilibrium offers novel investigation tools. Parameters reflecting the activities of new drugs targeted to their impact site and presenting few side effects are available. In addition to global clotting methods and chromogenic substrate-based assays, introduction of immunoassays has allowed measurement of most of the molecular markers of hemostatic activation. We recommend use of a panel of markers exploring the endothelial damage, the blood cell involvement, the early coagulant pathways' activation (XIIa and VIIa), the thrombin-formation pathways, the fibrin formation, and the evaluation of the global fibrinolytic capacity. When related to the clinical end points, all these laboratory assays offer useful and reliable monitoring of new drugs. They contribute to the establishment of new therapeutic strategies. Key Words: Hemostasis—Activation—Antithrombotic—Therapy— Laboratory monitoring.

Race as a predictor of delay from diagnosis to endarterectomy in clinically significant carotid stenosis

OBJECTIVE

Prompt carotid endarterectomy (CEA) in clinically significant carotid stenosis is important in the prevention of neurologic sequelae. The greatest benefit from surgery is obtained by prompt revascularization on diagnosis. It has been demonstrated that black patients both receive CEA less frequently than white patients do and experience worse postoperative outcomes. We sought to test our hypothesis that black race is an independent risk factor for a prolonged time from sonographic diagnosis of carotid stenosis warranting surgery to the day of operation (TDO).

METHODS

From 1998 to 2013 at a single institution, 166 CEA patients were retrospectively reviewed using Synthetic Derivative, a de-identified electronic medical record. Factors potentially affecting TDO, including demographics, preoperative cardiac stress testing, degree of stenosis, smoking status, and comorbidities, were noted. Multivariate analysis was performed on variables that trended with prolonged TDO on univariate analysis (P < .10) to determine independent (P < .05) predictors of TDO. Subgroup analyses were further performed on the symptomatic and asymptomatic stenosis cohorts.

RESULTS

There were 32 black patients and 134 white patients studied; the mean TDO was 78 ± 17 days vs 33 ± 3 days, respectively (P < .001). In addition to the need for preoperative cardiac stress testing, black race was the only variable that demonstrated a trend with (P < .10) or was an independent risk factor for (P < .05) prolonged TDO among all patients (B = 42 days; P < .001) and within the symptomatic (B = 35 days; P = .08) and asymptomatic (B = 35 days; P = .003) cohorts. On Kaplan-Meier analysis, black patients in each stratum of symptomatology (all, symptomatic, and asymptomatic patients) experienced prolonged TDO (log-rank, P < .03 for all three groups).

CONCLUSIONS

Black race is a risk factor for a temporal delay in CEA for carotid stenosis. Awareness of this disparity may help surgeons avoid undesirable delays in operation for their black patients.

Computed tomography and transcranial Doppler findings in acute and subacute phases of intracerebral hemorrhagic stroke

BACKGROUND AND PURPOSE

The hematoma volume is an important determinant of outcome and a predictor of clinical deterioration in patients with intracerebral hemorrhage (ICH). Our goal was to evaluate alterations in the cerebral circulation, in respect to hemorrhage and edema volume changes, using transcranial Doppler (TCD).

METHODS

Twenty patients with acute supratentorial ICH were examined. Brain, hematoma, and edema volumes were calculated from CT scans performed at admission and 2 weeks later. Data were compared with those obtained from bilateral TCD recordings of the middle cerebral arteries.

RESULTS

During TCD examination, blood flow velocities did not change, cerebral perfusion pressure (CPP) and resistance area product (RAP) decreased (P = .006, P = .002) while cerebral blood flow index (CBFI) remained constant on the affected side. Although hemorrhage volume did not correlate with RAP in the acute phase, correlation was found in the subacute phase (r = -.44, P = .04).

CONCLUSIONS

TCD monitoring sensitively demonstrates the hemodynamic change caused by ICH but the severity of the changes does not correlate with the volume of the ICH in acute stage. The CPP, RAP, and CBFI values are more sensitive parameters than the absolute velocity values, therefore they contribute more to the understanding of hemodynamic changes developed after spontaneous ICH.

Community Level Disadvantage and the Likelihood of First Ischemic Stroke

Background and Purpose. Residing in “disadvantaged” communities may increase morbidity and mortality independent of individual social resources and biological factors. This study evaluates the impact of population-level disadvantage on incident ischemic stroke likelihood in a multiethnic urban population. Methods. A population based case-control study was conducted in an ethnically diverse community of New York. First ischemic stroke cases and community controls were enrolled and a stroke risk assessment performed. Data regarding population level economic indicators for each census tract was assembled using geocoding. Census variables were also grouped together to define a broader measure of collective disadvantage. We evaluated the likelihood of stroke for population-level variables controlling for individual social (education, social isolation, and insurance) and vascular risk factors. Results. We age-, sex-, and race-ethnicity-matched 687 incident ischemic stroke cases to 1153 community controls. The mean age was 69 years: 60% women; 22% white, 28% black, and 50% Hispanic. After adjustment, the index of community level disadvantage (OR 2.0, 95% CI 1.7–2.1) was associated with increased stroke likelihood overall and among all three race-ethnic groups. Conclusion. Social inequalities measured by census tract data including indices of community disadvantage confer a significant likelihood of ischemic stroke independent of conventional risk factors.

Central poststroke pain: somatosensory abnormalities and the presence of associated myofascial pain syndrome

Background

Central post-stroke pain (CPSP) is a neuropathic pain syndrome associated with somatosensory abnormalities due to central nervous system lesion following a cerebrovascular insult. Post-stroke pain (PSP) refers to a broader range of clinical conditions leading to pain after stroke, but not restricted to CPSP, including other types of pain such as myofascial pain syndrome (MPS), painful shoulder, lumbar and dorsal pain, complex regional pain syndrome, and spasticity-related pain. Despite its recognition as part of the general PSP diagnostic possibilities, the prevalence of MPS has never been characterized in patients with CPSP patients. We performed a cross-sectional standardized clinical and radiological evaluation of patients with definite CPSP in order to assess the presence of other non-neuropathic pain syndromes, and in particular, the role of myofascial pain syndrome in these patients.

Methods

CPSP patients underwent a standardized sensory and motor neurological evaluation, and were classified according to stroke mechanism, neurological deficits, presence and profile of MPS. The Visual Analogic Scale (VAS), McGill Pain Questionnaire (MPQ), and Beck Depression Scale (BDS) were filled out by all participants.

Results

Forty CPSP patients were included. Thirty-six (90.0%) had one single ischemic stroke. Pain presented during the first three months after stroke in 75.0%. Median pain intensity was 10 (5 to 10). There was no difference in pain intensity among the different lesion site groups. Neuropathic pain was continuous-ongoing in 34 (85.0%) patients and intermittent in the remainder. Burning was the most common descriptor (70%). Main aggravating factors were contact to cold (62.5%). Thermo-sensory abnormalities were universal. MPS was diagnosed in 27 (67.5%) patients and was more common in the supratentorial extra-thalamic group (P <0.001). No significant differences were observed among the different stroke location groups and pain questionnaires and scales scores. Importantly, CPSP patients with and without MPS did not differ in pain intensity (VAS), MPQ or BDS scores.

Conclusions

The presence of MPS is not an exception after stroke and may present in association with CPSP as a common comorbid condition. Further studies are necessary to clarify the role of MPS in CPSP.

Cell-based therapy for stroke

Current treatments for stroke, such as the use of thrombolytic agents, are often limited by a narrow therapeutic time window. However, the regeneration of the brain after damage is still active days even weeks after stroke occurs, which might provide a second window for treatment. Cell-based therapy can be categorized into two strategies. One is transplantation of exogenous cells into the injured brain to replace the lost cells or support the remaining cells. The other strategy is to enhance the proliferation, differentiation, migration of endogenous stem or progenitor cells. Recent development in adult stem cell research and advancement in the induction of pluripotent stem cells from somatic adult cells provide a tremendous opportunity for transplantation therapy. Understanding the mechanisms and regulations involved in the endogenous neurogenesis will also help develop novel therapeutic interventions to promote neurogenesis and functional recovery in stroke. This review describes up-to-date progresses in cell-based therapy for the treatment of stroke.

Stem cells in the treatment of stroke

Stroke is an often devastating insult resulting in neurological deficit lasting greater than 24 hours. In the United States, stroke is the third leading cause of death. In those who do not succumb, any outcome from total recovery over a period of weeks to months to persistent profound neurological deficits is possible. Present treatment centers on the decision to administer tissue plasminogen activator, subsequent medical stabilization and early intervention with rehabilitation and risk factor management. The advent of stem cell therapy presents an exciting new frontier for research in stroke treatment, with the potential to cause a paradigm shift from symptomatic control and secondary prevention to reconstitution of neural networks and prevention of neuronal cell death after neurologic injury.

Tissue factor expression in the symptomatic carotid plaque

Background

The aims of this study were to identify that the differences in the natural history of patients with symptomatic and asymptomatic carotid stenosis may be reflected in differences in the expression of procoagulant protein factors.

Methods

Carotid artery plaques were obtained from 33 symptomatic and 4 asymptomatic patients with internal carotid artery stenosis of greater than 70%. These plaques were stained with monoclonal antibody against human tissue factor. Areas of staining for the cap and core were analysed using the analySIS computer programme.

Results

There were 37 patients, of whom 27 were male with a mean age 69.3 years and a range of 53 to 83 years. Statistical analysis using non-parametric tests revealed a significant increase in the area of positive staining for tissue factor in plaques taken from symptomatic patients when compared to those who were asymptomatic (P = 0001). Within the symptomatic patients group there was significantly increased tissue factor in the plaque core of those who were the most recently symptomatic (P = 0.003).

Conclusions

The unstable carotid artery plaque is associated with significantly increased tissue factor expression in the cap and core. Plaques from the most recently symptomatic patients have significantly more tissue factor in the core and this may represent part of the mechanism responsible for plaque destabilisation. More research is needed in this important area.

Keywords

Tissue Factor; Carotid stenosis; Stroke; Plaque stability

Potential of adult neural stem cells in stroke therapy

Despite state-of-the-art therapy, clinical outcome after stroke remains poor, with many patients left permanently disabled and dependent on care. Stem cell therapy has evolved as a promising new therapeutic avenue for the treatment of stroke in experimental studies, and recent clinical trials have proven its feasibility and safety in patients. Replacement of damaged cells and restoration of function can be accomplished by transplantation of different cell types, such as embryonic, fetal or adult stem cells, human fetal tissue and genetically engineered cell lines. Adult neural stem cells offer the advantage of avoiding the ethical problems associated with embryonic or fetal stem cells and can be harvested as autologous grafts from the individual patients. Furthermore, stimulation of endogenous adult stem cell-mediated repair mechanisms in the brain might offer new avenues for stroke therapy without the necessity of transplantation. However, important scientific issues need to be addressed to advance our understanding of the molecular mechanisms underlying the critical steps in cell-based repair to allow the introduction of these experimental techniques into clinical practice. This review describes up-to-date experimental concepts using adult neural stem cells for the treatment of stroke.

Is there a sex or race difference in stroke mortality?

OBJECTIVES

We sought to confirm previous studies for the presence and direction of sex and race difference in stroke mortality.

METHODS

Administrative data for 40,450 Medicare beneficiaries who were hospitalized in 1994 to 1996 with acute stroke were used in regression analyses to study sex and race differences in 1-year all-cause mortality among patients with different types of stroke and cause-specific mortality in patients with all types of stroke combined. Hazard ratios were adjusted for age, sex or race, state, year of index stroke, past stroke, subsequent stroke, and fatal coexisting conditions excluding cerebrovascular diseases.

RESULTS

Men with ischemic cerebral infarction, nonspecific stroke, or all types of stroke combined were at 21% to 35% higher risk of all-cause mortality than women, but there was no sex difference among patients with subarachnoid or intracerebral hemorrhage. Nonwhite patients with ischemic cerebral infarction had 11% higher all-cause mortality than white patients, but there were no race differences after adjustments for fatal coexisting conditions. Compared with women, mortality was higher in men with all types of stroke regardless of the cause of death. There was higher risk of death caused by cerebrovascular diseases in white patients with all types of stroke combined, but the risk of death caused by cardiovascular diseases other than ischemic heart disease was higher in nonwhite patients.

CONCLUSIONS

There was no sex or race difference in all-cause mortality in patients with hemorrhagic stroke and higher risk in men with ischemic and nonspecific stroke. Relatively higher risk of mortality caused by cerebrovascular diseases was found in men and white patients.

Urbanization and stroke prevalence in Taiwan: analysis of a nationwide survey

This study aims to explore the prevalence of strokes among individuals and the association with urbanization levels. A total sample of 9,794 individuals was obtained from a nationwide survey on Taiwan for subsequent analysis in this study. After adjusting for gender, age, other risk factors for stroke and individual socioeconomic status, a multivariate logistic regression model was employed to investigate the relationships existing between the prevalence of strokes and the level of urbanization. This study finds that those living in areas at the highest level of urbanization (level 1) had the highest prevalence of strokes (2.49%). With decreasing urbanization level, there was a general decline in stroke prevalence. After adjusting for other factors, the multivariate logistic regression analyses showed that compared to participants living in the highest urbanization level, the respective odds ratios of suffering a stroke for those living in areas at the lowest levels of urbanization (levels 7 and 8), were 0.43 and 0.30. We conclude that after adjusting for other stroke risk factors, the level of urbanization is an important contributory factor to the overall prevalence of strokes in Taiwan.

Cerebral ischemia probably related to isotretinoin

OBJECTIVE

To report a case of cerebral ischemia in a patient receiving oral isotretinoin for severe acne.

CASE SUMMARY

A 30-year-old right-handed man was admitted for left facial paralysis and dysarthria. He had received oral isotretinoin 45 mg/day for 3 months for treatment of severe acne. A cerebral computed tomography scan showed hypodensity in the right middle cerebral territory corresponding to cerebral ischemia. The patient reported having experienced a similar episode 7 years before, after 3 months' treatment with oral isotretinoin. No risk factors were identified. Isotretinoin was discontinued on admission and the disorders resolved.

DISCUSSION

Our patient did not present thrombotic risk factors and was not being treated with any drug other than isotretinoin; however, he developed 2 episodes of cerebral ischemia following 2 episodes of oral isotretinoin treatment. According to the Naranjo probability scale, the relationship of cerebral ischemia to administration of isotretinoin was probable. Other reports of thrombotic accidents, as well as some cases of hemorrhage in patients receiving isotretinoin, have been published. This drug seems to act on the coagulation process by a still unexplained mechanism.

CONCLUSIONS

Given that isotretinoin is a treatment prescribed most frequently for adolescents and young adults and that cerebral ischemia can produce serious handicaps, an evaluation of vascular risk should be made prior to treatment with this drug.

Cohort-specific trends in stroke mortality in seven European countries were related to infant mortality rates

OBJECTIVES

To assess, in a population-based study, whether secular trends in cardiovascular disease mortality in seven European countries were correlated with past trends in infant mortality rate (IMR) in these countries.

STUDY DESIGN AND SETTING

Data on ischemic heart disease (IHD) and stroke mortality in 1950-1999 in the Netherlands, England & Wales, France, and four Nordic countries were analyzed. We used Poisson regression to describe trends in mortality according to birth cohort, for the cohorts born between 1860 and 1939. Pearson correlation coefficients were calculated to determine associations between IMR and IHD, or stroke mortality.

RESULTS

IHD mortality increased for successive cohorts up to 1900, and then started to decline. Stroke mortality levels were virtually stable among birth cohorts up to 1880, but declined rapidly among later cohorts. A strong positive association was found between cohort-specific IMR levels and stroke mortality rates. There were no strong cohort-wise associations between IMR and IHD mortality.

CONCLUSION

These results support other studies in suggesting that living conditions in early childhood may influence population levels of stroke mortality. Future studies should determine the contribution of specific early life factors to the mortality decline in IHD and especially stroke.

Stroke Risk among Chinese Immigrants in New York City

BACKGROUND

Little is known of risk factors for stroke among Chinese immigrants to the United States. We have conducted a case-control study to identify risk factors for stroke among foreign-born Chinese in New York City.

METHODS

From September 2000 to June 2003, 187 sequential stroke cases (44 hemorrhagic) and 204 controls matched on age, gender, and years since immigration were recruited from New York Downtown Hospital, which was located next to New York City Chinatown. Risk factor status was assessed by questionnaire interview and medical chart review, which included clinical factors, sociodemographic characteristics, personal and family histories, and behavior and lifestyle factors, as well as behavioral changes after immigration to the United States.

RESULTS

For cases and controls, mean ages were 74.8 and 74.7 years, 47.3% of cases and 47.5% of controls were male, and mean years since immigration to the United States were 26.7 and 26.8, respectively. Sociodemographic characteristics and behavioral pattern including cigarette smoking, exercise, and usage of special diet or dietary supplements were similar between cases and controls. However, stroke patients were more likely to have hypertension (76% vs. 59%, p<or/=0.001), increased blood pressure (165/84 mmHg vs. 140/74 mmHg, p<or=0.001) and left ventricular hypertrophy (LVH) (10.1% vs. 4.3%, p<or=0.05), and less likely to consume poultry (odds ratio 0.80, 95% confidence interval (CI) 0.59-1.00); fish (0.70, 95% CI 0.42-0.96), fruit and vegetable juice (0.83, 95% CI 0.70-0.95), and grains (0.79, 95% CI 0.62-0.96) than were controls.

CONCLUSION

Among Chinese immigrants in New York City, as in general population, poor controlled hypertension was related to the risk of stroke. Therefore, Chinese immigrants presenting with hypertension and/or a family history of hypertension should be detected and followed up regularly to monitor the blood pressure level. In addition, difference in food intake between stroke and control patients may present an opportunity for behavior intervention to prevent stroke.

Change in quality of life of people with stroke over time: True change or response shift?

In many studies, assessments of change in self-report measures such as health-related quality of life must account for potential response shift, including reconceptualization and changes in internal standards of measurement.

OBJECTIVE

The objective of our study was to compare healthy controls and individuals with stroke on the extent to which changes in internal standards and reconceptualization of health related quality of life (HRQL) occurs over the first 6 months post-stroke.

METHODS

Confirmatory factor analysis was used to assess invariance of the SF-36 measurement model over time among 238 individuals with stroke and 392 controls, separately. This procedure assessed changes over time in the factor loadings, variances, and covariances of responses, and compared the extent of change between individuals with stroke and those in the control group. In addition a multisample comparison was made between individuals with stroke and members of the control group at the first evaluation in order to assess invariance of the SF-36 measurement model between the groups. The controls were considered to be a 'proxy' for the stroke cohort prior to the stroke.

RESULTS

We found no evidence of reconceptualization and changes in internal standards over time when the groups were assessed separately. There was a significant difference in the factor covariances (reconceptualization) between the two groups at the time of the first evaluation. However, measurement error was also significant for this comparison.

CONCLUSION

This study indicates that the improvement in HRQL over time is real rather than a result of reconceptualization or a recalibration. If response shift does occur with stroke it is likely to be mediated by the event itself and not the recovery process.

Diabetes mellitus as a risk factor for stroke incidence and mortality in Mexican American older adults

BACKGROUND

Little is known regarding diabetes mellitus as a risk factor for stroke incidence and death in older Mexican Americans. The authors studied diabetes and other potential risk factors for stroke in a sample of community-dwelling older Mexican Americans.

METHODS

A prospective cohort design was used that involved the Hispanic Established Population for the Epidemiologic Study of the Elderly, a longitudinal study using a weighted probability sample of Mexican Americans (aged older than 65 years) living in the southwestern United States. 3050 older Mexican American persons were originally interviewed and tested at baseline and then followed with reassessment at 2, 5, and 7 years. The incidence of stroke and stroke death were studied for the participants during a 7-year follow-up period.

RESULTS

690 participants were identified at baseline with diabetes. 238 participants experienced a first-time stroke during the follow-up period. 66 died as a result of a stroke. Cox proportional hazard regression analysis revealed an increased hazard ratio (HR) for stroke in persons with diabetes (HR, 1.80; 95% confidence interval [CI], 1.32 to 2.44; p <.0002) when adjusted for age, sex, body mass index, smoking, systolic blood pressure, previous heart attack, and lower extremity function. The stroke mortality rate was also higher (HR, 2.02; 95% CI, 1.04 to 3.93) for persons with diabetes when adjusted for covariates.

CONCLUSION

Diabetes was associated with an increased incidence of stroke and death in older Mexican Americans, particularly those taking insulin.

Education level and mortality in systemic lupus erythematosus (SLE): Evidence of underascertainment of deaths due to SLE in ethnic minorities with low education levels

OBJECTIVE

To determine if socioeconomic status, as measured by education level, is associated with mortality due to systemic lupus erythematosus (SLE), and to determine if these associations differ among ethnic groups.

METHODS

Sex- and race-specific mortality rates due to SLE by education level were computed for persons age 25-64 years using US Multiple Causes of Death data from 1994 to 1997. SLE-specific mortality rates were compared with all-cause mortality rates in 1997 to determine if the association between education level and mortality in SLE was similar to that in other causes of death.

RESULTS

Among whites, the risk of death due to SLE was significantly higher among those with lower levels of education, and the risk gradient closely paralleled the 1997 all-cause mortality risks by education level. However, in African American women and men and Asian/Pacific Islander women, the risk of death due to SLE was lower among those with lower education levels, contrary to the associations between education level and all-cause mortality in these groups. Comparing the distribution of education levels among deaths due to SLE and all deaths in 1997, persons with lower education levels were underrepresented among deaths due to SLE in African Americans and Asian/Pacific Islanders.

CONCLUSION

Among whites, higher education levels are associated with lower mortality due to SLE. These associations were not present in ethnic minorities, likely due to underascertainment of deaths due to SLE in less-well educated persons. This underascertainment may be due to underreporting of SLE on death certificates, but may also represent underdiagnosis of SLE in ethnic minorities with low education levels.

Stroke in the female: role of biological sex and estrogen

Women are protected from stroke relative to men until the years of menopause. Because stroke is the leading cause of serious, long-term disability in the United States, modeling sex-specific mechanisms and outcomes in animals is vital to research. Important research questions are focused on the effects of hormone replacement therapy, age, reproductive status, and identification of sex-specific risk factors. Available research relevant to stroke in the female has almost exclusively utilized rodent models. Gender-linked stroke outcomes are more detectable in experimental studies than in clinical trials and observational studies. Various estrogens have been extensively studied as neuroprotective agents in women, animals, and a variety of in vitro models of neural injury and degeneration. Most data in animal and cell models are based on 17 beta estradiol and suggest that this steroid is neuroprotective in injury from ischemia/reperfusion. However, current evidence for the clinical benefits of hormone replacement therapy is unclear. Future research in this area will need to expand into stroke models utilizing higher order, gyrencephalic animals such as nonhuman primates if we are to improve extrapolation to the human scenario and to direct and enhance the design of ongoing and future clinical studies and trials.

Evaluation of postural stability in the elderly with stroke

OBJECTIVE

To compare clinical and biomechanical measures of balance in elderly stroke patients with those of healthy elderly people.

DESIGN

Two-group comparison design.

SETTING

Laboratory environment.

PARTICIPANTS

Fifteen poststroke patients and 15 healthy age-matched older adults (N=30).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The biomechanical variable COP-COM, which represents the distance between the center of pressure (COP) and the center of mass (COM) in terms of root mean square. The mean of 4 trials of the COP-COM variable for each test condition was used for statistical analysis. Furthermore, the different systems (sensory, motor, central processor) related to postural stability were evaluated.

RESULTS

Statistical significance of the COP-COM variable was larger in the stroke group than in healthy subjects, in both the anteroposterior (AP) and mediolateral (ML) directions. Furthermore, statistically, stroke subjects showed amplitudes of the COP-COM variable that were significantly larger in the eyes-closed condition. The significant negative correlation demonstrated between COP-COM amplitude and the balance scales (Berg, Tinetti) indicated that the patients with larger COP-COM amplitudes had lower clinical balance score. Furthermore, correlation coefficient scores between COP-COM variables in both AP and ML directions and motor performance using Fugl-Meyer Assessment (rho=-.53, rho=-.51, respectively) and reaction time (rho=-.53, rho=-.44, respectively) were significant. Vibration (rho=.41) and touch-pressure (rho=.42) perception thresholds correlated significantly only in the AP direction.

CONCLUSIONS

Evaluating postural stability with COP-COM variable provided an accurate measure of postural stability in poststroke elderly people. Furthermore, postural stability in quiet stance, as measured by COP-COM amplitude, was related to functional measures of balance as well as physiologic factors relating to balance, such as visual conditions, lower-extremity peripheral sensibility, motor recovery, and simple reaction time.

Clinical and ethnic characteristics of stroke in an Israeli population: a study in a community hospital population

Background: Stroke mainly affects the older population, although it has also been reported in younger patients. In this study, we focused on patients 65 years of age or younger with stroke. Methods: The files of three patient populations were studied: 93 patients aged 65 years or younger with stroke (group A), 93 patients older than 65 with stroke (group B), and 604 patients without stroke representing the general population of patients admitted to our service during January 2000 (group C). We reviewed the patient files and compared patient characteristics, epidemiological features, clinical picture,imaging findings, and coagulation tests. Results: Overall, 318 patients were studied. The mean age of group A was 55 years compared to 77 years in group B and 71 years in group C. In both stroke groups (A and B), the male: female ratio was 2:1, in contrast with a balanced ratio in group C. Most of the patients in group A (63%) were of Sephardic origin compared to 39% in group B (P=0.002) and 30% in group C. The clinical picture in both stroke groups (A and B) was similar. The risk factor smoking was reported by 45% in group A and by only 29% in group B (P=0.034). Hypertension, diabetes mellitus, and hyperlipidemia were evenly prevalent in both stroke groups. The coagulation system was studied in the "young" patients (group A): hyperhomocysteinemia was found in 37%, high titers of anticardiolipin antibodies in 35%, low levels of antithrombin III in 13%, protein C deficiency in 5%, and activated protein C resistance (APCR) in 4%. Overall, 49% of the patients from group A were found to have coagulation abnormalities. Conclusions: We found in our study that the younger patient with stroke tends to be a Sephardic male with the classical risk factors as well as a history of smoking and coagulopathy. These findings suggest strict medical supervision and primary prophylaxis. This work also lays the basis for a prospective, interventional trial with younger patients.

The psychosocial determinants of hypertension

AIM

To present currently available evidence on the role that adverse psychosocial factors play in the pathogenesis of hypertension. The specific objectives of the review were to (1) provide a picture of what is known about the relationship between psychosocial factors and hypertension, (2) summarize the major methodological and conceptual pitfalls, and (3) identify gaps in the literature and suggest areas for future research.

DATA SYNTHESIS

The scope of the literature review was adults and the literature published since 1990 (acknowledging that some articles published earlier would need to be taken into account). A number of journal searches were carried out. They included Medline, PsychInfo, and SocioFile, with keywords, such as hypertension, blood pressure, psychosocial, psychological, social, acculturation, occupation, socio-economic status, social class, education, depression, anger, and anxiety. The search included articles related to hypertension in developed countries and was limited to studies in the English language.

CONCLUSION

A growing body of evidence supports the thesis that psychosocial factors play a role in the pathogenesis for hypertension.

Changes in the status of hospitalized stroke patients since inception of the prospective payment system in 1983

OBJECTIVE

To describe epidemiologically the changes in acute-care delivery services for stroke victims since the inception of the 1983 prospective payment system (PPS).

DESIGN

A cross-sectional comparison of 2 acute-care hospitalized samples of stroke patients before and after implementation of PPS.

SETTING

Fifteen acute-care hospitals.

PARTICIPANTS

A total of 1992 stroke patients discharged from 15 acute care hospitals in 1995-1996 were compared with 1665 patients studied in the same geographic area in 1981-1982.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Incidence rates, length of stay (LOS), discharge destinations, in-hospital transfers, and mortality.

RESULTS

Incidence rates between the 2 time periods remained similar (1.13-1.14/1000). Major changes between 1981-1982 and 1995-1996 included reengineering of hospitals to establish subacute units with an increased use of rehabilitation units, a 63% decrease in acute hospital LOS, a 44% increase in discharges to long-term care facilities, a 39% decrease in mortality, and a 5% decrease in discharge to home. Age (avg, 71y), gender, and living arrangements confounded discharge destinations. Significantly more men in 1995-1996 had strokes at younger ages, but overall 53% were women.

CONCLUSIONS

Institution of the PPS has dramatically influenced hospital LOS, location of treatment, and discharge destinations with no improvement in home discharges.

Accuracy of self-reported stroke among elderly veterans

The objective was to use secondary analysis of prevalence data from a prospective cohort study to ascertain the accuracy of self-reported stroke among veterans. The study comprised a community-dwelling population of 88 elderly veterans (from five counties in the Northern Piedmont of North Carolina, USA) who received health care at the local Veterans Health Administration (VHA) medical center and were respondents at the North Carolina site of the NIH-funded Established Populations for Epidemiologic Studies of the Elderly (EPESE) project. Self-report of stroke from the baseline interview of the EPESE project; and occurrence of stroke as verified by the national VHA hospital discharge database and the patients' medical records was measured. Results showed that self-report of stroke had a sensitivity of 86% and a specificity of 100%; the predictive value of a positive report was 100%. Veterans' self-reports of stroke are sufficiently accurate to use in preliminary epidemiological studies and health services research of cerebrovascular disease.

Ratings of physical function obtained by interview are legitimate for patients hospitalized after stroke

This study was conducted to examine the legitimacy of Barthel Index (BI) scores and subset of Functional Independence Measure (FIM) scores obtained by interview from patients hospitalized after stroke. This study included 82 patients with stroke. Interviews by a trained study coordinator were conducted to obtain BI and FIM subset (transfer, locomotion, feeding) scores from patients or a knowledgeable proxy. In addition, therapists' observational FIM scores on subset items recorded in the medical record were retrieved. The reliability, responsiveness, and validity of the BI and FIM subset were examined using Cronbach's alpha, effect size calculations, Wilcoxon tests, Spearman (r(S)) correlations, and regression analysis. Statistical analysis indicated that the post-stroke interview BI (.952) and FIM subset (.939) scores had excellent internal consistency. Large effect sizes and Wilcoxon test results between the prestroke and poststroke interview scores for the BI and FIM subset (z, -3.739 to -6.168) indicated that these 2 instruments were responsive to changes in patients' physical function status that accompanied stroke. Excellent correlations were found between BI and FIM interview scores poststroke (r(s), .913 to .971). The FIM subset interview scores and therapists' scores showed correlations that were moderate to good (r(s), .508 to .754). Length of stay correlated significantly with both the interview BI score (r(s), -.604) and the interview FIM subset score (r(s), -.583). Length of stay was correlated also with the National Institutes of Health Stroke Scale scores (r(s), .484). The regression analysis depicted the BI interview scores as the best predictor of the length of stay. Results provide support for the use of functional scores obtained by interview from hospitalized stroke patients. Both the BI and the FIM subset examined in this study are legitimate for this purpose.

The association of blunted nocturnal blood pressure dip and stroke in a multiethnic population

Nondipping has been defined as a reduction in the mean systolic and diastolic blood pressure (BP) of <10% from awake to sleep. We hypothesized that nondipping might be associated with stroke in minority populations. We monitored BP over a 24 h period with an ambulatory device in 166 cases from a multiethnic population of stroke survivors (63 blacks, 61 non-Hispanic whites, and 42 Caribbean Hispanics, aged 69.5 +/- 11 years) and 217 community control subjects (73 blacks, 107 non-Hispanic whites, and 67 Caribbean Hispanics, aged 69 +/- 9 years). Prevalence of nondipping was significantly greater among cases than among control subjects (64% v. 37%, P < .001). In a multiple logistic regression model adjusted for traditional risk factors for stroke, nondipping conferred an increased risk for stroke. Probability of stroke associated with nondipping (odds ratio (OR) 2.5, confidence interval (CI) 1.6 to 4.0) was equal to that of traditional risk factors. Nondipping increased the chance of having a stroke in both non-Hispanic whites (OR 4.2, P < .001) and blacks/Caribbean Hispanics (OR 1.9, P = .03). The strength of the contribution of nondipping to stroke risk was similar in all ethnic groups. Nondipping was associated with stroke in both men and women. Given the previous reports that nondipping contributes to stroke risk in European and Asian populations, these data suggest that nondipping may be universally associated with risk for stroke.

Factors affecting the diagnosis of peripheral vascular disease before vascular surgery referral

OBJECTIVE

Many new patients evaluated by vascular surgeons are referred by internal medicine physicians (IMPs). Objectives shared by vascular surgeons and IMPs include early identification of peripheral arterial disease (PAD), improved referral relationships, and reduction of health care costs. The approach to PAD by IMPs and identification of deficiencies that might contribute to suboptimal care form the basis for this report.

METHODS

An anonymous survey was mailed to all IMPs (n = 843) in the central and southern parts of Illinois. Questions concerned IMP demographics, approach to diagnostic testing, referral patterns, perception of adequacy of education of PAD, and how often parts of the history and physical examination for PAD would be performed on the initial office visit of a hypothetical 65-year-old male with hypertension (each answer measured as 0%-25%, 25%-50%, 50%-75%, and 75%-100% of the time completed).

RESULTS

There was a response from 360 IMPs: 230 IMPs (27.3%) returned the questionnaire, and 130 IMPs (15.4%) declined to participate. Practice locations for IMPs returning the questionnaire included rural (36%), suburban (22%), and urban (40%). Practice types included academic (7%), solo private (29%), group private (53%), and other (14%). A history of cardiac disease was obtained most of the time by 92% of IMPs (75%-100% answer category). Histories for pulmonary disease, diabetes mellitus, stroke, and smoking were obtained most of the time with similar frequencies (85%, 86%, 73%, and 96%, respectively). In contrast, only 37% obtained a history for claudication, and 26% obtained a history for foot ulceration 75% to 100% of the time (P <.05, all comparisons). Examination of the heart (95%) and lungs (96%) occurred most of the time (75%-100% answer category) compared with each part of the pulse examination (range, 34%-60%; P <.05, all comparisons) and aortic aneurysm palpation (39%; P <.05). If pedal pulses were absent, examination by IMPs with Doppler scan and ankle-arm indices were mostly distributed in the 0% to 25% answer category (79% and 79%, respectively). After suspecting PAD, most IMPs obtained diagnostic tests first compared with specialist referral: carotid disease (91% vs 9%), aortic aneurysm (91% vs 9%), and lower extremity PAD (86% vs 14%). Initial referral patterns were made to vascular surgeons (49%), general surgeons (33%), cardiothoracic surgeons (13%), cardiologists (4%), and radiologists (1%). Most IMPs believed medical school (70%) and residency (73%) provided adequate training for PAD diagnosis.

CONCLUSIONS

Deficiencies may exist in the identification of PAD by IMPs that could adversely affect diagnosis, time to referral, health care costs, and ultimately, patient outcome. Improvements in medical school education and IMP training in the diagnosis of PAD are needed.

Why do we have a stroke belt in the southeastern United States? A review of unlikely and uninvestigated potential causes

Although there is widespread recognition of a region with high stroke mortality in the southeastern United States that has persisted over the past 50 years (ie, the "stroke belt"), there is little agreement as to its underlying cause(s). Herein, we review data supporting 10 potential causes for the stroke belt, and assess: (1) the likelihood that each is the contributing factor to the excess mortality, and (2) areas of investigation where data are lacking and that require additional research efforts.

The sequelae of hospitalization for ischemic stroke among older adults

OBJECTIVES

To estimate the independent effect of hospitalization for ischemic stroke on change in functional status, subsequent hospitalization, and mortality.

DESIGN

Secondary analysis of the nationally representative Longitudinal Study on Aging. Baseline (1984) interview data were linked to Medicare hospitalization and death records for 1984-1991 and to functional status reports at three biennial follow-ups.

SETTING

In-person and telephone interviews were conducted.

PARTICIPANTS

A total of 6071 noninstitutionalized respondents 70 years old or older at baseline.

MEASUREMENTS

Hospitalization for ischemic stroke was defined as having one or more episodes with primary discharge ICD9-CM codes of 433.0-434.9, 436, and 437.0-437.1. Two reference groups were used: those who were hospitalized for something other than stroke, and those who were not hospitalized at all. The statistical methods employed were multivariable proportional hazards, logistic, and linear regression.

RESULTS

The adjusted hazards ratio for having a primary hospital discharge diagnosis of ischemic stroke on mortality was 7.57 (CI95% = 6.47 to 8.85) versus 3.67 (CI95% = 3.28 to 4.10) for having been hospitalized for something other than stroke (both compared with the reference category of those not hospitalized at all). The adjusted odds ratio for having any subsequent hospitalization associated with having a primary hospital discharge diagnosis of ischemic stroke (compared with having been hospitalized for something other than stroke) was not significantly elevated (AOR = 1.16; CI95% = .94 to 1.42). However, the percent increases in the subsequent number of hospital episodes, total charges, and total length of stay for those who were hospitalized for ischemic stroke relative to those hospitalized for something other than stroke were significant (P < .001), and ranged from 16.3 to 39.0%. Hospitalization for ischemic stroke was also related significantly to greater increases in the regression-adjusted mean number of instrumental activities of daily living and lower body function limitations at follow-up.

CONCLUSION

Hospitalization for ischemic stroke among older adults substantially increases the risk of subsequent mortality, the volume of hospital resource consumption, and greater functional decline, even when compared with hospitalization for something other than stroke. Therefore, greater attention to the prevention and management of ischemic stroke is needed.

Sociodemographic differences among members of two ethnic groups in a geriatric rehabilitation unit in Israel

The Assessment of Dependency for Long-Term Care Benefits form was used to explore differences among 336 elderly Ashkenazi and Sephardi Jews during their first phase of recovery in a geriatric rehabilitation unit in Israel. Sephardi Jews were more likely to be younger, widowed at an earlier age, poorer, less educated, hold less prestigious jobs, and have fewer social roles. They were also more likely to be religious and to live in multigenerational households. In contrast, a higher proportion of Ashkenazi Jews owned their own houses or apartments and lived only with their spouses. No differences were observed in these two groups in terms of the number and duration of visits they received during their hospitalization; most of them had fairly extensive visits. Most of these elderly people reported having good family relationships. This perception was related to their living arrangements, number of social roles, marital situation, level of education, and identity of the main visitor during their hospitalization. Patients' social roles affected both the number of visits they received and the perceived relationships within the family.

The risk of hospitalization for ischemic stroke among older adults

OBJECTIVES

The purpose of this study was to identify risk factors for stroke and to estimate their relative importance in a large, nationally representative sample of very old men and women.

METHODS

The study was designed as a secondary analysis of the Longitudinal Study on Aging. Baseline (1984) in-person interview data were linked to Medicare hospitalization records for 1984 to 1991. Participants were 6,071 noninstitutionalized adults 70 years old or older at baseline. Hospitalization for ischemic stroke was defined as having one or more episodes with a primary discharge diagnosis containing ICD-9-CM codes of 433.0-434.9, 436, and 437.0-437.1. Multivariable proportional hazards regression was used to estimate the risks associated with previously identified epidemiologic factors.

RESULTS

Five hundred and three persons (8.3%) had at least one primary discharge diagnosis of ischemic stroke. In descending order of importance-based on the partial r statistics associated with their adjusted hazards ratios (AHRs), the salient risk factors were having a previous history of stroke (AHR = 2.86), age (AHR = 1.04 per year), diabetes (AHR = 1.78), male gender (AHR = 1.42), lower body limitations (AHR = 1.09 per limitation), arthritis (AHR = 0.74), hypertension (AHR = 1.29), and poverty (AHR = 1.33).

CONCLUSION

Patients presenting with the high risk factors identified in this study should be considered for further evaluation and monitoring. Current protocols for the therapeutic management of these higher risk patients should be considered, and compliance should be encouraged.

[Socioeconomic characteristics of patients with stroke]

We studied the socioeconomic status of 206 stroke patients seen at Escola Paulista de Medicina--São Paulo in the period of 1991-1992. We found that 25% of patients were less than 50 years old; men were married significantly more often than women; 82% of patients had less than 8 years of formal education and 60% of the families survived with US$ 98 to 198. The socioeconomic impact caused by a stroke is very important. Low education and poverty influence the treatment and prevention of the disease. The Social Assistance Service can detect and attempt to solve the social problems in order to obtain a better control of systemic diseases and risk factors for stroke, and to give orientation concerning the local resources.

Educational needs of stroke survivors and their family members, as perceived by themselves and by health professionals

This study identified informational needs of stroke survivors and their family members as perceived by themselves and by health professionals. The source of information, and the desired source for future information were also explored. Green's Precede-Proceed model was used as a theoretical framework. In the study 35 stroke survivors, 39 family members and 43 health professionals participated. The results show that stroke survivors and family members indicated to desire the most information regarding reducing the chance of a new stroke. Stroke survivors rated as the major gaps of information: reducing the chance of a new stroke and coping with stress. Family members rated as the major gaps of information: sources to apply for help; strategies to perform activities of daily living, and reducing the chance of a new stroke. Stroke survivors and their family members expressed as the most desired source of information the doctor in the hospital. Health professionals expressed a high level of concern about the amount of information stroke survivors and family members receive; they expressed a substantial need for information about all topics for both groups, which should be provided by several sources. Some needs are recognized, but in most cases not met. Family members of stroke survivors who suffered more than one stroke seem to have received more information--and to desire less. Both highly educated stroke survivors and family members indicate to have received less information and desire more information than lower educated respondents.

Thrombolytic therapy with streptokinase in acute ischemic stroke

BACKGROUND

In patients with acute ischemic stroke, early treatment with thrombolytic agents is thought to permit reperfusion of ischemic neurons and to promote recovery of function. The Multicenter Acute Stroke Trial-Europe (MAST-E) was designed to assess the efficacy and safety of streptokinase in patients with acute ischemic stroke.

METHODS

Patients with moderate-to-severe ischemia in the territory of the middle cerebral artery were randomly assigned to receive streptokinase (1.5 million units over a period of one hour) or placebo within six hours after the onset of stroke. The primary efficacy outcome was a binary criterion combining mortality and severe disability at six months, with severe disability defined as a score of 3 or higher on the Rankin scale. The primary safety outcomes were mortality at 10 days and cerebral hemorrhage.

RESULTS

All randomized patients (156 in the streptokinase group and 154 in the placebo group) were evaluated at six months. The incidence of the primary efficacy outcome was similar in the two groups (124 patients in the streptokinase group and 126 in the placebo group died or had a Rankin score > or = 3). However, the mortality rate at 10 days was significantly higher in the streptokinase group than in the placebo group (34.0 percent vs. 18.2 percent, P = 0.002). The higher rate in the streptokinase group was mainly due to the hemorrhagic transformation of ischemic cerebral infarcts. At six months, more deaths had occurred in the streptokinase group than in the placebo group (73 vs. 59, P = 0.06).

CONCLUSIONS

In patients with acute ischemic stroke, treatment with streptokinase resulted in an increase in mortality. The routine use of streptokinase cannot be recommended in acute ischemic stroke.

Hypertension, coronary artery and cerebrovascular diseases in the population. Has epidemiology changed in the last decades?

Life expectancy has significantly increased in the last decades in many western populations, due to the fall of total and cardiovascular death rate. However, morbidity from cardiovascular diseases has decreased to a smaller extent. The overall population risk profile has improved, but it is still unsatisfactory. This is true for blood pressure control (with only 20% of hypertensive patients achieving normotension with antihypertensive drugs), hypercholesterolemia (with borderline-high serum cholesterol levels in 50% of the population), and smoking habits. Other potential causes of the poor cardiovascular prevention are: 1) a limited knowledge of the optimal blood pressure goal with antihypertensive treatment, 2) scanty information on the long term effects of antihypertensive drugs on cerebral and coronary circulation. Finally, little is being done to improve primary prevention in youth, when the slowly progressing atherosclerotic plaque formation is already on the way. To improve the cost / effectiveness of cardiovascular prevention, efforts must concentrate on the early identification of the subjects at the highest risk and on health promotion among youngsters. Large epidemiological trials conducted from the early 50s have provided convincing evidence of the multifactorial origin of cardiovascular diseases and encouraged the implementation of population based primary and secondary preventive measures, including antihypertensive treatment, as well as dietary and life-style modifications. It is now time to start asking ourselves whether or not we are satisfied with the results obtained in terms of reduced morbidity and mortality, whether these results are the direct consequence of these measures and whether or not we can do even better. The present work reviews some of the most recent comparative reports on the epidemiology of cardiovascular diseases in different populations, and some intervention trials to answer these questions and to help in identifying the most cost-effective approach to cardiovascular disease prevention in the next few years.