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Opare-Addo PA, Sarfo FS, Aikins M, Bediako SA, Ovbiagele B. Epigenetics as a target to mitigate excess stroke risk in people of African ancestry: A scoping review. J Stroke Cerebrovasc Dis 2024; 33:107585. [PMID: 38253246 PMCID: PMC11060795 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 01/12/2024] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Globally, individuals of African ancestry have a relatively greater stroke preponderance compared to other racial/ethnic groups. The higher prevalence of traditional stroke risk factors in this population, however, only partially explains this longstanding disparity. Epigenetic signatures are transgenerational and could be a plausible therapeutic target to further bend the stroke disparities curve for people of African ancestry. There is, however, limited data on epigenetics and stroke risk in this population. PURPOSE To examine existing evidence and knowledge gaps on the potential contribution of epigenetics to excess stroke risk in people of African ancestry and avenues for mitigation. MATERIALS AND METHODS We conducted a scoping review of studies published between January 2003 and July 2023, on epigenetics and stroke risk. We then summarized our findings, highlighting the results for people of African ancestry. RESULTS Of 104 studies, there were only 6 studies that specifically looked at epigenetic mechanisms and stroke risk in people of African ancestry. Results of these studies show how patterns of DNA methylation and non-coding RNA interact with lifestyle choices, xenobiotics, and FVIII levels to raise stroke risk in people of African ancestry. However, no studies evaluated epigenetic patterns as actionable targets for the influence of psychosocial stressors or social context and excess stroke risk in this population (versus others). Also, no studies interrogated the role of established or novel therapeutic agents with the potential to reprogram DNA by adding or removing epigenetic markers in people of African ancestry. CONCLUSION Epigenetics potentially offers a promising target for modifying the effects of lifestyle, environmental exposures, and other factors that differentially affect people of African ancestry and place them at relatively greater stroke risk compared to other populations. Studies that precisely assess the pathways by which epigenetic mechanisms modulate population-specific disparities in the risk of stroke are needed.
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Affiliation(s)
| | - Fred Stephen Sarfo
- Komfo Anokye Teaching Hospital, Kumasi, Ghana; Neurology Division, Kwame Nkrumah University of Science & Technology, P. O. Box 1934, Kumasi, Ghana.
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Simmonds KP, Atem FD, Welch BG, Ifejika NL. Racial and Ethnic Disparities in the Medical Management of Poststroke Complications Among Patients With Acute Stroke. J Am Heart Assoc 2024; 13:e030537. [PMID: 38390802 PMCID: PMC10944023 DOI: 10.1161/jaha.123.030537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 01/04/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND To inform clinical practice, we sought to identify racial and ethnic differences in the medical management of common poststroke complications. METHODS AND RESULTS A cohort of acutely hospitalized, first-time non-Hispanic White (NHW), non-Hispanic Black, and Hispanic patients with stroke was identified from electronic medical records of 51 large health care organizations (January 1, 2003 to December 5, 2022). Matched propensity scores were used to account for baseline differences. Primary outcomes included receipt of medication(s) associated with the management of the following poststroke complications: arousal/fatigue, spasticity, mood, sleep, neurogenic bladder, neurogenic bowel, and seizure. Differences were measured at 14, 90, and 365 days. Subgroup analyses included differences restricted to patients with ischemic stroke, younger age (<65 years), and stratified by decade (2003-2012 and 2013-2022). Before matching, the final cohort consisted of 348 286 patients with first-time stroke. Matching resulted in 63 722 non-Hispanic Black-NHW pairs and 24 009 Hispanic-NHW pairs. Non-Hispanic Black (versus NHW) patients were significantly less likely to be treated for all poststroke complications, with differences largest for arousal/fatigue (relative risk (RR), 0.58 [95% CI, 0.54-0.62]), spasticity (RR, 0.64 [95% CI, 0.0.62-0.67]), and mood disorders (RR, 0.72 [95% CI, 0.70-0.74]) at 14 days. Hispanic-NHW differences were similar, albeit with smaller magnitudes, with the largest differences present for spasticity (RR, 0.67 [95% CI, 0.63-0.72]), arousal/fatigue (RR, 0.77 [95% CI, 0.70-0.85]), and mood disorders (RR, 0.79 [95% CI, 0.77-0.82]). Subgroup analyses revealed similar patterns for ischemic stroke and patients aged <65 years. Disparities for the current decade remained significant but with smaller magnitudes compared with the prior decade. CONCLUSIONS There are significant racial and ethnic disparities in the treatment of poststroke complications. The differences were greatest at 14 days, outlining the importance of early identification and management.
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Affiliation(s)
- Kent P Simmonds
- Department of Physical Medicine and Rehabilitation UT Southwestern Medical Center Dallas TX USA
| | - Folefac D Atem
- Department of Physical Medicine and Rehabilitation UT Southwestern Medical Center Dallas TX USA
- Department of Biostatistics University of Texas Health Science Center at Houston School of Public Health Houston TX USA
| | - Babu G Welch
- Department of Neurological Surgery UT Southwestern Medical Center Dallas TX USA
| | - Nneka L Ifejika
- Department of Physical Medicine and Rehabilitation UT Southwestern Medical Center Dallas TX USA
- Department of Neurology UT Southwestern Medical Center Dallas TX USA
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Opare-Addo PA, Sarfo FS, Berchie PO, Aikins M, Ovbiagele B. Participation by patients from low- and middle-income countries (LMICs) in trial evidence supporting secondary stroke prevention guideline recommendations. J Neurol Sci 2023; 448:120641. [PMID: 37028264 DOI: 10.1016/j.jns.2023.120641] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND One out of every four strokes is a highly preventable recurrent stroke. However, while low-and-middle-income countries (LMICs) experience a disproportionate global burden of stroke, individuals in these regions seldomly participate in pivotal clinical trials, which form the basis for international expert consensus guideline recommendations. OBJECTIVE To evaluate a contemporary and globally prominent expert consensus secondary stroke prevention guideline statement for the participation of clinical trial subjects recruited from LMICs in formulating key therapeutic recommendations. METHODS We examined the 2021 American Heart Association/American Stroke Association Guideline for the Prevention of Stroke in Patients with Stroke and TIA. All randomized controlled trials (RCTs) cited in the Guideline were independently reviewed by two authors for study populations and participating countries with a focus on trials for vascular risk factor control and management by underlying stroke mechanism. We also reviewed all cited systematic reviews and meta-analyses for the original RCTs. RESULTS Among 320 secondary stroke prevention clinical trials, 262 (82%) focused on vascular risk control addressing diabetes (n = 26), hypertension (n = 23), obstructive sleep apnea (n = 13), dyslipidaemia (n = 10), lifestyle (n = 188) and obesity (n = 2); and 58 focused on stroke mechanism management including atrial fibrillation (n = 10), large vessel atherosclerosis (n = 45) and small vessel disease (n = 3). Overall, 53 of 320 studies (16.6%) had contributions from LMICs ranging from 55.6% for dyslipidemia, 40.7% for diabetes, 26.1% for hypertension, 15.4% for OSA, 6.4% for lifestyle, 0% for obesity, and by mechanism: 60.0% for atrial fibrillation, 22.2% large vessel atherosclerosis and 33.3% for small vessel disease trials. Only 19 (5.9%) of the trials had participatory contributions from a country in sub-Saharan Africa (South Africa only). CONCLUSIONS Compared to their global burden of stroke, LMICs are underrepresented in key clinical trials used in formulating a prominent global stroke prevention guideline. While current therapeutic recommendations are likely applicable to practice settings throughout the world, greater involvement of patients from LMIC settings will enhance the contextual relevance and generalizability of recommendations to these disparate populations.
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Bensken WP, Alberti PM, Khan OI, Williams SM, Stange KC, Vaca GFB, Jobst BC, Sajatovic M, Koroukian SM. A framework for health equity in people living with epilepsy. Epilepsy Res 2022; 188:107038. [PMID: 36332544 PMCID: PMC9797034 DOI: 10.1016/j.eplepsyres.2022.107038] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/22/2022] [Accepted: 10/17/2022] [Indexed: 12/31/2022]
Abstract
Epilepsy is a disease where disparities and inequities in risk and outcomes are complex and multifactorial. While most epilepsy research to date has identified several key areas of disparities, we set out to provide a multilevel life course model of epilepsy development, diagnosis, treatment, and outcomes to highlight how these disparities represent true inequities. Our piece also presents three hypothetical cases that highlight how the solutions to address inequities may vary across the lifespan. We then identify four key domains (structural, socio-cultural, health care, and physiological) that contribute to the persistence of inequities in epilepsy risk and outcomes in the United States. Each of these domains, and their core components in the context of epilepsy, are reviewed and discussed. Further, we highlight the connection between domains and key areas of intervention to strive towards health equity. The goal of this work is to highlight these domains while also providing epilepsy researchers and clinicians with broader context of how their work fits into health equity.
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Affiliation(s)
- Wyatt P Bensken
- Department of Population and Quantitative Health Sciences, School of Medicine Case Western Reserve University, Cleveland, OH, USA.
| | - Philip M Alberti
- AAMC Center for Health Justice, Association of American Medical Colleges, Washington, DC, USA
| | - Omar I Khan
- Epilepsy Center of Excellence, Baltimore VA Medical Center US Department of Veterans Affairs, Baltimore, MD, USA
| | - Scott M Williams
- Department of Population and Quantitative Health Sciences, School of Medicine Case Western Reserve University, Cleveland, OH, USA; Department of Genetics and Genome Sciences, School of Medicine Case Western Reserve University, Cleveland, OH, USA
| | - Kurt C Stange
- Department of Population and Quantitative Health Sciences, School of Medicine Case Western Reserve University, Cleveland, OH, USA; Center for Community Health Integration, Departments of Family Medicine & Community Health, and Sociology Case Western Reserve University, Cleveland, OH, USA
| | - Guadalupe Fernandez-Baca Vaca
- Department of Neurology, University Hospitals Cleveland Medical Center, School of Medicine Case Western Reserve University, Cleveland, OH, USA
| | - Barbara C Jobst
- Department of Neurology, Geisel School of Medicine Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Martha Sajatovic
- Department of Neurology, University Hospitals Cleveland Medical Center, School of Medicine Case Western Reserve University, Cleveland, OH, USA; Department Psychiatry, University Hospitals Cleveland Medical Center, School of Medicine Case Western Reserve University, Cleveland, OH, USA
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, School of Medicine Case Western Reserve University, Cleveland, OH, USA
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Ikeme S, Kottenmeier E, Uzochukwu G, Brinjikji W. Evidence-Based Disparities in Stroke Care Metrics and Outcomes in the United States: A Systematic Review. Stroke 2022; 53:670-679. [PMID: 35105178 DOI: 10.1161/strokeaha.121.036263] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stroke disproportionately affects racial minorities, and the level to which stroke treatment practices differ across races is understudied. Here, we performed a systematic review of disparities in stroke treatment between racial minorities and White patients. A systematic literature search was performed on PubMed to identify studies published from January 1, 2010, to April 5, 2021 that investigated disparities in access to stroke treatment between racial minorities and White patients. A total of 30 studies were included in the systematic review. White patients were estimated to use emergency medical services at a greater rate (59.8%) than African American (55.6%), Asian (54.7%), and Hispanic patients (53.2%). A greater proportion of White patients (37.4%) were estimated to arrive within 3 hours from onset of stroke symptoms than African American (26.0%) and Hispanic (28.9%) patients. A greater proportion of White patients (2.8%) were estimated to receive tPA (tissue-type plasminogen activator) as compared with African American (2.3%), Hispanic (2.6%), and Asian (2.3%) patients. Rates of utilization of mechanical thrombectomy were also lower in minorities than in the White population. As shown in this review, racial disparities exist at key points along the continuum of stroke care from onset of stroke symptoms to treatment. Beyond patient level factors, these disparities may be attributed to other provider and system level factors within the health care ecosystem.
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Affiliation(s)
- Shelly Ikeme
- CERENOVUS, Johnson & Johnson, Irvine, CA (S.I., E.K.)
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Mendizabal A, Fan JH, Price RS, Hamilton RH. Feasibility and effectiveness appraisal of a neurology residency health equities curriculum. J Neurol Sci 2021; 431:120040. [PMID: 34748973 DOI: 10.1016/j.jns.2021.120040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/28/2021] [Accepted: 10/20/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Despite increasing awareness of inequities in healthcare in neurology, health equity is not a core competency of neurology training. To meet this need, we implemented a health equities curriculum for neurology residents at the Hospital of the University of Pennsylvania. METHODS A seven-lecture health equities curriculum was implemented during the 2019-2020 academic year. Surveys were distributed pre-and post-curriculum to assess resident demographics, previous training in health equities, curriculum effectiveness addressing health equities topics, and resident appraisal of the curriculum. RESULTS On average, residents attended 2-3 lectures. Most of the residents who participated were White-Non Latinx women. Residents who did not participate in the curriculum listed clinical responsibilities as the main reason for absenteeism. Residents who participated felt the curriculum was at least somewhat effective in addressing health disparities, cultural competency, and implicit bias. 64% of the residents felt the curriculum was effective in improving their preparedness in caring for underserved patients. CONCLUSION Implementing a health equities curriculum in neurology residency programs is feasible and well-received by residents. Given inconsistent attendance and a small sample size, we are unable to assess its true effectiveness. Nonetheless, residents felt it prepared them in addressing disparities in neurological care. A longer curriculum will help in assessing the effectiveness of this curriculum intervention. A standard health equities curriculum should be implemented across neurology residency programs, and health equities should be considered a core competency topic for the American Board of Psychiatry and Neurology (ABPN) certification.
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Affiliation(s)
- Adys Mendizabal
- Department of Neurology, University of California-Los Angeles, Los Angeles, CA, USA.
| | - Jessica H Fan
- Department of Neurology, University of California-San Francisco, San Francisco, CA, USA
| | - Raymond S Price
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Roy H Hamilton
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Goldberg EB, Meier EL, Sheppard SM, Breining BL, Hillis AE. Stroke Recurrence and Its Relationship With Language Abilities. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2021; 64:2022-2037. [PMID: 34043446 PMCID: PMC8740764 DOI: 10.1044/2021_jslhr-20-00347] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 11/23/2020] [Accepted: 02/20/2021] [Indexed: 06/12/2023]
Abstract
Purpose Many factors influence poststroke language recovery, yet little is known about the influence of previous stroke(s) on language after left hemisphere stroke. In this prospective longitudinal study, we investigated the role of prior stroke on language abilities following an acute left hemisphere ischemic stroke, while controlling for demographic and stroke-related factors, and examined if earlier stroke impacted language recovery at a chronic time point. Method Participants (n = 122) with acute left hemisphere ischemic stroke completed language evaluation and clinical neuroimaging. They were divided into two groups: single stroke (SS; n = 79) or recurrent stroke (RS; n = 43). A subset of participants (n = 31) completed chronic-stage re-evaluation. Factors studied included age, education, diabetes and hypertension diagnoses, lesion volume and broad location, group status, aphasia prevalence, and language scores. Results Groups did not differ in language performance across time points. The only significant group differences were that participants with RS were older, had smaller acute lesions, and were less educated. Stroke group membership (SS vs. RS) was not associated with language performance at either time point. In patients with prior stroke, large acute lesion volumes were associated with acute language performance, whereas both large acute and chronic volumes influenced recovery. Conclusions History of prior stroke in itself may not significantly influence language impairment after an additional acute left hemisphere stroke, unless it contributes substantially to the total volume of infarcted brain tissue. Chronic and acute lesion volumes should be accounted for in studies investigating poststroke language performance and recovery. Supplemental Material https://doi.org/10.23641/asha.14669715.
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Affiliation(s)
- Emily B. Goldberg
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Erin L. Meier
- Department of Communication Sciences and Disorders, Bouvé College of Health Sciences, Northeastern University, Boston, MA
| | - Shannon M. Sheppard
- Department of Communication Sciences and Disorders, Crean College of Health and Behavioral Sciences, Chapman University, Irvine, CA
| | - Bonnie L. Breining
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Argye E. Hillis
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
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Hill M. Is Stroke an Accident? J Neurosci Nurs 2021; 53:55. [PMID: 33605650 DOI: 10.1097/jnn.0000000000000581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Michelle Hill
- Questions or comments about this article may be directed to Michelle Hill, MS RN AGCNS-BC CNRN SCRN, at . Stroke Coordinator, Quality, Riverside Methodist Hospital, Columbus, OH
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Simmonds KP, Luo Z, Reeves M. Race/Ethnic and Stroke Subtype Differences in Poststroke Functional Recovery After Acute Rehabilitation. Arch Phys Med Rehabil 2021; 102:1473-1481. [PMID: 33684363 DOI: 10.1016/j.apmr.2021.01.090] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/16/2021] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Significant racial/ethnic disparities in poststroke function exist, but whether these disparities vary by stroke subtype is unknown. Study goals were to (1) determine if racial/ethnic disparities in the recovery of poststroke function varied by stroke subtype and (2) identify confounding factors associated with these racial/ethnic disparities. DESIGN Secondary analysis of the 1-year Stroke Recovery in Underserved Populations Cohort Study. SETTING Eleven inpatient rehabilitation facilities (IRFs) across the United States. PARTICIPANTS A total of 1066 patients (n=868 with ischemic stroke and n=198 with hemorrhagic stroke, N=1066) who self-identified as White (n=813), Black (n=183), or Hispanic (n=70). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES FIM scores at IRF admission, discharge, 3 months, and 12 months were modeled using multivariable mixed effects longitudinal regression. RESULTS Compared with White patients, Black (-6.1 and -4.6) and Hispanic (-10.1 and -9.9) patients had significantly lower FIM scores at 3 and 12 months, respectively. A significant (P<.01) 3-way interaction (race/ethnic*subtype*time) indicated that disparities varied by stroke subtype. The stroke subtype differences were most prominent for Black-White disparities because disparities in hemorrhagic stroke were present at IRF admission (vs 3 months for ischemic stroke). Additionally, at 12 months, the magnitude of Black-White disparities was over 3 times larger for hemorrhagic stroke (-10.4) than ischemic stroke (-3.1). Age primarily influenced Black-White disparities (especially for hemorrhagic stroke), but factors that influenced Hispanic-White disparities were not identified. Sensitivity analyses showed that there were stroke subtype differences in racial/ethnic disparities for cognitive (but not motor) function, and results were robust to adjustments for missing data because of attrition. CONCLUSIONS There are significant differences between stroke subtypes in the timing and magnitude of Black-White disparities in poststroke function. Age was a major confounding factor for Black-White disparities (particularly for hemorrhagic stroke). Overall, Hispanic patients had the lowest levels of poststroke function, and more work is needed to identify significant factors that influence Hispanic-White disparities.
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Affiliation(s)
- Kent P Simmonds
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI; DO/PhD Program, College of Osteopathic Medicine, Michigan State University, East Lansing, MI.
| | - Zhehui Luo
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI
| | - Mathew Reeves
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI
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Hussain M. Primordial prevention: The missing link in neurological care. J Family Med Prim Care 2021; 10:31-34. [PMID: 34017699 PMCID: PMC8132846 DOI: 10.4103/jfmpc.jfmpc_1806_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/25/2020] [Accepted: 11/22/2020] [Indexed: 11/04/2022] Open
Abstract
Stroke, and neurodegenerative diseases represents, a major and rapidly growing burden of mortality and morbidity. The risk factors for stroke starts very early in life. Similarly, the changes of neurodegenerative diseases starts decades earlier than the clinical manifestations. Primordial prevention is necessary to prevent the establishment of risk factors to keep the population disease free. This will help to not only increase the life span, but also to prolong the health span.
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Affiliation(s)
- Masaraf Hussain
- Department of Neurology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Mawdiangdiang, Shillong, Meghalaya, India
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Corches CL, McBride AC, Robles MC, Rehman N, Bailey S, Oliver A, Skolarus LE. Development, Adaptation and Scale-up of a Community-wide, Health Behavior Theory-based Stroke Preparedness Intervention. Am J Health Behav 2020; 44:744-755. [PMID: 33081873 DOI: 10.5993/ajhb.44.6.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objective: Acute stroke treatments reduce the likelihood of post-stroke disability, but are vastly underutilized. In this paper, we describe the development, adaptation, and scale-up of the Stroke Ready program - a health behavior theory-based stroke preparedness intervention that addresses underlying behavioral factors that contribute to acute stroke treatment underutilization. Methods: Through a community-based participatory research (CBPR) approach, we conducted needs and determinant assessments, which informed creation and pilot testing of Stroke Ready. Based on these results, we then scaled Stroke Ready to the entire community by greatly expanding the delivery system. Results: The scaled Stroke Ready program is a community-wide stroke preparedness education program consisting of peer-led workshops, print materials, and digital, social, and broadcast media campaigns. Whereas the Stroke Ready pilot workshop was delivered to 101 participants, 5945 participants have received the scaled Stroke Ready peer-led workshop to date. Additionally, we have sent mailers to over 44,000 households and reached approximately 35,000 people through our social media campaign. Conclusion: Strategies including an expanded community advisory board, adaptation of the intervention and community-engaged recruitment facilitated the scale-up of Stroke Ready, which may serve as a model to increase acute stroke treatment rates, particularly in majority African-American communities.
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Affiliation(s)
- Casey L. Corches
- Casey L. Corches, Project Manager, Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, United States;,
| | - A. Camille McBride
- A. Camille McBride, Research Assistant, Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Maria Cielito Robles
- Maria Cielito Robles, Research Area Specialist, Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Narmeen Rehman
- Narmeen Rehman, Research Assistant, Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Sarah Bailey
- Sarah Bailey, Bridges Into the Future, Flint, MI, United States
| | - Alina Oliver
- Alina Oliver, Bethlehem Temple Church, Flint, MI, United States
| | - Lesli E. Skolarus
- Lesli E. Skolarus, Associate Professor, Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, United States
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Bello UM, Chutiyami M, Salihu D, Abdu SI, Tafida BA, Jabbo AA, Gamawa A, Umar L, Lawan A, Miller T, Winser SJ. Quality of life of stroke survivors in Africa: a systematic review and meta-analysis. Qual Life Res 2020; 30:1-19. [PMID: 32712933 DOI: 10.1007/s11136-020-02591-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Functional impairments and socioeconomic constraints associated with stroke affect quality of life (QoL). With limited care and social support resources, there is a greater anticipated decline in QoL among stroke survivors in Africa. This study aims to examine post-stroke QoL, properties of outcome measures adopted and predictors of the QoL among African stroke survivors. METHODS African Journals Online, CINAHL, PsychINFO, PubMed and Web of Science databases were searched from inception to February 2020. Methodological quality was assessed using the Agency for Healthcare Research and Quality (ARHQ) methodology checklist for observational studies. RESULTS Twenty-eight studies recruiting 2572 (76.4%) stroke survivors and 795 (23.6%) healthy volunteers were included. Studies were conducted in eight African countries between 2007 and 2019. Methodological quality of studies was good. Overall, stroke survivors reported a low QoL. Six studies comparing QoL between stroke survivors and healthy controls were pooled for meta-analysis. Results showed a biased-adjusted standardised mean difference (Hedges's g) of 1.13 (95% CI 0.71 to 1.56; p < 0.001), indicating better QoL among healthy controls. Only 4 (14.3%) studies used translated or cross-culturally adapted QoL assessment tools. The most commonly reported predictor of QoL was post-stroke disability (35.8% of studies) which is followed by depression (28.6%) and stroke severity (28.6%). CONCLUSIONS Overall, African stroke survivors reported comparatively lower QoL as compared to age-matched healthy controls. This highlights the need for cross-culturally validated assessment tools and more robust post-stroke QoL evaluation across the African continent. To improve QoL of stroke survivors in Africa, early interventions should focus on reducing disability and depression associated with stroke. PROSPERO registration number: CRD42019137653.
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Affiliation(s)
- Umar Muhammad Bello
- Yobe State University Teaching Hospital, Damaturu, Yobe State, Nigeria.,Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China
| | - Muhammad Chutiyami
- Faculty of Human Sciences, Macquarie University, Sydney, Australia. .,Shehu Sule College of Nursing and Midwifery Damaturu, Damaturu, Yobe State, Nigeria.
| | - Dauda Salihu
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong, China
| | - Sham'un Isah Abdu
- Physiotherapy Department, Kazaure General Hospital, Kazaure, Jigawa State, Nigeria
| | | | - Abdulhamid Ardo Jabbo
- Department of Physiotherapy, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria
| | - Adamu Gamawa
- Physiotherapy Department, Bauchi State Specialist Hospital, Bauchi, Bauchi State, Nigeria
| | - Lawan Umar
- Physiotherapy Department, Federal Medical Centre, Azare, Bauchi State, Nigeria
| | - Aliyu Lawan
- Department of Rehabilitation Sciences, University of Maiduguri, Maiduguri, Borno State, Nigeria
| | - Tiev Miller
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China
| | - Stanley John Winser
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China
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Feldman PH, McDonald MV, Trachtenberg M, Trifilio M, Onorato N, Sridharan S, Silver S, Eimicke J, Teresi J. Reducing Hypertension in a Poststroke Black and Hispanic Home Care Population: Results of a Pragmatic Randomized Controlled Trial. Am J Hypertens 2020; 33:362-370. [PMID: 31541606 PMCID: PMC7109355 DOI: 10.1093/ajh/hpz148] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/18/2019] [Accepted: 09/11/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Uncontrolled hypertension (HTN) is a leading modifiable stroke risk factor contributing to global stroke disparities. This study is unique in testing a transitional care model aimed at controlling HTN in black and Hispanic poststroke, home health patients, an understudied group. METHODS A 3-arm randomized controlled trial design compared (i) usual home care (UHC), with (ii) UHC plus a 30-day nurse practitioner transitional care program, or (iii) UHC plus nurse practitioner plus a 60-day health coach program. The trial enrolled 495 black and Hispanic, English- and Spanish- speaking adults with uncontrolled systolic blood pressure (SBP ≥ 140 mm Hg) who had experienced a first-time or recurrent stroke or transient ischemic attack. The primary outcome was change in SBP from baseline to 3 and 12 months. RESULTS Mean participant age was 67; 57.0% were female; 69.7% were black, non-Hispanic; and 30.3% were Hispanic. Three-month follow-up retention was 87%; 12-month retention was 81%. SBP declined 9-10 mm Hg from baseline to 12 months across all groups; the greatest decrease occurred between baseline and 3 months. The interventions demonstrated no relative advantage compared to UHC. CONCLUSION The significant across-the-board SBP decreases suggest that UHC nurse/patient/physician interactions were the central component of SBP reduction and that additional efforts to lower recurrent stroke risk should test incremental improvements in usual care, not resource-intensive transitional care interventions. They also suggest the potential value of pragmatic home care programs as part of a broader strategy to overcome HTN treatment barriers and improve secondary stroke prevention globally. CLINICAL TRIALS REGISTRATION Trial Number NCT01918891.
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Affiliation(s)
- Penny H Feldman
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, USA
| | - Margaret V McDonald
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, USA
| | - Melissa Trachtenberg
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, USA
| | - Marygrace Trifilio
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, USA
| | - Nicole Onorato
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, USA
| | - Sridevi Sridharan
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, USA
| | - Stephanie Silver
- Research Division, Hebrew Home at Riverdale, RiverSpring Health, Bronx, New York, USA
| | - Joseph Eimicke
- Research Division, Hebrew Home at Riverdale, RiverSpring Health, Bronx, New York, USA
| | - Jeanne Teresi
- Research Division, Hebrew Home at Riverdale, RiverSpring Health, Bronx, New York, USA
- Columbia University Stroud Center at New York State Psychiatric Institute, New York, USA
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14
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Bliton J, Muscarella P, Friedmann P, Parides M, Papalezova K, McAuliffe JC, In H. Perioperative Mortality Does Not Explain Racial Disparities in Gastrointestinal Cancer. J Gastrointest Surg 2019; 23:1631-1642. [PMID: 30652243 DOI: 10.1007/s11605-018-4064-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 11/21/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Racial minorities with gastrointestinal cancer suffer disproportionately poor overall and disease-specific survival. We used a nationally representative sample to examine the relationship between race/ethnicity and mortality and determine whether these disparities were observed in the perioperative period. MATERIALS AND METHODS The Nationwide Inpatient Sample (NIS) was used to examine patients undergoing surgery for cancers of the esophagus, stomach, pancreas, colon and rectum ("GI cancer") between 2008 and 2012. Logistic regression was used to evaluate whether race/ethnicity was associated with perioperative mortality after adjusting for sociodemographic characteristics, perioperative factors and presentation (ER vs elective). RESULTS A total of 110,044 subjects were identified, including 75.8% Whites, 10.5% Black patients, 7.2% Hispanic patients, and 3.1% Asian/Pacific Islanders (API). Whites were generally older than minorities. In adjusted multivariable generalized linear mixed logistic models, no increase in perioperative mortality was seen for minorities. Worse outcomes were observed for those with higher Elixhauser comorbidity score (OR 6.90, CI 5.96-7.99), lower income region (OR 1.24, CI 1.10-1.40), males (OR 1.54, CI 1.42-1.68), and those without private insurance (Medicare OR 1.34, CI 1.16-1.55; Medicaid OR 1.27, CI 1.02-1.58; self-pay OR 1.64, CI 1.24-2.17). Differences in mortality were predominantly driven by comorbidities (pseudo %ΔR2 = 38.56%) and only minimally by race (pseudo %ΔR2 = 0.49%). CONCLUSION Minority groups do not suffer higher rates of perioperative mortality for GI cancer surgeries after controlling for clinical and demographic factors. Future work to address cancer disparities should focus on areas in the cancer care trajectory such as cancer screening, surveillance, socioeconomic factors, and access.
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Affiliation(s)
- J Bliton
- Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - P Muscarella
- Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - P Friedmann
- Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - M Parides
- Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - K Papalezova
- Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - J C McAuliffe
- Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - H In
- Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA.
- Department of Epidemiology and Population Health, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA.
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15
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Silberberg M, Goldstein LB, Weaver S, Blue C. Increasing Stroke Knowledge and Decreasing Stroke Risk in a Latino Immigrant Population. J Immigr Minor Health 2019; 20:1490-1499. [PMID: 29362945 DOI: 10.1007/s10903-018-0690-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Stroke knowledge is poor and stroke risk is growing for the U.S. Latino immigrant population. We present results of an evaluation of a tailored, community-based intervention in Durham, North Carolina. The intervention included integration of stroke knowledge into classes and workshops at a community-based organization. Knowledge surveys were administered to participants immediately before and after stroke education, and at multiple points over the following year. For both low-risk participants receiving classroom-based education and individually care managed participants with risk factors, stroke knowledge improved dramatically and remained high among those who could be reached for follow-up. Evidence of behavior change and change in clinical status was weak. These findings from an observational study conducted in a real-world context complement the results of previously reported efficacy studies, indicating potential gains from health education for Latino immigrants, even from classroom-based education for low-risk individuals.
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Affiliation(s)
- Mina Silberberg
- Department of Community and Family Medicine, Duke University Medical School, Durham, NC, USA. .,Division of Community Health, Duke University Medical School, DUMC 104425, Durham, NC, 277210, USA.
| | | | - Sarah Weaver
- Department of Community and Family Medicine, Duke University Medical School, Durham, NC, USA
| | - Colleen Blue
- UNC Institute for Global Health and Infectious Diseases, Chapel Hill, NC, USA
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16
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Feldman PH, McDonald MV, Eimicke J, Teresi J. Black/Hispanic Disparities in a Vulnerable Post-Stroke Home Care Population. J Racial Ethn Health Disparities 2018; 6:525-535. [PMID: 30560319 DOI: 10.1007/s40615-018-00551-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 11/21/2018] [Accepted: 11/27/2018] [Indexed: 12/01/2022]
Abstract
Significant racial and ethnic disparities in stroke risk factors, occurrence, and outcomes persist in the USA. This article examines socio-economic and health disparities in a diverse, hypertensive sample of 495 post-stroke Black, non-Hispanic and Hispanic home health patients at risk of a recurrent stroke due to elevated systolic blood pressure (SBP), defined as SBP > 140 mmHg. The article, which analyzes cross-sectional data, focuses on correlates of patients' SBP-the leading modifiable cause of stroke-and physical function-a key stroke sequela and indicator of post-stroke quality of life. Of the 495 participants, 69.7% were Black, non-Hispanic, and 30.3% Hispanic. Black participants had significantly higher mean SBP than Hispanics. After controlling for multiple potential confounders/predictors, being Black was associated with a 3.55 mmHg elevation in SBP relative to being Hispanic. There were no significant Black/Hispanic differences in physical function measures. Seven independent variables significantly predicted better physical function: being male, younger, having fewer comorbidities, lower BMI, fewer depressive symptoms, higher health literacy, and current alcohol drinking (vs. abstinence). Our data provide a unique comparison of homebound Black and Hispanic stroke survivors at heightened risk of recurrent stroke absent targeted intervention. The finding of a significant Black/Hispanic disparity in SBP is striking in this narrowly defined home health care population all of whom are at risk for recurrent stroke. Priority should be given to culturally tailored interventions designed to link vulnerable home care patients to continuous, responsive hypertension care.
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Affiliation(s)
- Penny H Feldman
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, NY, USA
| | - Margaret V McDonald
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, NY, USA.
| | - Joseph Eimicke
- Research Division, Hebrew Home at Riverdale, RiverSpring Health, 5901 Palisade Avenue, Bronx, NY, 10471, USA
| | - Jeanne Teresi
- Research Division, Hebrew Home at Riverdale, RiverSpring Health, 5901 Palisade Avenue, Bronx, NY, 10471, USA.,Columbia University Stroud Center at New York State Psychiatric Institute, New York, NY, USA
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17
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Jacobson LT, Hade EM, Collins TC, Margolis KL, Waring ME, Van Horn LV, Silver B, Sattari M, Bird CE, Kimminau K, Wambach K, Stefanick ML. Breastfeeding History and Risk of Stroke Among Parous Postmenopausal Women in the Women's Health Initiative. J Am Heart Assoc 2018; 7:e008739. [PMID: 30371157 PMCID: PMC6201437 DOI: 10.1161/jaha.118.008739] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 06/20/2018] [Indexed: 11/16/2022]
Abstract
Background Stroke is the third leading cause of death among US Hispanic and non-Hispanic black women aged 65 and older. One factor that may protect against stroke is breastfeeding. Few studies have assessed the association between breastfeeding and stroke and whether this association differs by race and ethnicity. Methods and Results Data were taken from the Women's Health Initiative Observational Study with follow-up through 2010; adjusted hazard ratios for stroke subsequent to childbirth were estimated with Cox regression models accounting for left and right censoring, overall and stratified by race/ethnicity. Of the 80 191 parous women in the Women's Health Initiative Observational Study, 2699 (3.4%) had experienced a stroke within a follow-up period of 12.6 years. The average age was 63.7 years at baseline. Fifty-eight percent (n=46 699) reported ever breastfeeding; 83% were non-Hispanic white, 8% were non-Hispanic black, 4% were Hispanic, and 5% were of other race/ethnicity. After adjustment for nonmodifiable potential confounders, compared with women who had never breastfed, women who reported ever breastfeeding had a 23% lower risk of stroke (adjusted hazard ratio=0.77; 95% confidence interval 0.70-0.83). This association was strongest for non-Hispanic black women (adjusted hazard ratio=0.52; 95% confidence interval 0.37-0.71). Further, breastfeeding for a relatively short duration (1-6 months) was associated with a 19% lower risk of stroke (adjusted hazard ratios=0.81; 95% confidence interval 0.74-0.89). This association appeared stronger with longer breastfeeding duration and among non-Hispanic white and non-Hispanic black women (test for trend P<0.01). Conclusions Study results show an association and dose-response relationship between breastfeeding and lower risk of stroke among postmenopausal women after adjustment for multiple stroke risk factors and lifestyle variables. Further investigation is warranted.
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Affiliation(s)
- Lisette T. Jacobson
- Department of Preventive Medicine and Public HealthSchool of Medicine‐WichitaUniversity of KansasWichitaKS
| | - Erinn M. Hade
- Center for BiostatisticsDepartment of Biomedical InformaticsThe Ohio State UniversityColumbusOH
| | - Tracie C. Collins
- Department of Preventive Medicine and Public HealthSchool of Medicine‐WichitaUniversity of KansasWichitaKS
| | | | | | | | - Brian Silver
- Department of NeurologyUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Maryam Sattari
- Department of MedicineUniversity of Florida College of MedicineGainesvilleFL
| | | | - Kim Kimminau
- Department of Family MedicineUniversity of Kansas Medical CenterKansas CityKS
| | - Karen Wambach
- School of NursingUniversity of Kansas Medical CenterKansas CityKS
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18
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Ellis C, Hardy RY, Lindrooth RC. Greater healthcare utilization and costs among Black persons compared to White persons with aphasia in the North Carolina stroke belt. J Neurol Sci 2017; 376:76-83. [DOI: 10.1016/j.jns.2017.02.062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 01/31/2017] [Accepted: 02/28/2017] [Indexed: 11/29/2022]
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