Socioeconomic status and stroke severity: Understanding indirect effects via risk factors and stroke prevention using innovative statistical methods for mediation analysis

Influence of smoking on glycaemic control in individuals with type 1 diabetes using flash glucose monitoring and its mediating role in the relationship between socioeconomic status and glycaemic control

Objective

This study examined the influence of smoking on glycaemic control in individuals with type 1 diabetes (T1D) using flash continuous glucose monitoring (F-CGM) systems, as well as its potential mediating role in the relationship between socioeconomic status (SES) and glycaemic control.

Methods

This study included 378 subjects with T1D (18% smokers). Glucose metrics cloud downloads were obtained over a period of 14 days. Mean annual net income per person based on census tract data was used as a proxy for SES. Mediation analysis was performed using four-way effect decomposition procedures.

Results

Smokers exhibited significantly lower net income than non-smokers (p < 0.001). Compared to smokers, non-smokers showed better glycaemic control characterized as higher time in range (TIR) 70-180 mg/dL (p = 0.002) and lower glycosylated haemoglobin levels (p = 0.008). Mediation analysis revealed a significant mediating role of smoking in the relationship between SES and glycaemic control (TIR).

Conclusions

Our data suggest that smoking exerts a detrimental effect on glycaemic control in individuals with T1D using F-CGM systems. In addition, tobacco use partially mediates the relationship between SES and glycaemic control. Thus, adopting smoking cessation measures could lead to improved glycaemic control and help mitigate the impact of social inequalities on T1D.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-024-01535-y.

Trajectory patterns and influencing factors of supportive care needs in stroke patients: A longitudinal study

AIM

To investigate the trajectory patterns and influencing factors of supportive care needs in stroke patients.

DESIGN

A longitudinal study.

METHODS

In total, 207 stroke patients who received treatment at the Department of Neurology in a hospital in Xuzhou between July 2022 and July 2023 were recruited using convenience sampling. Questionnaires including supportive care needs, hospital anxiety and depression scale, and the Barthel index were investigated at baseline and at 1, 3, and 6 months. A latent class growth model was applied to identify the supportive care needs trajectories. Multiple logistic regression was used to determine the predictors for membership. This study adheres to STROBE reporting guidelines.

RESULTS

Three patterns of supportive care needs trajectories were identified: A high needs slow decline group (20.8%), a medium needs stable group (56.5%) and a medium needs rapid decline group (22.7%). Based on further analysis, the findings indicated that age, education level, monthly income, comorbidity, activities of daily living, anxiety and depression were associated with the trajectory categories of supportive care needs with stroke patients.

CONCLUSION

This study demonstrates heterogeneity in changes in supportive care needs among stroke patients. Healthcare providers need to consider these different categories of needs and develop individualized care measures based on the characteristics of different patients.

IMPACT

Healthcare providers should be aware of the fluctuations in care needs of stroke patients at various stages. Additionally, the study aimed to identify patients' specific needs based on their circumstances, monitor the rehabilitation process and establish a more personalized and optimized care plan through multidisciplinary collaboration. The ultimate goal was to alleviate symptomatic distress and address the long-term care needs of patients.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Parental divorce's long shadow: Elevated stroke risk among older Americans

Although studies have investigated the association between adverse childhood experiences and chronic health outcomes including stroke, few studies have investigated the association between parental divorce and stroke among adults with no history of childhood abuse. The objectives of this study were to investigate the association between parental divorce in childhood and stroke in older adulthood among those who did not experience child abuse and to examine whether this association differs between men and women. This study utilized population-based data from the 2022 Behavioral Risk Factor Surveillance System. An analytic sample of 13,205 adults aged 65 and above (56.6% female) who have never experienced childhood physical nor sexual abuse were analyzed using binary logistic regression. The outcome variable investigated was self-report of a physician-diagnosis of stroke, and the main exposure of interest was parental divorce. In this sample of older adults, 7.3% reported having stroke, while 13.9% reported that their parents had divorced before the respondent was 18 years old. Controlling for the effects of other factors, respondents who experienced parental divorce had 1.61 times higher odds of having a stroke when compared to their counterparts who did not experience parental divorce (AOR = 1.61, 95% CI = 1.15-2.24). The association between parental divorce and stroke was not dependent on sex; however, compared to females, males had 1.47 times higher odds of having a stroke (AOR = 1.47, 95% CI = 1.11-1.93). The findings of this study suggest that individuals in this cohort whose parents divorced as children were at greater risk for stroke later in life. Potentially moderating variables were hypothesized, including childhood poverty, sleep hygiene, and hypertension.

Equitable Access, Lasting Results: The Influence of Socioeconomic Environment on Bariatric Surgery Outcomes

PURPOSE

Low socioeconomic status (SES) correlates with higher obesity rates and challenges in accessing treatments like bariatric surgery (BS). This study aims to assess SES's influence on medium-term BS outcomes in a setting of universal healthcare, ensuring equitable treatment access.

MATERIAL AND METHODS

We conducted a retrospective analysis of 193 BS patients (1997-2018) at a tertiary care hospital. Weight loss was expressed as change in % total weight loss (%TWL) and excess body weight (EBW) loss. Successful BS was defined as > 50% EBW loss. SES was gauged using quartiles of the Spanish Deprivation Index. A multivariable Cox regression model evaluated SES impact on BS success over follow-up.

RESULTS

The mean follow-up was 6.9 ± 4.6 years; patients averaged 43.9 ± 11.8 years, with 29.7% men. Preoperative BMI was 48.2 ± 8.2 kg/m2. At follow-up, BMI was 33.9 ± 6.6 kg/m2, with 29.3 ± 12.02% of %TWL. No SES quartile differences in BS success were noted at follow-up (log rank p = 0.960). Cox regression revealed no SES disparities in BS outcomes post-adjustment. However, female sex (HR 1.903; p = 0.009) and diabetes mellitus (HR = 0.504; p = 0.010) correlated with weight-related outcomes.

CONCLUSION

In a universal healthcare system with equitable treatment access, medium-term BS outcomes remain consistent irrespective of patients' socioeconomic status.

Disparities in Access to, Use of, and Quality of Rehabilitation After Stroke in the United States: A Scoping Review

OBJECTIVES

To summarize current reports in the literature on disparities in rehabilitation after stroke; identify gaps in our understanding of rehabilitation disparities; and make recommendations for future research.

DATA SOURCES

A health sciences librarian developed a search string based on an a priori protocol and searched Medline (Ovid) Embase (Elsevier), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL and EBSCO).

STUDY SELECTION

A 2-step screening process of titles and abstracts followed by full-text review was conducted. Primary observational studies conducted in the United States that reported on disparities in rehabilitation (ie, physical, occupational, or speech therapy) among adults after stroke were retained. Eligible disparity populations included racial minorities; ethnic minorities; sex and gender minorities; older populations; socioeconomically disadvantaged populations; and geographic minorities (inner city/rural).

DATA EXTRACTION

Data extracted from retained articles included: aims/objectives; data source; sample characteristics, rehabilitation outcomes examined; types of disparities examined; statistical methods used; and disparity findings.

DATA SYNTHESIS

Seven thousand eight hundred fifty-three titles and abstracts were screened, and 473 articles underwent full-text review. Forty-nine articles were included for data extraction and analysis. Many articles examined more than 1 disparity type with most examining disparities in race and/or ethnicity (n=43, 87.7%), followed by sex (n=25, 53.0%), age (n=23, 46.9%), socioeconomic status (n=22, 44.9%), and urban/rural status (n=8, 16.3%). Articles varied widely by sample characteristics, data sources, rehabilitation outcomes, and methods of examining disparities.

CONCLUSIONS

Although we found some consistent evidence of disparities in rehabilitation for older individuals, non-White races, and individuals of lower socioeconomic status, the variability in methods made the synthesis of findings challenging. Further work, including additional well-designed studies and systematic reviews, and/or meta-analyses of current studies, is needed to better understand the extent of rehabilitation disparities after stroke.

Association of aortic valve calcium with dementia and stroke: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND AND AIMS

Calcific aortic valve disease is associated with increased thrombin formation, platelet activation, decreased fibrinolysis, and subclinical brain infarcts. We examined the long-term association of aortic valve calcification (AVC) with newly diagnosed dementia and incident stroke in the Multi-Ethnic Study of Atherosclerosis (MESA).

METHODS

AVC was measured using non-contrast cardiac CT at Visit 1. We examined AVC as a continuous (log-transformed) and categorical variable (0, 1-99, 100-299, ≥300). Newly diagnosed dementia was adjudicated using International Classification of Disease codes. Stroke was adjudicated from medical records. We calculated absolute event rates (per 1000 person-years) and multivariable adjusted Cox proportional hazards ratios (HR).

RESULTS

Overall, 6812 participants had AVC quantified with a mean age of 62.1 years old, 52.9 % were women, and the median 10-year estimated atherosclerotic cardiovascular disease (ASCVD) risk was 13.5 %. Participants with AVC >0 were older and less likely to be women compared to those with AVC=0. Over a median 16-year follow-up, there were 535 cases of dementia and 376 cases of stroke. The absolute risk of newly diagnosed dementia increased in a stepwise pattern with higher AVC scores, and stroke increased in a logarithmic pattern. In multivariable analyses, AVC was significantly associated with newly diagnosed dementia as a log-transformed continuous variable (HR 1.09; 95 % CI 1.04-1.14) and persons with AVC ≥300 had nearly a two-fold higher risk (HR 1.77; 95 % CI 1.14-2.76) compared to those with AVC=0. AVC was associated with an increased risk of stroke after adjustment for age, sex, and race/ethnicity, but not after adjustment for ASCVD risk factors.

CONCLUSIONS

After multivariable adjustment, AVC >0 was significantly associated with an increased risk of newly diagnosed dementia, but not incident stroke. This suggests that AVC may be an important risk factor for the long-term risk of dementia beyond traditional ASCVD risk factors.

Retrospective review of food insecurity screening in an outpatient stroke clinic using electronic and paper-based surveys

Objective

To assess the feasibility of administrating an electronic and paper-based food insecurity screener among patients presenting to a stroke clinic during the study period. We aimed to ensure a consecutive sample for our retrospective analysis and evaluate the prevalence and characteristics of food insecurity in this population.

Materials and methods

We conducted a retrospective review of patients with an initial telemedicine or in-person appointment to a stroke outpatient clinic between February 1 and July 31, 2021. Prior to their initial visit, patients were sent an electronic questionnaire to screen for food insecurity using the 2-item Hunger Vital Sign™ and to collect socio-demographic characteristics. Patients who were evaluated in-person were given a paper questionnaire if the electronic version was not completed upon clinic appointment. We collected data on patient demographics, screener completion rates, and the prevalence of food insecurity. The feasibility was evaluated by comparing the amount of missing data between electronic and paper-based screeners.

Results

Among 406 adult stroke survivors, 365 (89.9 %) completed the food insecurity screener, with 234 (64.1 %) completing it electronically and 131 (35.9 %) by paper. Overall, 14.3 % of the stroke patients experienced food insecurity. A higher prevalence of food insecurity was observed among patients who completed paper-based compared to electronic questionnaires (21.4 % vs 10.2 %, p = 0.004). Hispanic patients were more likely to complete paper-based questionnaires (32.1 %) compared to electronic questionnaires (18.0 %, p = 0.011). Patients with a 12th grade education or less were more likely to complete paper-based (49.5 %) vs. electronic questionnaires (36.4 %, p = 0.029). Feasibility was evaluated by comparing the amount of missing data between the screener delivery modalities. A higher percentage of socio-demographic characteristics was missing in the paper-based questionnaires compared to electronic questionnaires (105.3 % vs. 14.11 %).

Conclusions

Sample characteristics differ based on the mode of questionnaire delivery, suggesting that different screening modalities may be necessary to identify patients at the highest risk for food insecurity. Our study provides detailed insights into the feasibility of using electronic and paper-based screeners in a clinical setting, highlighting the importance of considering delivery methods in food insecurity assessments. It is important to note that the Spanish language electronic survey was only available during the last two months of the study, which may affect the findings regarding Hispanic patients' preference for paper surveys.

A Retrospective Analysis of the Underlying Health Status of Patients Treated for Stroke in the Emergency Department of a Community Hospital Situated in a Health Professional Shortage Area

Background Hypertension, diabetes, and hyperlipidemia are known contributors to the incidence of stroke. These and other risk factors such as smoking can be managed with effective primary care, but living in a medically underserved area and racial background can limit access, thereby deleteriously affecting underlying medical conditions and disproportionately contributing to negative stroke outcomes. Our goal is to learn about the on-admission health of 1,731 stroke patients who presented to the Crouse Hospital emergency department (ED) between January 2019 and January 2021 to better understand the circumstances affecting these patients. Crouse Hospital is a community hospital in Syracuse, New York, and an award-winning comprehensive stroke center in the region. The hospital is located in a health professional shortage area (HPSA) and serves both rural and urban patients of various ethnic backgrounds and socioeconomic statuses. Methodology We retrospectively examined the stroke patient data to determine how access to primary care and race affected smoking status, arrival time following the onset of symptoms, stroke severity, thrombolytic administration, and metrics relating to hypertension, diabetes, hyperlipidemia, and depression. Results We determined that, while most patients stated that they had a primary care provider, stroke incidents were typically associated with high blood pressure and high blood glucose despite the prevalence of prescriptions to treat these conditions and that both conditions affected the underserved and non-White patients (Black, Hispanic, Asian, Indigenous, and Other) more so than the served and White populations. Underserved and non-White patients, were also more likely to be associated with smoking behavior. Conclusions The data indicated the major health factors affecting the patients and highlighted those influenced by limited access to primary care and racial background. As a result, we developed a survey to gauge patients' perspectives on primary care and underlying medical conditions before and after their stroke. This patient-centered approach will help refine our stroke education efforts to improve stroke outcomes in the community.

Educational attainment, severity and short-term prognosis of intracerebral haemorrhage

Background

Educational attainment is a critical social determinant of health that impacts the risk and severity of incident ischaemic stroke, but less is known of its impact on intracerebral haemorrhage (ICH). The objective of this study is to determine whether educational attainment is associated with ICH severity and short-term prognosis.

Methods

Subjects were enrolled in a prospectively ascertained cohort with primary ICH from 1994 to 2020 at Massachusetts General Hospital. Educational attainment, medical history of ICH risk factors, ICH volume and ICH score were obtained on admission. The primary outcomes were ICH volume and the ICH score.

Results

Of 2539 eligible patients eligible, the median age of the sample was 74 (IQR 64-82) and 2159 (85%) had high school-only education. 1655 (65%) presented with an ICH volume less than or equal to 30 mL and 1744 (69%) presented with an ICH score less than 3. In multivariable logistic regression analyses controlling for age, income, employment history and prestroke diagnoses of hypertension and coronary artery disease, patients with high school-only education were more likely to have an ICH volume greater than 30 mL compared with college diplomates (OR 1.58, 95% CI 1.24 to 2.08) and more likely to have an ICH score of 3 or greater compared with college diplomates (OR 2.37, 95% CI 1.77 to 3.19).

Discussion

Prestroke educational attainment is independently associated with ICH severity and short-term prognosis, with lower educational attainment associated with larger ICH volumes and higher ICH scores. Future studies should examine how educational attainment impacts exposure to traditional clinical risk factors.

Development and Validation of Machine Learning Algorithms to Predict 1-Year Ischemic Stroke and Bleeding Events in Patients with Atrial Fibrillation and Cancer

In this study, we leveraged machine learning (ML) approach to develop and validate new assessment tools for predicting stroke and bleeding among patients with atrial fibrillation (AFib) and cancer. We conducted a retrospective cohort study including patients who were newly diagnosed with AFib with a record of cancer from the 2012-2018 Surveillance, Epidemiology, and End Results (SEER)-Medicare database. The ML algorithms were developed and validated separately for each outcome by fitting elastic net, random forest (RF), extreme gradient boosting (XGBoost), support vector machine (SVM), and neural network models with tenfold cross-validation (train:test = 7:3). We obtained area under the curve (AUC), sensitivity, specificity, and F2 score as performance metrics. Model calibration was assessed using Brier score. In sensitivity analysis, we resampled data using Synthetic Minority Oversampling Technique (SMOTE). Among 18,388 patients with AFib and cancer, 523 (2.84%) had ischemic stroke and 221 (1.20%) had major bleeding within one year after AFib diagnosis. In prediction of ischemic stroke, RF significantly outperformed other ML models [AUC (0.916, 95% CI 0.887-0.945), sensitivity 0.868, specificity 0.801, F2 score 0.375, Brier score = 0.035]. However, the performance of ML algorithms in prediction of major bleeding was low with highest AUC achieved by RF (0.623, 95% CI 0.554-0.692). RF models performed better than CHA2DS2-VASc and HAS-BLED scores. SMOTE did not improve the performance of the ML algorithms. Our study demonstrated a promising application of ML in stroke prediction among patients with AFib and cancer. This tool may be leveraged in assisting clinicians to identify patients at high risk of stroke and optimize treatment decisions.

Mediation Analyses of the Mechanisms by Which Socioeconomic Status, Comorbidity, Stroke Severity, and Acute Care Influence Stroke Outcome

BACKGROUND AND OBJECTIVES

Low socioeconomic status (SES) is associated with increased risk of death and disability after stroke, but interventional targets to minimize disparities remain unclear. We aim to assess the extent to which SES-based disparities in the association between low SES and death and dependency at 3 months after stroke could be eliminated by offsetting differences in comorbidity, stroke severity, and acute care.

METHODS

This nationwide register-based cohort study included all 72 hospitals caring for patients with acute stroke in Sweden. All patients registered with an acute ischemic stroke in the Swedish Stroke Register in 2015-2016 who were independent in activities of daily living (ADL) during stroke were included. Data on survival and SES the year before stroke were retrieved by cross-linkage with other national registers. SES was defined by education and income and categorized into low, mid, and high. Causal mediation analysis was used to study the absolute risk of death and ADL dependency at 3 months depending on SES and to what extent hypothetical interventions on comorbidities, stroke severity, and acute care would equalize outcomes.

RESULTS

Of the 25,846 patients in the study, 6,798 (26.3%) were dead or ADL dependent 3 months after stroke. Adjusted for sex and age, low SES was associated with an increased absolute risk of 5.4% (95% CI 3.9%-6.9%; p < 0.001) compared with mid SES and 10.1% (95% CI 8.1%-12.2%; p < 0.001) compared with high SES. Intervening to shift the distribution of all mediators among patients with low SES to those of the more privileged groups would result in absolute reductions of these effects by 2.2% (95% CI 1.2%-3.2%; p < 0.001) and 4.0% (95% CI 2.6%-5.5%; p < 0.001), respectively, with the largest reduction accomplished by equalizing stroke severity.

DISCUSSION

Low SES patients have substantially increased risks of death and ADL dependency 3 months after stroke compared with more privileged patient groups. This study suggests that if we could intervene to equalize SES-related differences in the distributions of comorbidity, acute care, and stroke severity, up to 40 of every 1,000 patients with low SES could be prevented from dying or becoming ADL dependent.

Association between neighborhood socioeconomic status and mechanical thrombectomy for acute ischemic stroke: A nationwide multilevel observational study

OBJECTIVE

Acute ischemic stroke is a major health burden worldwide and mechanical thrombectomy is the treatment of choice for large-vessel occlusion stroke. This study aimed to evaluate the association between neighborhood socioeconomic status (SES) and the likelihood of receiving mechanical thrombectomy in patients with acute ischemic stroke.

METHODS

A nationwide cross-sectional study was conducted using the National Emergency Department Information System database. Patients who were diagnosed with ischemic stroke in the emergency department (ED) within 24 h of symptom onset between 2018 and 2021 were included. The neighborhood SES index was measured at the county level using property tax per capita, education level, and the proportions of single families and single-parent households. The study population was divided into quartiles based on the neighborhood SES index. The study outcome was mechanical thrombectomy. Multilevel multivariable logistic regression was performed. An interaction analysis between mental status at the ED triage and neighborhood SES was also performed.

RESULTS

Among the 196,007 patients, 8968 (4.6%) underwent mechanical thrombectomy. Compared with the affluent group, the deprived-middle and deprived groups were less likely to receive mechanical thrombectomy; the adjusted ORs (95% CIs) were 1.00 (0.92-1.09), 0.82 (0.74-0.91), and 0.82 (0.72-0.93) for the affluent-middle, deprived-middle, and deprived groups, respectively. Altered mental status at the ED triage strengthened the association between neighborhood SES and the likelihood of receiving mechanical thrombectomy (adjusted ORs [95% CIs] 0.85 [0.81-0.89] for the affluent-middle to deprived-middle group and 0.66 [0.65-0.66] for deprived groups, p-value for interaction < 0.05).

CONCLUSIONS

For patients diagnosed with acute ischemic stroke at the ED, low neighborhood SES is associated with low odds of receiving mechanical thrombectomy. Public health strategies should be developed to resolve these disparities and to decrease the health care burden of acute ischemic stroke.

Racial and Ethnic Differences in the Risk of Ischemic Stroke After Nontraumatic Intracerebral Hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) is associated with an increased risk of ischemic stroke. Whether there are racial and ethnic disparities in the risk of ischemic stroke after ICH is poorly understood. We therefore aimed to test the hypothesis that non-Hispanic Black and Hispanic ICH patients have a higher risk of ischemic stroke compared with non-Hispanic White ICH patients.

METHODS

We performed a retrospective cohort study using the Healthcare Cost and Utilization Project (HCUP) on all hospitalizations at all nonfederal hospitals in Florida from 2005 to 2018 and New York from 2006 to 2016. Race and ethnicity were coded as a single variable in HCUP. We included patients with an ICH, and without a prior or concomitant diagnosis of ischemic stroke, ascertained using validated International Classification of Diseases-Clinical Modification-9 and 10 diagnosis codes. Using Cox proportional hazard models, we studied the relationship between race and risk of ischemic stroke starting from the time of discharge from ICH hospitalization, after adjustment of demographics and vascular comorbidities.

RESULTS

We included 91 342 patients with ICH-62% non-Hispanic White, 18% non-Hispanic Black, and 12% Hispanic patients. Non-Hispanic Black and Hispanic patients were younger and had a higher prevalence of cardiovascular comorbidities; however, atrial fibrillation was more prevalent among non-Hispanic White patients. During a median follow-up period of 4.4 years (interquartile range, 1.5-8.1), an incident ischemic stroke occurred in 3377 (6%) non-Hispanic White, 1323 (8%) non-Hispanic Black, and 844 (8%) Hispanic patients. In adjusted Cox models, the risk of an ischemic stroke was significantly higher among non-Hispanic Black patients (hazard ratio, 1.6 [95% CI, 1.5-1.8]) and Hispanic patients (hazard ratio, 1.4 [95% CI, 1.3-1.5]), compared with non-Hispanic White patients. Similar results were obtained in sensitivity analyses when using death as a competing risk and after excluding patients with atrial fibrillation and valvular heart disease.

CONCLUSIONS

In a large heterogeneous cohort of patients with ICH, we found that non-Hispanic Black and Hispanic patients had a significantly higher risk of ischemic stroke compared with non-Hispanic White patients.

Mobile health-technology integrated care in secondary prevention atrial fibrillation patients: a post-hoc analysis from the mAFA-II randomized clinical trial

AF patients with history of thromboembolic events are at higher risk of thromboembolic recurrences, despite appropriate antithrombotic treatment. We aimed to evaluate the effect of mobile health (mHealth) technology-implemented 'Atrial fibrillation Better Care' (ABC) pathway approach (mAFA intervention) in secondary prevention AF patients. The Mobile Health Technology for Improved Screening and Optimized Integrated Care in AF (mAFA-II) cluster randomized trial enrolled adult AF patients across 40 centers in China. The main outcome was the composite outcome of stroke or thromboembolism, all-cause death, and rehospitalization. Using Inverse Probability of Treatment Weighting (IPTW), we evaluated the effect of the mAFA intervention in patients with and without prior history of thromboembolic events (i.e., ischemic stroke or thromboembolism). Among the 3324 patients enrolled in the trial, 496 (14.9%, mean age: 75.1 ± 11.4 years, 35.9% females) had a previous episode of thromboembolic event. No significant interaction was observed for the effect of mAFA intervention in patients with vs. without history of thromboembolic events [Hazard ratio, (HR): 0.38, 95% confidence interval (CI):0.18-0.80 vs. HR 0.55, 95% CI 0.17-1.76, p for interaction = 0.587); however, a trend towards lower efficacy of mAFA intervention among AF patients in secondary prevention was observed for secondary outcomes, with significant interaction for bleeding events (p = 0.034) and the composite of cardiovascular events (p = 0.015). A mHealth-technology-implemented ABC pathway provided generally consistent reduction of the risk of primary outcome in both primary and secondary prevention AF patients. Secondary prevention patients may require further specific approaches to improve clinical outcomes such as bleeding and cardiovascular events.Trial registration: WHO International Clinical Trials Registry Platform (ICTRP) Registration number ChiCTR-OOC-17014138.

Incidence, lethality, and post-stroke functional status in different Brazilian macro-regions: The SAMBA study (analysis of stroke in multiple Brazilian areas)

Background

Stroke is the second leading cause of death in Brazil. The social and financial burden of stroke is remarkable; however, the epidemiological profile remains poorly understood.

Objective

The aim of this study was to report the incidence, lethality, and functional status at 30 and 90 days post-stroke in the cities of different Brazilian macro-regions.

Methods

This is an observational, prospective, and population-based study, led in Canoas (South), Joinville (South, reference center), Sertãozinho (Southeast), and Sobral (Northeast) in Brazil. It was developed according to the three-step criteria recommended by the World Health Organization to conduct population-based studies on stroke. Using different sources, all hospitalized and ambulatory patients with stroke were identified and the same criteria were kept in all cities. All first events were included, regardless of sex, age, or type of stroke. Demographic and risk factor data were collected, followed by biochemical, electrocardiographic, and radiological test results. Functional status and lethality were obtained using the mRankin scale through telephonic interview (validated Brazilian version).

Results

In 1 year, 932 stroke cases were registered (784 ischemic stroke, 105 hemorrhagic stroke, and 43 subarachnoid hemorrhage). The incidence rates per 100,000 inhabitants, adjusted for the world population, were 63 in Canoas, 106 in Joinville, 72 in Sertãozinho, and 96 in Sobral. The majority (70.8%) were followed for 90 days. Kaplan-Meier curves showed that 90-day survival was different among cities. Sobral, which has the lowest socioeconomic indexes, revealed the worst results in terms of lethality and functional status.

Conclusion

This study expands the knowledge of stroke epidemiology in Brazil, a middle-income country with enormous socioeconomic and cultural diversity. The discrepancy observed regarding the impact of stroke in patients from Joinville and Sobral highlights the need to improve the strategic allocation of resources to meet the health priorities in each location.